Addressing Adverse Childhood Experiences for Children Birth to Age 5 in Clinical Practice
Summary
Evidence suggests that exposures to Adverse Childhood Experiences (ACE) before the age of 18 play a significant role in mental and physical health outcomes. Examples of ACEs include witnessing domestic violence, living with family substance abuse or child abuse/neglect. Recently, the CDC reported that 5 out of 10 leading causes of death were associated with ACE.1 Evidence demonstrates that unrelenting early childhood adversity, particularly in the absence of a safe, stable and nurturing caregiver, can produce a toxic stress response, which can result in epigenetic changes that damage the brain, immune and metabolic systems.2–5 These deleterious effects early in development can lead to behavioral and physical health problems that may persist into adulthood.6
Advances in treating or preventing health concerns linked to ACE have been limited due to the absence of clear, actionable guidance for screening and addressing ACE in clinical settings. This poses a significant barrier to intervention, particularly in children. Capturing an accurate picture of children’s history and ACE exposure must be balanced with the feasibility of implementing a screening tool and providing useful recommendations.7
Our work has led to ACE screening and response protocols being successfully implemented in non-clinical community setting targeting young children. Specifically, using The Family Map Inventories (FMI), a family-friendly, comprehensive system implemented by early childhood staff.5,8 Embedded in the FMI are items (FMI-ACE) that serve as a screen for potential ACE.9 This project will translate a similar tool into clinical settings.10 Our 123Go project will establish a team of clinical and research partners to identify and guide the input from clinical professionals. The work will contribute to a Phase I SBIR application to NICHD currently under development.
Aim 1: Obtain ACE screening design input and continuing education needs from clinical teams in diverse clinical settings (e.g., pediatric, family medicine, large and small clinics). The team will engage clinical staff for a review of the project goals and identification of barriers and solutions. We expect the workflow and implementation protocol will be critical to ensuring that that the information can be available to clinical staff while not adding to time burden. This may be addressed using electronic assessment before the clinical visit (e.g., MyChart) and/or integrated into the EMR workflow. We also expect the process of linking results to an actionable ‘prescription’ to benefit from input.
Aim 2: Obtain acceptability and feasibility ratings of Aim 1 options from parents of children birth to age 5 years receiving services in each clinical setting. We will present parents with multiple acceptable options supported by the results of Aim 1. We will use measures developed for implementation science to assess these constructs.11
Our long-term goal is to change clinic practice to improve ACE-related health outcomes with successful early intervention steps to buffer the child from the risk and/or supporting the parents to strengthen the environment to reduce ongoing child exposure to ACE (e.g., seek treatment for depression).
Keywords:
- electronic health record (EHR)
- Health Care
- Translational Research
- adverse events
- Community