Identifying Adverse Childhood Experiences (ACEs) in a Federally Qualified Health Center using the Pediatric ACEs and Related Life Events Screener

Abstract

Background: Evidence links adverse childhood experiences (ACEs) to health issues later in life. Most research has been conducted in adults but there is a lack of recent research on the impact of ACEs in the pediatric population particularly in relation to mental health conditions. Utilizing the Pediatric ACEs Screener (PEARLS) health care providers can screen for ACEs at earlier ages. Purpose: The aim of this evidence-based project is to determine if there is an increase of newly diagnosed mental health related disorders when using PEARLS compared to not using PEARLS in the previous months before implementation. Methods: ACEs were identified using PEARLS at well-child visits. Regardless of scores, participants received verbal or written education on reducing stressors related to ACEs. Behavioral health outcomes were obtained via chart audits. Results: A total of 2,037 PEARLS were administered. Of that, 1949 screened negative for ACEs and 88 (4.3%) screened positive. Screening for ACEs identified that patients who screened positive who had a higher frequency of having a behavioral health diagnosis. Implications for Practice: Screening for ACEs exposure in pediatrics can provide early detection and timely interventions to reduce the adverse impacts of ACEs. Conclusion: Implementing of ACEs screening in a pediatric population was simple but did not result in an increase in identification of behavioral health diagnoses. IDENTIFYING ACES IN A FQHC USING PEARLS 3 Identifying Adverse Childhood Experiences (ACEs) in a Federally Qualified Health Center using the Pediatric ACEs and Related Life Events Screener Growing research and evidence links adverse childhood experiences (ACEs) to health issues that can be experienced later in life. Felitti et al. (1998) found a strong dose response relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults. Disease conditions included ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease, as well as poor self-rated health also showed a graded relationship to the breadth of childhood exposures (Felitti et al., 1998). Current studies have been conducted in adults with a history of experiencing one or more ACEs, there is limited research on ACEs’ impact in the pediatric population particularly in relation to mental health conditions. Due to the recent introduction of the Pediatric ACEs Screener (PEARLS) health care providers can screen for ACEs at an earlier age, thereby providing opportunities to reduce the risk of the negative impact of ACEs as an adult. In a recent study, researchers were able to demonstrate concurrent validity in that the PEARLS was effective at identifying children at high risk for a number of clinically significant outcomes, including mental health illnesses, atopic conditions, and obesity (Thakur et al., 2020). Literature Synthesis A literature review was conducted using the following electronic databases: EBSCOhost, CINAHL Plus, Academic Search Premier, Health Source: Nursing/Academic Edition, and APA Psych Articles. The following key words were used during the search for articles closely related IDENTIFYING ACES IN A FQHC USING PEARLS 4 to the topics outlined in this project: “adverse childhood experiences”, “toxic stress”, “pediatric”, “population”, “mental health”, “ACEs”, “pediatric setting”, “screening”. Background The ACEs term was first introduced in a study conducted by the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente in which the study described the longterm relationship of negative childhood experiences to important medical and public health problems by assessing, retrospectively and prospectively, the long-term impact of abuse and household dysfunction during childhood (Felitti et al., 1997). The following outcomes were addressed in adults: disease risk factors and incidence, quality of life, health care utilization, and mortality (Felitti et al., 1998). The results of this study along with subsequent studies demonstrate that there is a strong relationship with ACEs and chronic health implications often experienced in adulthood. Hughes et al. (2017) synthesized evidence for the effect of multiple ACEs and for all outcomes examined, pooled odds ratios which indicated an increased risk among individuals with at least four ACEs compared with those reporting none. The original study population were adults (ages of 19 to 92), who were primarily Caucasian, middle class, employed, college educated, and privately insured (Felitti et al., 1998). This differs drastically from the populations in recent studies attempting to understand the impact of ACEs. Compared to the adult population, there are fewer studies outlining the impact of ACEs among the pediatric population. Children at or below the poverty level are at a greater risk for ACEs, therefore require early screening, detection, prevention, and intervention (Bethell et al., 2016). Although ACEs has been studied for over two decades, there had not been a validated screening tool to identify ACEs in a pediatric setting. However, from 2015 to 2017 The Center for Youth Wellness and Benioff Children’s Hospital Oakland (BCHO) developed a final IDENTIFYING ACES IN A FQHC USING PEARLS 5 Pediatric ACE and other Determinants of Health Questionnaire. (Koita et al., 2018). Providers can access PEARLS in a variety of languages through the California ACEs Aware website and use the versions available in their clinical setting. PEARLS envelopes three main domains with subcategories: abuse (physical, emotional, sexual), neglect (physical and emotional neglect), household dysfunction (parental incarceration, mental illness, substance abuse, parental separation, and intimate partner violence). The screener has two main versions: identified versus deidentified. In the identified version of the screener, the participant selects the “yes” response to the specific question asked. Therefore, the provider can easily view the responses to the screener and choose to adjust the well child visit according to the responses. In the deidentified version, the responses to each question are not individually identified. The participant is not required to indicate “yes” or “no” to each individual question, but merely counts the total “yes” responses. Regardless of the version used, the screener identifies that ACEs are present in the individual which leads to the appropriate interventions to best meet the patients’ needs. The American Academy of Pediatrics (AAP) advocates for the screening of Adverse Childhood Experiences (ACEs) during well-child visits by pediatric health care providers (Bryant & VanGraafeiland, 2019). Current evidence demonstrates a strong correlation between children with high ACE scores and the likelihood of physical and mental health problems as adults (Bryant & VanGraafeiland, 2019). Research has continued to identify the range of adversity experienced by the pediatric population, which is an area that was not captured within the original ACE study. Studies have demonstrated a strong association between early life adversities (ACEs before 5 years of age) and mental health outcomes, including attention deficit hyperactivity disorder (ADHD) diagnosis, in middle childhood (Hunt, Berger, & Slack, 2017; IDENTIFYING ACES IN A FQHC USING PEARLS 6 McKelvey et al., 2018). Thakur et al. (2020) conducted a study in which the population’s mean age was 5.9-year population, 76% reported one or more adversity, and older age being associated with higher PEARLS score. This highlights the importance of health care providers’ roles in a pediatric setting being able to identify children who are at risk for ACEs. Description of EBP Project This evidence-based practice project implemented ACES screening using PEARLS at two Federally Qualified Health Centers (FQHC) in a large southern California city. Screening with PEARLS was implemented from September 1st, 2020 to December 31st, 2020. The aim was to determine if there was an increased identification of newly diagnosed mental health related disorders when using PEARLS compared to not using PEARLS months before implementation. Project Implementation/Process Plan The Chief Medical Director demonstrated a strong interest in implementing ACEs screening using PEARLS at both clinical sites in March 2020. Approval from Institutional Review Board was obtained. Various meetings were held to discuss the purpose of the screening tool and organize it into the workflow of the clinics. A driving force in implementing PEARLS was the financial incentive in being reimbursed for screening for ACEs. Effective January 1, 2020, California introduced an opportunity in which participating providers screening for Adverse Childhood Experiences (ACEs) could receive a reimbursement rate up to $29 for each qualifying ACEs screener (Department of Health Care Services-DHCS, 2019). In order to receive reimbursement, participating providers were required to complete the DHCS training for ACEs screening and trauma-informed care (DHCS, 2019). The translated versions of the screening tool and patient education materials were gathered to meet the language specific needs IDENTIFYING ACES IN A FQHC USING PEARLS 7 of the population. The electronic health record was updated in order to accurately display and account for the PEARLS screening scores. The screening tool was piloted at one clinical site to randomly selected patients of two providers whose patients were between 4 and 18 years of age. It should be noted the screenings completed during the two-week pilot period are not included in the final data or results of this project. The screening tool was launched shortly after the stakeholder meeting at both sites in September 2020. Over the ensuing four months, data was collected, and chart audits were performed. Data and results were reviewed in