New Jersey has seen ever increasing interest in Adverse Childhood Experiences (ACEs) and the important role that they play in the lives of children and parents.Three major NJ foundations,The Nicholson Foundation,The Burke Foundation, and Turrell Fund developed the NJ Funders ACEs Collaborative to systematically explore the opportunities to prevent, protect, and heal from the effects of ACEs in New Jersey. A major outcome of this work was the establishment of an Office of Resilience that is funded by the three foundations and resides in but not of the NJ Department of Children and Families. Publication of their efforts in 2019 listed five core strategies for NJ that include 1) Supporting parents and caregivers; 2) Providing training and professional development in trauma-informed care; 3) Promoting community awareness of ACEs; 4) Advancing policies and practices that help children and families thrive; and 5) Collecting, analyzing, and sharing data and findings from research and practice.
NJAAP has been working for a number of years on prevention and early detection of child abuse and neglect. The focus on ACEs has expanded that work and recognizes the prevalence of childhood ACEs and the potential damaging impact it has during childhood and extending into the adult years. The recognition that over 25% of children and adults have experienced more than 2 separate adverse experiences has led to a national movement to train physicians and health care workers to become trauma informed; to make an effort to ensure the patient care environment is a safe place for children and families; and to ask ‘what happened to you’, rather than ‘what’s wrong with you’.
This awareness has also led to well-intentioned efforts to regularly screen for ACEs in health care settings. The original 10 question ACE survey that was developed and used by researchers at Kaiser Permanente that led to the epidemiologic findings of ACE prevalence and their correlation with multiple adult behavioral, mental health and physical disorders has been touted as an actual screening tool ready for use in clinical practice. California has led the way and made screening a state wide initiative. And there are a few publications that show that such screening can be useful and reproducible.
The original questions, however, were never intended for generalized screening.The questions do not ask about extent of the adverse experience, age at onset, duration, or intensity. There are many other adverse experiences in addition to the family centric focus of the ACE survey.There is no evidence that a particular score should serve as a pass or fail mark and there are no established steps that a clinician should take based on a certain score. One recent study, not unexpectedly, showed that a history of sexual abuse was weighted much more damaging than the other ACE histories.
So where does this all fit with the many ‘shoulds’ that pediatricians are being asked to add to their clinical priorities. Although asking ACE questions to families is not yet a tool that yields a score and actionable steps, asking about trauma allows
for a more complete understanding of the child and family. It allows clinicians to explore family stress and resilience factors and helps understand the multi-generational involvement of ACEs. Exploring such history also reinforces on a daily basis the prevalence of trauma in the lives of children of all backgrounds, all socio-economic classes and all ethnic and racial groups.
All of this leads back to the value of pediatric practices to be trauma informed and the importance of training staff and physicians on these principles: a safe place, transparency, staff support, empowering families, culturally responsive and strengths-based.