Background & Aims
This study aims to review the quality improvement process and clinical pathway our pediatric pain clinic team developed to screen for Adverse Childhood Experiences (ACEs). This exploratory study will reviews the steps taken to implement the clinical pathway, and its impact on overall clinical care.
ACEs are potentially traumatic events that happen in a child’s life between the ages of 0-17. Epidemiological research on ACEs and toxic stress has demonstrated a profound link between ACEs and chronic health problems(1-4). Moreover, current literature also indicates a meaningful relationship between ACEs exposure and development of chronic pain conditions in youth (5-13). Thus, to develop effective treatment plans, pain providers should be sensitive to a patient’s trauma exposure and identify gaps in a patient’s access to resources. For effective ACEs screening, providers and staff should be trained in the language and practice of trauma-informed care(14-17).
Methods
To train providers effectively, the UCSF pediatric pain clinic developed a clinical pathway that involves mandatory participation in trauma-informed care education and skills practice prior to implementation of ACEs screening. All staff completed the Becoming ACEs Aware in California Core Training online(18) and attended annual maintenance meetings. Additional targeted education on vicarious trauma, diversity and inclusion, and conflict de-escalation was available to staff. Following initial training, we implemented a structured workflow for screening, and an algorithm for clinical responses to the information collected. New pediatric patients were screened in-person using the Pediatric ACEs and Related Life Events Screener (PEARLS)(19), one for the parent and one for patients 12 and older.
Results
This study reviews the medical records of these patients between 2021-2023 and will examine aggregate data on ACE total scores reported, demographic information, related pain diagnoses, and the types of follow-up conducted by social work or nursing. Reasons for failed screenings will also be reported. Of 107 patient encounters that met screening criteria during the study period, 79 (74%) had at least one PEARLS questionnaire administered. Spanish language PEARLS were used in 9/79 (11%) encounters, and the remainder used English language PEARLS. Among patient-completed screeners, 24% reported no ACEs, 32% reported 1-2 ACEs, and 44% reported 3+ ACEs. Among parent-completed screeners, 3329% reported no ACEs, 27% reported 1-2 ACEs, and 44% reported 3+ ACEs. Of 20 encounters where parents reported 0 ACEs for patients 12 or older, there were 8 (40%) in which patients reported at least one ACE. In at least two cases, PEARLS identified previously undisclosed cases of abuse.
Conclusions
ACE screening using a trauma-informed approach is feasible in a pediatric pain clinic using PEARLS. The majority of patient encounters resulted in successful ACE screening. Clinically significant ACEs were present in the majority of new patients screened. Use of PEARLS identified instances of ACE exposure in pediatric patients whose parents reported no patient ACE exposures, and identified previously undisclosed ACEs that warranted a change in care plans.
References
1 Center for Disease Control and Prevention, Press Release (2019). Preventing Adverse Childhood Experiences (ACEs) to Improve U.S. Health. Retrieved from https://www.cdc.gov/media/releases/2019/p1105-prevent-aces.html
2 Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., …Marks, J.S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245-58.
3 Flaherty, E. G., Thompson, R., Dubowitz, H., Harvey, E. M., English, D. J., Proctor, L. J., & Runyan, D. K. (2013). Adverse childhood experiences and child health in early adolescence. JAMA pediatrics, 167(7), 622–629. https://doi.org/10.1001/jamapediatrics.2013.22
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5Abrahamyan, A., Lucas, R., Soares, S., Talih, M., & Fraga, S. (2022). Adverse childhood experiences and bodily pain at 10 years of age: Findings from the Generation XXI cohort. Child Abuse & Neglect, 128, 105620.
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8Nelson, S., Bento, S., & Enlow, M. B. (2021). Biomarkers of Allostatic Load as Correlates of Impairment in Youth with Chronic Pain: An Initial Investigation. Children, 8(8), 709.
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13Nelson, S., Smith, K., Sethna, N., & Logan, D. (2019). Youth with chronic pain and a history of adverse childhood experiences in the context of multidisciplinary pain rehabilitation. The Clinical journal of pain, 35(5), 420-427.
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18Becoming ACEs Aware in California. Retrieved from https://training.acesaware.org/aa/
19Koita K, Long D, Hessler D, Benson M, Daley K, Bucci M, Thakur N, & Burke Harris N (2018). Development and implementation of a pediatric adverse childhood experiences (ACEs) and other determinants of health questionnaire in the pediatric medical home: A pilot study. PLOS ONE, 13(12), e0208088. 10.1371/journal.pone.0208088
Presenting Author
William Bernal
Poster Authors
Topics
- Racial/Ethnic/Economic Differences/Disparities