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The ISF Blog

Pediatric providers discuss how and when they want to know about ACEs

Martha's picture
Written by Martha
Published on 2/18/2013

By Anndee Hochman

Do you ever have nightmares? What’s different for you since Mommy and Daddy got divorced? Do you feel safe at school? What happens when you misbehave?

In an ideal world of health care for children, questions like these would be routine, as commonplace as asking about whether a family has pets, guns or cigarette smokers in the house. And the answers would cue pediatricians about stresses—at home, at school, in the neighborhood—that can have enormous impact on their patients’ well-being.
 
Past and ongoing studies of—Adverse Childhood Experiences (ACEs)—have driven home a stark conclusion: abuse and neglect, as well as other significant negative life experiences, shape the way children learn, play and grow. Emerging developmental science is showing that repeated trauma re-wires the brain. Stress can make you sick. What happens at home absolutely affects your health.
 
At a January meeting of the Philadelphia ACE Task Force, a citywide group of pediatricians, nurse practitioners, mental health professionals, scholars, and other community members convened and led by the Institute For Safe Families, discussed how to bring their understanding of ACEs into practice: What questions do pediatricians ask, or should they ask, to learn about sources of stress in their patients’ lives? What are the barriers to finding out about ACEs? And if providers do learn that something disturbing is happening in a child’s life, what can they do about it?
 
Practitioners agreed that childhood trauma should not be a secret. “We need to talk about ACEs and bring these issues out of the closet,” said Maria D. McColgan, assistant professor of pediatrics and emergency medicine at St. Christopher’s Hospital for Children and director of the hospital’s child protection program.
 
Some pediatricians said that while they may not ask direct questions about ACEs, they will go “through the back door,” engaging children and caregivers in discussions about sleep, eating habits and discipline. “I might say [to a child], ‘Who do you sleep with? Would you like to sleep alone? Do you have scary dreams?’…Sometimes I will say [to the parent and child], ‘I’d like to see you both separately,’” said Beth Rezet, a pediatrician at Children’s Hospital of Philadelphia.
 
Task Force members agreed that they must walk a delicate line, learning about possible stresses in children’s lives while building trust and rapport with their adult caregivers. Parents may fear that disclosing trouble at home—family violence, an incarcerated adult, mental illness—will put them at risk of losing their children to protective custody.
 
And what if parents or patients do tell pediatricians what’s really happening? Several members of the Philadelphia ACE Task Force said they hesitate to ask about family violence, substance abuse or other at-home stresses when referrals or follow-up care are not readily available. Others noted that doctors, eager to “fix” what’s wrong, may shy away from probing into areas where there are no quick remedies or easy answers.
 
Ideally, they said, pediatric care settings would include a behavioral health specialist, and behavioral assessments would be part of every visit. Ingre Walters, assistant professor of psychiatry and behavioral science at Temple University School of Medicine, said that a psychiatrist “embedded” in every pediatric office could provide support to parents who are suffering from depression or post-traumatic stress, as well as to their children.

 

“I think that’s going to take a re-conceptualization of what we do in childhood care. And that’s going to take an inter-generational change in medical education.”

Lee Pachter, Chief of Pediatrics at St. Christopher’s Hospital for Children and a professor of pediatrics at Drexel University College of Medicine

 

“I think that’s going to take a re-conceptualization of what we do in childhood care,” said Lee Pachter, chief of pediatrics at St. Christopher’s Hospital for Children and a professor of pediatrics at Drexel University College of Medicine. “And that’s going to take an inter-generational change in medical education.”
 
“We have to change the model of pediatric care to emphasize the importance of psycho-social factors,” agreed Esther Chung, professor of pediatrics at Jefferson Medical College and Nemours. “I always remind students and residents who ask ‘why am I doing the job of a social worker?’ that it is their job as doctors to understand the psychosocial factors that impact their patient’s health and health behaviors.”
 
Study of ACEs and their impact on health should be part of medical and nursing education beginning in undergraduate courses, some Task Force members said. They also suggested public policy changes—such as Medicaid reimbursement for ACEs screening and referrals—that would make such screening more viable.
 
“But policy changes are just one piece of the ACEs equation,” said Joel Fein, Attending Physician at The Children’s Hospital of Philadelphia. Every day, pediatricians have a chance to practice what they’ve learned about childhood trauma. Every child in the waiting room has a family story that may write the course of his or her future health.
 
“The underlying theme is: How do we prevent this from happening in the next generation?” asked Maria McColgan. “That is the ultimate goal. If you know what the ACEs are going into this generation, [the aim is] to halt that and keep it from continuing.”