Screening and Case Finding for Adverse Childhood Experiences

Annie Lewis-O’Connor, PhD, NP-BC, MPH; Nadine Burke-Harris, MD, MPH; and Susan McCormick-Hadley, PhD, MPH

Incidence and prevalence studies show a strong correlation between ACEs and long-term health outcomes.1 Screening and case finding for ACEs, which are designed to uncover past experiences of child maltreatment and other major stressors that occur in childhood, may provide opportunities for intervention and support that may otherwise be overlooked or misinformed. Data from the ACE Study and similar research suggests that one important way to help understand an adult’s health is to understand their ACEs exposure.

The ACE score is the total number of categories from a list of 10 major adverse experiences during childhood and adolescence selected by the ACE Study co-investigators. Identifying these exposures during a healthcare visit also enables health providers to consider the impact and context of these exposures upon the patient’s current health as well as offering affirmation and an informed plan of care.

Screening or case finding for ACEs requires a change in practice and redefines how a healthcare provider takes a health history from patients. There are a number of promising programs worth highlighting. These programs incorporate screening for the 10 ACEs included in the ACE Study:

(1) emotional/psychological abuse

(2) physical abuse

(3) sexual abuse

(4) emotional neglect

(5) physical neglect

(6) mother treated violently

(7) household substance abuse

(8) household mental illness

(9) growing up in a home with only one biological parent

(10) growing up in a home where there was an incarcerated household member

Other significant childhood stressors are included in some of the newer instruments to assess major childhood stress, such as the Childhood Trust Events Survey (CTES), which is available for different age groups and respondents on the Childhood Trust website

The Center for Youth Wellness in San Francisco, founded and directed by Nadine Burke Harris, MD, MPH, is incorporating ACEs into the assessment and care of children from mostly low socioeconomic status families.2 A retrospective chart review of 701 children with a mean age of 8.1 was conducted. Documentation of ACEs were coded using prior ACE criterion of a score of 1 for each category of traumatic event (range 0-9). The majority of subjects (67.2%, N=471) had experienced 1 or more categories of ACEs and 12% (N=84) had experienced 4 or more ACEs.  Increased ACE scores strongly correlated with increased risk for learning/behavioral requirements and obesity. Early detection may promote earlier interventions and may improve outcomes.

In a another section of this online document  R. J. Gillespie and Terri Petersen describe the approach used in their Portland, Oregon primary care pediatric practice to screen new parents for both ACEs and resilience factors.  They report that this screening does not significantly diminish the productivity of their practice and is well accepted by parents and providers who believe it improves the quality of their care. 

Researchers are also finding that events that occur during pregnancy (low-birthweight babies, pre-eclampsia and gestational diabetes) pose risks to an adult’s health later in life. Inquiry related to the women’s reproductive years along with ACEs are important components for a comprehensive past medical history.3,4 The public health department in Port Townsend, WA, has incorporated ACEs screening into their family services, particularly asking pregnant women about their exposures. Screening for ACEs is now incorporated into assessments for all pregnant women in this clinic. Here is an assessment of a group of clients.

Annie Lewis-O’Connor NP, PHD, MPH, founder and director of the Women’s C.A.R.E Clinic - Coordinated Approach to Recovery and Empowerment, a clinic for women who have experienced gender-based violence in the context of intimate partner violence and sexual assault, reports that assessing for ACEs has been helpful for developing a more informed plan of care for these patients. Before implementing ACEs screening, these care plans were often based on a single event of violence and failed to consider the broader context of the patients’ other traumatic life experiences, resulting in less well-informed treatment plans. Using a quality improvement approach with ACEs as a quality measure, O’Connor found that 72% of the patients had at least one ACE and 23% had four ACEs.

Vincent Felitti, MD, co-investigator of the ACE Study, is currently working on the first version of the North American Health Index (NAHI). NAHI will be a uniquely comprehensive, Internet-based medical history questionnaire that patients can fill out and give to their provider. It contains biomedical, psychological, occupational, developmental, family, and trauma-oriented components. Such tools and approaches seek to transform healthcare from symptom-reactive to a more individualized and contextualized approach to clinical practice.

Approaches to Screening and Case Finding

Computerized questionnaires emerged in the 1990s as means of assessing a patient’s health history, medication history, and sexual and HIV risk history.5,6,7,8  There has been much exploration of screening approaches relative to intimate partner violence (IPV). This body of literature can serve to inform us as we think about screening for ACEs. MacMillan and colleagues found in a randomized control trial that prevalence rates for IPV were dependent on the method used, the healthcare setting, and the instrument used. Specifically, a significant interaction between method and instrument was found: Prevalence was lower on the written instrument. The face-to-face approach was least preferred by participants.9 Lewis-O’Connor found similar findings in a pediatric setting. Mothers preferred the tablet format over the paper/pencil and face-to-face format. The questionnaire was completed during the visit and took 9 to 11 minutes to complete.10

In an emergency department study, comparing face-to-face interviews to tape recorded questionnaire with responses recorded on an answer sheet, no significant differences existed between the two methods of screening.11 Bair-Merritt and colleagues used a randomized clinical trial in a pediatric emergency department and found that 50 of 497 (10%) participants reported IPV, 30 of 266 (11%) in the audiotape group, and 20 of 231 (9%) in the written questionnaire group (p=.30). Women in both groups preferred their given method over the idea of directly being asked.12 These results support use of the alternative methods studied as an alternative to direct questioning in that the indirect method yielded similar levels of disclosure and was preferred by some patients. Methods such as computer-based interviews and questionnaires appear reasonable for clinical use. Additional evaluation through quality improvement efforts and research is warranted. 

Ghandour and colleagues recently proposed a vision of universal screening and intervention for intimate partner violence that occurs routinely as part of comprehensive physical and behavioral health services that are both patient centered and trauma informed.13 Similarly, collecting information about exposures to ACEs offers an opportunity to develop a plan of care for patients that is better informed, provides more context in relation to the patients’ health histories, and strives to improve health outcomes and patient satisfaction. Best-practice guidelines for screening and case findings regarding ACEs and other toxic stressors are evolving. To date, there is no well researched, standardized and validated questionnaire that includes the original ACEs and other major stressors that subsequent research finds similarly associated with long-term health and behavioral impairment.  In assessing for ACEs, providers may use face-to-face, computer-based or questionnaires. These kinds of inquiries appear well tolerated and appreciated by many patients. Some healthcare providers such as those cited above have integrated ACEs screening or case finding into their practice and have found this information helpful for care planning. More research is needed to determine if identifying and addressing ACEs earlier in life will affect health outcomes. 

References and Resources

1.  Felitti VJ, Anda RF, Nordenberg D, et al. 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 1998;14:245–58.

2.  Burke N, Hellman J, Scott B, et al. The impact of adverse childhood experiences on an urban pediatric population. Child Abuse & Neglect. 2011:408-13.

3.  Rich-Edwards JW. Reproductive health as a sentinel of chronic disease in women. Women's Health. 2009;5:101–5

4.  Rich-Edwards JW, McElrath TF, Thomas F, et al. Breathing Life Into the Lifecourse Approach: Pregnancy History and Cardiovascular Disease in Women. Hypertension. 2010;56:331-334.

5.  DeLeo J, Pucino F, Calis K, et al. (1993). Patient-interactive computer system for obtaining medication histories. American Journal Hospital Pharmacies. 1993;50:2348-54.

6.  Locke S, Kowaloff H, Hoff R, et al. Computer-based interview for screening blood donors for risk of HIV transmission. JAMA. 1992;268:1301-6.

7.  Paperny D, Aono J, Lehman R, et al. Computer assisted detection and intervention in adolescent high-risk health behaviors. Journal Pediatrics. 1990;116:456-61.

8.  Schneider D, Taylor E, Prater L, and Wright M. Risk assessment for HIV infection: Validation study of a computer-assisted preliminary screen. AIDS Education Prevention 1991;3:215-9.

9.  MacMillan HL, Wathen N, Jamieson E, et al. Approaches to screening for intimate partner violence in health care settings: a randomized trial. JAMA. 2006;296(5):530-6.

10.  Lewis-O’Connor A.  Screening Mothers for IPV During their child’s pediatric visit. Doctoral Dissertation. Boston College.

11.  Furbee P, Sikora R, Williams J and Derks S. Comparison of domestic violence screening methods: A pilot study. Ann Emerg Med. 1998;31:495-501.

12. Bair-Merritt M, Feudtner C, Mollen C, et al. Screening for intimate partner violence using an audiotape questionnaire: a randomized clinical trial in a pediatric emergency department. Arch Pediatr and Adolesc Med. 2006;160:311-6.

13. Ghandour, R., Campbell, J., & Lloyd, J. Screening and counseling for intimate partner violence: a vision for the future. Journal of Women’s Health. 2015; 24(1):57-61.

© 2015 by Academy on Violence and Abuse