Please find attached my assignment 2. Sorry for the delay.
I think you did a great job explaining the pathophysiologic pathway through which ACEs could lead to adverse health outcomes later in life, and exploring reasons for why your gap exists on the provider level. I wonder if there are also additional factors on the system-level that impede providers from screening for ACEs more widely: as you mentioned last week, there is currently no standardized and validated screening tool, which might add to insecurity among the providers on how to actually screen for ACEs. Are screening tools that are currently used easy and straightforward enough and readily available to be easily and quickly implemented in everyday clinical practice? In addition I'm wondering whether there is evidence showing that screening or intervening on patients with ACEs would lead to better clinical outcomes later in life? If not, this lack of evidence might cause doubt about the effect and usefulness of screening for ACEs among the providers. It's interesting to see that there don't seem to be major barriers on the patient/caregiver-level, as they are generally not opposed to the screening and seem to be comfortable discussing trauma exposure with their provider!
Great analysis, thanks Christine.
It is true that there is no evidence that screening itself would lead to better outcomes. However, screening is seen to the first step for an intervention to impact outcomes. But a great point worth considering in the analysis.
As of the screening tool itself, there is no standardized validated one. Providers are using different ones, and the Center for Youth Wellness has made its ACEs screening tool available to pediatricians for free to download and use.
More to come...
I agree with Christine - you do a great job of describing the pathophysiology in a way that is convincing and builds the case for intervention.
Something that I am not used to as a non-pediatrician is how to navigate patient / caregiver / physician dynamics, and I think that you could clarify your description for outsiders like me! From what I understand, you are concerned about ACEs among children and you have evidence that suggests that their caregivers are open to screening. Can that create difficult situations, depending on the potential role of the caregiver in the adverse event? An associated question is how asking about previous ACEs is different than screening for current child abuse and neglect. I looked at the initial Kaiser study that you mentioned, and it seemed that they were screening adults about their childhood experiences, not asking children and their children about something that is either recent or ongoing.
In terms of the models, I thought that it was very appropriate that you used the COM-B model from the provider's perspective. In the setting of short appointments and many acute needs in primary care, it can be very helpful to have screening become either automated or performed by other caregivers. Something else you could think of would be to work with a small number of practices to try out the screening in a protocolized using medical assistants, and then if it works, use diffusion of innovations to try to spread use of not just your validated questionnaire, but all of the practice improvements that go with it.
Hi Kevin,
Thank you for your insightful feedback. As the science is emerging, providers are understanding now that many of the conditions in adulthood have their roots in childhood. The idea is that something can be done if things are caught early (primary and secondary prevention). Screening for ACEs differs from the conventional neglect and abuse screening in that it covers a broader range of adversities. Catching those early enough would allow providers to intervene not only with intervention, but also to prevent further exposure with anticipatory guidance. As adversities can occur as early as in-utero, caregivers are in the position of knowing and reporting for their children.
For your suggestion of starting small, I think it is a great idea. That is what the Center for Youth Wellness has just engaged in. The center started a project to select and train a number of sites to start implementing screening. Those sites will then recruit and train more sites and we get all pediatric primary care settings to screen.
I Like the COM-B analysis as well; though I might need to revise it.
Kadi
Hi Kadia,
I think you are progressing in the right direction with your gap. I think Christine and Kevin brought up some really strong points in their comments. I would encourage you to continue to look at evidence for assessing at specific ages. I think you should start thinking about how you would like to address this issue and what would be the best approach. Maybe providing the questionnaires in the waiting room that can be reviewed and flagged by the MA's if there appears to be evidence of ACEs? So many different methods to come at this from. I know there is not a lot of evidence for ACEs specifically but are there other childhood psychological tests/screening protocols that are in place? Might be a good place to start to get a better idea of what to focus your gap on.