P0038 - Barriers to Implementing Adverse Childhood Experience (ACEs) Screening in an Urban Primary Care Clinic

Background: Adverse Childhood Experiences (ACEs) are a recognized childhood epidemic, affecting approximately 34 million children nationally and increasing risk for negative health, behavioral, and developmental outcomes. Pediatricians are uniquely positioned to engage in conversations with families about childhood adversity and toxic stress, and universal ACEs screening can help eliminate selection bias in addressing this topic with families. Several barriers exist in implementing ACEs screening however, leading to questions on how to best incorporate the screen into practice.

Purpose: Implement a child and parental ACEs screen in a primary care clinic. Identify barriers to screening completion and strategies to increase screening rates.

Methods: A 17-item parent/child ACEs screen was adapted from the Center for Youth Wellness Questionnaire. Screenings were completed from May 2018 to July 2019 at a community health center in Washington, D.C. Screens were administered to caregivers at 6, 12, 24, and 36 month well visits. A quality improvement project was implemented to improve low screening rates. PDSA cycles focused on obtaining feedback from providers and clinic leadership, modifying the ACEs screen to include resiliency measures, and adjustments to the electronic health record to facilitate data entry.

Results: After 14 months, 524 people were screened. The average ACEs screening completion rate was 28% with 34% of children and 60% of parents experiencing at least one ACE. Rates of completion did not change significantly after several PDSA cycles. The majority of providers surveyed (78%, n=7) did not feel ACEs screening had a positive impact on patients. They identified time constraints, work flow issues, screen complexity, fear of re-traumatization, lack of resources, and poor ACEs understanding amongst caregivers as barriers to ACEs screening.

Conclusion: Several challenges exist with new universal ACEs screening implementation. Given the sensitive nature of the topic, a trauma-informed system is required for successful implementation. Key stakeholder buy-in that includes parent, staff, provider, and IT support with a clear referral process can improve screening completion and documentation, leading to increased recognition of individual patient risk.