By Andrew J. Barnes, MD, MPH, Assistant Professor, Developmental-Behavioral Pediatrics, Division of General Pediatrics and Adolescent Health, University of Minnesota and Tom Scott, MD, Clinical Professor, Developmental-Behavioral Pediatrics, Division of General Pediatrics and Adolescent Health, University of Minnesota
Although there are normative challenges during childhood – for example, separating from parents for daycare – many children experience frequent or ongoing stress that is overwhelming. Such stress, including Adverse Childhood Experiences (ACEs) and extreme poverty, can lead to modified gene expression, problems with cognitive and social-emotional development, and chronic health conditions. These negative outcomes are less likely for children with ample protective factors, whether internal (such as self-regulation) or external (such as a consistent, nurturing adult caregiver). These factors improve children’s capacity to succeed and develop well in the context of threat or challenge – i.e., resilience.
Recognizing this, the AAP’s 2006 policy statement on developmental-behavioral screening and surveillance in the medical home recommends that clinicians identify risk and protective factors for all children and families in their care. However, in a 2013 survey, one-third of AAP members never inquired about these factors; of those who usually did inquire, most did so only for maternal depression or parental separation. Other common ACEs — such as parental alcohol/drug use, domestic violence, and parental incarceration – were rarely screened for or discussed. Indeed, to date there is scant evidence about how and when to best do so.
As we await such evidence and further guidance, there are several tools that pediatric clinics can use right now to fully implement the AAP’s recommendations. One such tool, the Family Psychosocial Screen, is available for free from AAP Bright Futures (http://brightfutures.org/mentalhealth/pdf/professionals/ped_intake_form.pdf). This 2-page form includes home safety, parent depression, substance abuse, domestic violence, parent abuse history, socioeconomic factors, and social supports.
Another free tool, the Survey of Well-Being for Young Children (http://theSWYC.org), is a one-page broadband developmental-behavioral screen for children 0 to 5 that includes brief, well-validated psychosocial screening measures for parent depression, substance abuse, food insecurity, and domestic abuse.
Some primary care clinics are beginning to adapt the original 10-item ACEs questionnaires (for children and their parents), administered either anonymously (i.e., parents tally their own score, 0-10, and report only the total score to the clinician), by interview, or on paper; a cut-off score of 4 is usually recommended for referral, based on the initial ACEs studies among adults. The AAP clinical report, Promoting Optimal Development: Screening for Behavioral and Emotional Problems (2015), includes an ACE screening resource, as well as a Resilience scale that can help clinicians provide effective parent education and anticipatory guidance in primary care settings — both of particular interest to pediatricians developing this emerging and highly important area of clinical practice (both screens available at http://acestoohigh.com/got-your-ace-score).
As pediatric clinicians we are well positioned to sensitively ask about risk and protective factors for the children we serve – whether with a formal screening tool, routine surveillance, or (ideally) both. Doing so enables us to prevent harm and promote health by reinforcing current areas of strength and resilience; bolstering protective factors that are limited or absent; and reducing risk through intervention when needed.
