| Description |
Background: Adverse childhood experiences (ACEs) are negative experiences that occur in children between 0 and 17 years old and include domestic violence, physical, mental, emotional, and sexual child abuse, neglect, drug use and abuse, incarceration of a family member, and the death of a loved one (CDC, 2024; Filletti et al., 1998). Unrecognized and unaddressed ACEs increase the likelihood of chronic health conditions later in adulthood, such as obesity, diabetes, heart disease, hypertension, cancer, and early death (Gilgoff et al., 2020; Sherfinski et al., 2021; Dube, 2020). Local Problem: In a pediatric emergency department (ED), only patients who have experienced a physically traumatic event are screened for post-traumatic stress disorder (PTSD). This practice accounts for approximately 10-20% of the patients in this ED. This ED currently screens every patient for physical and sexual abuse and neglect, only three of the known ACEs. Therefore, many patients who would benefit from ACEs and PTSD screening are not screened for or receiving the support and resources needed. Methods: This needs assessment aimed at assessing the feasibility and usability of integrating a validated ACEs screening tool into the ED workflow for every patient seen in the pediatric ED. Interventions: Key stakeholders were engaged in planning and designing the needs assessment. A 3-month retrospective chart review was performed on pediatric patients seen by this ED's trauma team to assess the current workflow, policies, and procedures and screened patient characteristics. A survey of ED staff was conducted to assess their knowledge, understanding, and ability to screen for ACEs. A SWOT analysis of the current workflow, policies, and potential ACEs screening tool integration was conducted. Benchmarking was performed. Results: The retrospective chart review revealed 59 patients screened, 13.5% (n=8) requiring a second assessment, and one patient (1.6%) was referred to mental health services. We surveyed 75 ED staff members. Common barriers included a lack of training (27%, n=7) and discomfort discussing ACEs (27%, n=7). Advocacy for patients (81%, n=21) and the hospital's philosophy of "The child first and always" (81%, n=21) were the most common facilitators. Benchmarking revealed that none of the four children's hospitals in Texas, Washington, California, and Philadelphia actively screen for ACEs in their ED. California is ahead of every state in screening (ACEs Aware, 2025) and legislation requiring insurance companies to reimburse for ACEs screening (CA SB428). This could be an area of interest for future research and quality improvement (QI) projects. A SWOT (strengths, weakness, opportunities, and threats) analysis was performed. The strengths of this project are that the trauma team is already screening traumatically injured patients for PTSD, and this ED is screening for physical and sexual abuse and neglect. Adding additional screening for the other ACEs is both feasible and reasonable. Conclusion: ACEs are physical, mental, and emotional wounds unique to this population. They are challenging to see and even more difficult to address. The pediatrician's office is a good place to start screening but is not the only place to address ACEs. We demonstrated that screening for ACEs is feasible and inexpensive, and staff feel it is "appropriate" (73%, n=19) and "beneficial" (80.7%, n=21). Before screening is implemented, resources and referral options need to be developed. Additionally, QI projects related to resources, implementation, and monitoring are needed. |
