Screening for Toxic Stress In The 4 Year Old Child

Introduction: The purpose of this project was to assist an urban clinic in implementing a quality improvement (QI) project to screen 4-year-old children at well child visits for symptoms of toxic stress, and to assist with the development and implementation of a sustainability plan. Problem Statement: Children in the Utah are being exposed to traumatic experiences beginning at a young age. Adverse experiences at a young age can cause permanent changes in brain, and interferes with periods of critical development. Although the field of pediatrics is familiar with the effects of traumatic experiences in children, many primary care providers are failing to screen children for symptoms of toxic stress exposure. Objectives: The specific objectives of this project were to: 1. Provide team leadership in a QI project to implement standardized screening for symptoms of toxic stress in an urban clinic. 2. Develop a QI process for screening 4- year-old children during the well child visit using the Traumatic Experiences Questionnaire. 3. Develop and implement a sustainability plan by March 2015. 4. Evaluate the Project by March 2015 5. Disseminate the information related to this as a poster presentation at a regional pediatric conference. Brief Literature Review: Toxic stress is the result of strong, frequent and/or prolonged responses to adversity in the absence of the buffering protection of a supportive, adult relationship. Toxic stress disrupts the brain circuits and organ and metabolic systems causing anatomic changes and physiologic dysregulations. Children are at higher risk of stress affects due to the plasticity of their developing brains, which makes them sensitive to the lifelong effects of stress. Results of the Adverse Childhood Experiences study indicate that these children are also at an increased risk for poor health as adults. Implementation and Evaluation: I participated as a team leader in implementing a QI project at an urban clinic. The project was conducted in conjunction with the Utah Pediatric Partnership to Improve Healthcare Quality. I attended monthly staff meetings, participated in UPIQ webinars, reported team progress to UPIQ, and in collaboration with the clinic team, I developed a screening process for toxic stress, adapted resources from the American Academy of Pediatrics, including parent handouts on toxic stress. Ongoing evaluation of the project included a monthly chart review. Lastly, I met to discuss the feasibility of standardized screening at the clinic and developed a sustainability plan. Final results were reported to UPIQ and the healthcare team. I then submitted for a poster presentation at the Utah NAPNAP conference. Results: 84 well child visits were completed between September 2014-January 2015 with 72.3% of children screened with the TEQ. Of those screened 13.7% had positive symptoms and experiences with 86.3% having no symptoms or experiences. Conclusions: By screening children at a young age the provider can intervene and refer families to trauma informed resources to lessen the lifelong effects of abuse and toxic stress. I have found that screening for toxic stress at the 4-year-old visit is a feasible task.