FAQ: TRIADS Screening and Response – Questions from Clinicians and their Patients

The main purpose of screening is to help patients understand that difficult life experiences can have negative health effects and that the patients’ strengths and resources can help improve their physical health and wellbeing. The provider’s sincere interest and caring attitude during the process of screening and response helps patients reflect on the possible links between their painful childhood experiences and their current health challenges, which in turn can increase patient motivation to engage in the treatment plan.

This approach is based on the concept that the healthcare provider’s effort to understand the patient’s challenges is more important than the concrete number of ACES in helping patients become motivated to follow their treatment plan. For patients, naming what happened to them is often healing in itself because it relieves them from the burden of painful secrets. Patients can feel relief from shame and guilt when the provider explains that adverse childhood experiences are very common, validates and normalizes the impact of these adversities on physical and emotional health, and highlights the patient’s successes in coping with stress and engaging in self-care. Research shows that an open, supportive provider-patient relationship increases patient positive treatment response, raises provider job satisfaction, and decreases provider burnout.

Members of the healthcare care team are likely to have experienced childhood adversity and trauma because of the high prevalence of these events in the general population. To help providers prevent becoming triggered and engage in self-care, trauma-informed ACES screening and response includes helping providers reflect on their own experiences, how they were affected, and what helps them with their physical and emotional health and wellbeing. Most healthcare providers report that they do not become dysregulated while conducting the screening and responding to their patients. However, the health care team should be offered the choice of whether or not to engage in this role when it is not an integral part of their job description. 

Some possible strategies to decrease screening-related health care team distress include:  

1. Administering the de-identified version of the ACES screener.
   
2. Asking patients to fill out the screener on their own rather than have the staff member read the questions aloud.
   
3. Create sources of support within the clinic, so that colleagues who have screening-response experience are available for debriefing after a team member has a stressful encounter with a patient. 

It is helpful to remember that although the screen-response procedure may cause some discomfort, surveys and research findings consistently show that ACES screening and response is received well by both patients and providers.

This could happen for several different reasons.  For example, the patient may not have understood the instructions, or the patient may want to let the provider know about adverse or traumatic events as a form of asking for help. It is important to give patients the option to respond to the screener as they wish to. The MA may explain that although the instruction is to simply count the total number of ACES, the patient is welcome to circle specific experiences if that is preferred.

Patients may do this for different reasons, such as not understanding the instructions or wishing to reveal what happened to them as a way of getting help.  The provider accepting response opens an opportunity for dialogue. For example, the provider may say, “Mrs. Smith, I noticed that you circled some ACES.  Would you like to talk about them?”  This invitation could Patients may do this for different reasons, such as not understanding the instructions or wishing to reveal what happened to them as a way of getting help.  The provider’s accepting response opens an opportunity for dialogue. For example, the provider may say, “Mr. S., I noticed that you circled some ACES.  Would you like to talk about them?”  This invitation could start a fruitful conversation about the patient’s needs that can in turn inform the treatment plan.

When teens are accompanied by a parent or caregiver, it is important to introduce the ACES  screener with the explanation that this form is administered to all patients as part of the clinic’s standard practice, and that teens are asked to complete the screener on their own to protect their privacy.  This explanation should also include mention of clinic policy regarding confidentiality and the laws regarding mandatory reporting.

Providers increase their patients’ trust when they express respect for patient choice and emphasize patient autonomy. Patients are more likely to follow up on a referral when the provider offers the referral as part of a conversation about the patient’s specific needs and wishes. Individually tailored referrals where the provider explains the reasons for the recommendation are more likely to be successful.  However, patients always have the choice of declining a referral.  When the patient seems hesitant, the provider may comment that the patient can take some time to reflect on different alternatives and that the provider is available to continue thinking with them about what might be most useful to them. The knowledge that the provider continues to be available and supportive of their wellbeing helps patients maintain an open mind about the provider’s recommendation even if they choose not to follow up when it is first offered.

This can happen frequently because traumatic events affect all the members of the family and are often repeated across generations. When caregivers provide information about other family members, they are showing trust in the provider and a need for help.  We can address the patient’s adversity, distress, and strengths while keeping in mind that any information shared by the caregiver about another family member’s experience can help us understand the family context and make better informed recommendations about treatment and referrals. If we only pay attention to one child in a family who is struggling, we might refer to individual therapy.  But if we learn that other members of the family are also struggling, family therapy or therapy for the caregiver might be more useful referrals.  Even in the absence of referrals, a simple empathic acknowledgement that each member of the family has experienced difficult events can start a conversation about what could help as a starting point for later recommendations.