Questions from the Health Care Team
All of our patients have 4+ Adverse Childhood Experiences (ACEs), so why screen?
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.
What do I do if a healthcare team member is ‘triggered’ by the screening?
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:
- Administering the de-identified version of the ACES screener.
- Asking patients to fill out the screener on their own rather than have the staff member read the questions aloud.
- 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.
A patient circles items on a de-identified screen, what should the Medical Assistant (MA) or person introducing the screener do?
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.
A patient has self-identified particular ACEs on a de-identified screener, what should the provider do?
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.
How to address a caregiver of a teen? And give teen privacy to answer?
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.
What do you do if a patient decides they do not want a referral, or does not follow up on an agreed upon referral?
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.
A caregiver starts talking about their own history of trauma or that of another family member during a child’s screen or an adult patient talks about their child’s trauma during an adult screen – what does the provider do?
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.
Questions from Patients
Does what happened to me before affect my health now during pregnancy?
Pregnancy is often a time of increased openness to increased self-understanding as parents-to-be prepare for their role as parents of a new baby. Pregnant patients routinely report increased health concerns about themselves and their unborn baby. The provider’s empathic listening and specific information in response to the patient’s concerns can be enormously helpful in making patients feel heard and supported. Adversity and trauma are often transmitted from one generation to the next, and prenatal care offers a valuable setting to interrupt this intergeneration cycle by speaking with the patient about possible links between childhood experiences and current health and emotional challenges. Providers can name and highlight parental strengths that promote the parent-baby bond (e.g., “I really hear your excitement about having your baby, and how much you want to help your baby be healthy and happy”), normalize worries the patient may have (e.g., “I hear your concern; this is something that many of my pregnant patients experience”), and offer developmental guidance as well as access to resources tailored to the patient’s concerns.
I’m a foster parent, but I don’t know if my foster child has had any experiences on the PEARLS. How can I help them?
Foster parents frequently express frustration about not knowing specific events in the lives of the children placed in their care. This is a valuable opportunity to acknowledge to the foster parents that some form of parental maltreatment must have occurred that led to the child’s removal from the biological parents.
Providers can encourage foster parents to answer the questions they know while also empathizing with their wish to know more about the child’s experiences. Providers can promote greater understanding of the child by offering developmental guidance, including the information that maltreated children and children separated from their parents show their distress through somatic complaints, problems eating and sleeping, and displays of strong emotion such as anger, sadness, withdrawal, defiance, and aggression. This conversation can be followed by the offer of resources and referrals, as well as by encouraging the foster parent to understand the child’s challenging behaviors as likely responses to the fear and confusion that the child experienced both prior to placement and as a result of separation from the parents.