Improving health outcomes for children requires us to look at the big picture


It was a simple chief complaint: sore throat and fever. As expected, the little girl’s rapid Strep was positive. Instructions given. Antibiotics sent. This was Peds 101. But for some reason, before mom walked out the door, she made mention of their stay at the shelter.

Although I had seen this child many times before, somehow, I never knew that she was homeless. Nothing in my detailed history and exam had ever provided this seemingly crucial yet basic piece of information.

I pride myself on having an intimate relationship with my families. I know the names of their siblings. I remember the schools they attend. I often learn that my teens are having sex well before their parents ever find out. Yet, I did not know this significant detail of this family’s life; they had no place to live.

I became even more acutely aware of my medical tunnel vision on another instance. A mom came in with her seven-year-old son. She was very frustrated.  She was receiving calls from his teachers constantly about his behavior; disruptive, unfocused, aggressive, and even defiant are words teachers used to describe his behavior. The constant calls placed her at risk of losing her job, and she was overwhelmed by his behavior at home. She believed the only remedy was a pill. As had become my custom, I asked mom to visit with our behavioral health counselors.

A few days later, our counselor came into my office to discuss her assessment of this seven year old. As we talked about his symptoms, she said, “You do know that this child saw his father shot and killed when he was two years old?”  My eyes met hers with horror and confusion. I had no idea this child had a history of significant trauma. How could I not know this? Undoubtedly, the symptoms this child had were the result of post-traumatic stress disorder, not attention deficit hyperactivity disorder.

Upon reflection of these encounters, I realized that even if I followed all the standard protocols taught to me in medical school and residency, there was no way for me to know this boy’s trauma history or this girl’s housing status. The who, what when, where, and for how long questions of a standard medical history would never lead me to this end. Although I spend most of my time with patients discussing vaccinations, nutrition, and anticipatory guidance, the social determinants of health will be the factors that truly determine my patients’ long-term morbidity and mortality. Adverse childhood experiences (ACEs) are strong predictors of child and adult health outcomes.

In the past several months, my office began ACE screening. The process has been enlightening for both me and my families. I now get a better understanding of my patients’ trauma histories. The process also gives me an opportunity to inform parents about their own power to heal. Consistent, nurturing caretakers foster resilience and limit the toxicity caused by ACEs.

Starting the ACE screening took a bit of prep work. Families were already completing between 5 to 9 pages of paperwork at every well-child check-up: developmental screenings, social-emotional screenings, autism screenings, post-partum depression screenings, and high-risk behavior screenings. While I knew that all these screenings were valuable, I also knew that I had to limit parent paperwork to provide leeway for parents to complete the ACE screening.  So, for children less than six years old, I switched to the survey of the well-being of young children (SWYC), created by the Floating Hospital for Children at Tufts Medical Center. The SWYC is only two pages and includes mini versions of recommended age-appropriate screenings. Inclusion of this brief screen in lieu of the lengthier screens meant that parents were more likely to complete the ACE screening.

Inclusion of the ACE screening has been a rewarding addition to our practice. I feel more informed about the families I serve. I can also provide them vital information and services. As I talk to families about the consequences of a high ACE score, many families respond with a knowing nod, acknowledging the role of ACEs in their own lives. This is often followed by a brief look of despair that seems to betray their best attempts at stoicism. Finally, as I remind them of their power as parents to promote resilience, parents inevitably smile and draw their children closer to them. At that moment, I have a chance to offer healing resources that have a much longer half-life than any pill.

I encourage all providers caring for children 18 years and younger to administer the ACE questionnaire. A child-specific modified version of the questionnaire, CYW-ACE Q, is available via free download through the Center for Youth Wellness. Inclusion of the ACE screening in the care of your patients will allow you to provide more holistic care for your patients and improve their chances of having a healthy future.

Khadijia Tribie is a pediatrician.

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