Table 6.

Case 4: Elizabeth and Gary - Easy to miss ACES.

Assessment	Gary is an 18-month-old male with weight-for-length > 95th percentile and possible speech delay. There are no obvious risk factors for obesity or speech delay.
Actionable Steps	Medical Assessment: Screen every patient with obesity for ACEs and home environmental safety
	1)SEEK (Safe Environment for Every Kid) Questionnaire [53]: screens for parental depression, parental substance abuse, major parental stress, intimate partner or domestic violence, food insecurity and harsh punishment
	2)Screen for ACEs
	3)Perform screenings for early identification of mental health and medical issues
	4)Use the electronic medical record to document and share screenings and other medical information
Additional History & Discharge Plan	•Elizabeth answered “yes” on the SEEK Questionnaire for symptoms of parental stress, parental depression and intimate partner violence. She explains that she is still breastfeeding Gary, but it consumes much of her time. Among other things, she and Gary's father disagreed about when to wean. For years, disagreements often became violent but worsened with the pregnancy which prompted Elizabeth to seek divorce.
	•She has utilized toddler milk and sometimes juice in an effort to wean Gary from the breast as she is not able to keep up with the demands of work, household chores and caring for Gary on her own.
	•During anticipatory guidance, you attempt to reassure Elizabeth that if Gary is eating table food, then it's okay for him to have milk with meals and water the rest of the day. Try to limit juice to 4 oz/day.
	•You ask Elizabeth if she would like to meet with the lactation consultant (LC) during today's visit. She declines. You offer her a list of community resources for victims of domestic violence. She declines. Finally, you refer Gary to speech therapy. Elizabeth again declines and explains with frustration that she cannot afford to miss work. She leaves without scheduling the 2-year well visit.
Follow-Up	•You call Elizabeth a few weeks later to apologize for not being sensitive to her work schedule and her being Gary's primary caregiver. She admits that she is interested in all of the services you offered but just doesn't know to fit it in the day without missing work.
	•After some discussion, Elizabeth remembers seeing signs at work about telemedicine visits with EAP. She agrees to look into it. Since she has access to the patient portal, you offer to have the LC reach out so they can find a time to talk more. Elizabeth agrees.
	•Elizabeth asks if it's true that singing and reading to children can help with their speech development. She read it in a parent magazine when she was pregnant but with the divorce, she hasn't been doing any of those things.
	•Before hanging up, Elizabeth thanks you for reaching out. She reassures you that she will look into EAP. She asks to hold off on the speech referral until the 2-year well visit. She wants to get back to singing and reading to Gary.

EAP = Employee Assistance Program.