The report by DiGangi et al supports the feasibility of primary-care screening for adverse childhood experiences (ACEs) in pediatric primary care, however, significant controversy persists about the wisdom and clinical utility of implementing universal screening in pediatric primary care. In fact, many experts suggest that universal ACEs screening may introduce more harm than good. Instead, the study's findings provide an opportunity to raise awareness. Such a high prevalence of ACEs among children carries practical implications for primary care and public policy (https://www.acesaware.org/treat/clinical-assessment-treatment-planning/). Trauma-informed care could be considered a universal need for primary care practice.
In fact, the response to the COVID-19 pandemic may be amplifying some ACEs. There are several ways in which ACEs may be exacerbated by the social isolation, job loss, school closures, and other stressors unleashed by the pandemic. First, the pandemic may have increased intra-familial adversity, by exposing children to increased parental anxieties, especially those associated with job loss, food insecurity, and housing insecurity. Second, by amplifying toxic stress, increased family adversity may impair child brain development, particularly during the early years. Third, the pandemic's indirect social and economic impact on family stress may linger for months or years. Fourth, the pandemic and its response are disproportionately affecting low-income and ethnic minority populations, which are already at increased risk for ACE-impacted chronic conditions like preterm birth, diabetes, hypertension, and chronic lung disease. Taken together, the indirect effects of the pandemic response could exacerbate each of the common ACEs in children's lives.
Instead of adopting universal screening for ACEs, the evidence base suggests other pediatric responses (Am J Prevent Med 2020 https://doi.org/10.1016/j.amepre.2020.01.009) (Acad Pediatr 2020 PMID: 32272231). Medical providers can assure that all staff members are trained in trauma-informed care. Universal screening in primary care should include attention to actionable social needs, including unmet healthcare access, and a subset of ACEs, including household food insecurity, housing insecurity, job loss, and intimate-partner violence. Pediatric-care offices may offer additional structural buffers, including integrated mental-health services and partnerships with local agencies, including food shelters, schools, and legal aid. Beyond the clinic, local public-health officers may offer training in social-determinants screening and trauma-informed care. In fact, local leaders might extend this social-skills training to the new cadre of COVID-19 “contact tracers,” who while mitigating the direct effects of the virus, may also help mitigate the long-term impact of ACEs on child health.
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