The clinic’s roll-out
Dr. Pettersen learned about the ACE study and related research about 8 years ago while on a sabbatical to learn more about mental health issues. It “changed everything” about the way she viewed children and families and adversity. “I knew (we) didn’t have the infrastructure at the clinic, or the clinic’s support, to really start assessing children for what was happening to them,” she said, so she began thinking about ACE prevention and a focus on parenting.
Dr. Gillespie, in the meantime, was active in various quality improvement efforts at the state and national level, and had also become increasingly bothered by visits in which he saw children affected by maternal depression, abnormal attachment, and other problems. “I was seeing the consequences of ACEs, but I didn’t know specifically what was going on or how to talk about it,” he said.
The two pediatricians agreed to ask parents about ACEs at the 4-month well visit – a time when the families “knew us a little bit” and when “we could still influence parenting styles.”
In March 2013, they and their colleagues in the pilot group began giving parents a questionnaire that included the 10 ACE questions from Felitti’s study, questions about resilience from the Children’s Resilience Initiative, and a list of potential resources so they could understand parents’ needs.
They created a confidential field in their electronic medical record for documentation that appears during a visit, but does not print into notes and therefore will not be inadvertently released.
As they moved through the pilot phase, the pediatricians used various approaches to follow up on the assessment face-to-face. Eventually, they chose three particular questions as nonthreatening and helpful for conversation: Are there any experiences that still bother you? Of those experiences that don’t bother you, how did you get to the point where they don’t bother you? And how do these experiences affect your parenting now?
“It’s a motivational interviewing sort of style,” said Dr. Gillespie. “Parents can start identifying for themselves the solutions for the problems they’ve experienced, and they can start thinking about how their parenting might be impacted by things that have happened [or are still happening] to them.”
As the project rolled out, the physicians tweaked their process. They added four more ACE questions to address issues – community violence, extreme bullying, racism and prejudice, and foster care exposure – that they thought might lead to toxic stress in their population, for instance. And rather than ask on the written questionnaire for a “yes” or “no” to each of the ACE questions, they began asking the parent how many of the ACE questions applied to them. Moving away from the yes-no format to asking for a total count has led to more disclosures, Dr. Gillespie said.
To “keep the conversation going” in subsequent well-child visits, they developed a few questions to ask high-risk parents, like “How do you and your partner resolve conflict?” and “How did your parents resolve conflict in your household when you were a child?” And they provided training to all of the clinic’s staff on trauma-informed care and the need for support and compassion in their interactions with family members.
In the 3-plus years since incorporating ACEs assessments, the clinic’s pediatricians have made soft referrals to mental health professionals in only several cases – in each case, by suggesting that the parent contact their primary care physician. What most parents have wanted, says Dr. Gillespie, is recommendations for parenting classes and support groups. The clinic’s care manager assists the pediatricians in maintaining and providing links and handouts for various resources.
For Dr. Gillespie, the impact of the culture shift has been dramatic. “I’ve had 8-10 moms spontaneously reveal domestic violence to me in a subsequent visit, and say that they need a little help, because they’ve gotten the message that this is a safe place to talk about their experiences,” he said. “That had never happened to me in the previous 12 years of so of my career.”
Dr. Pettersen’s relationships with parents became “more intimate and more honest.” There was more trust. “If we can talk with parents [about ACEs] and not judge them for it,” she said, “then nothing is off the table.”
The ‘Two-Gen’ approach
Courtesy Children's Mercy Hospitals
Dr. Denise Dowd