A National Trauma-Informed Adverse Childhood Experience Screening and Intervention Evaluation Project

Abstract

Background/objectives: Adverse childhood experiences (ACEs) are traumatic childhood events that can disrupt neurologic, endocrine, and immune regulation and increase the risk for poor health outcomes. This Trauma-Informed ACE Screening and Intervention Evaluation (TASIE) Quality Improvement (QI) Project, ECHO, evaluated (1) pediatric provider knowledge of ACEs, toxic stress, and trauma-informed care principles, (2) implementation of ACE screening and clinical response in practice, and (3) patient and provider perspectives around benefits and challenges of ACE screening.

Methods: From November 2021 to May 2024, three cohorts, totaling 46 pediatric practices across the U.S., participated in the TASIE Project, which included 2 h ACE training, eight monthly 75 min ECHO sessions, and monthly QI coaching. A mixed-methods approach was used to evaluate monthly data, while patient and provider surveys and provider focus groups were used to evaluate the program.

Results: All 46 participating practices implemented ACE screening by the project's conclusion. Of the patients eligible for ACE screening, over half were screened for ACEs during the program. Providers increased comfort with discussing ACEs and screening questions. During the first month, the practices were reported to have provided education to 56% of patients, and by the end of the project, this rate increased to 79% of patients. Overall, 97% of caregivers and 92% of adolescents screened agreed or somewhat agreed that it is important for providers to know about ACEs and toxic stress so they can offer better care. By the end of the project, for each cohort, providers reported that they were able to screen effectively and efficiently in routine practice and were more familiar with local resources.

Keywords: adolescent; adverse childhood experiences; caregiver; intervention; pediatric provider; practice; resilience; screening; toxic stress; trauma-informed care; wellness.

Figure A1

States with practices participating in the TASIE Project, Cohorts 1-3, n = 46 (source: enrollment data).

Figure A2

TASIE Project clinical response algorithm (Source: TASIE Implementation Guide).

Figure 1

Eligible patients by screening status, n = 46 practices (source: QIDA).

Figure 2

Average screening rate by practice starting readiness, n = 36 practices (Source: QIDA and provider survey). In total, 36 of the 46 practices had providers who responded to the pre- and post-survey with readiness ratings.

Figure 3

Average screening rate by eligible patient volume, n = 46 (source: QIDA).

Figure 4

Knowledge of ACE screening and trauma-informed care, pre- and post-program (source: provider survey; n = 68 providers).

Figure 5

Knowledge of the science of ACEs and toxic stress and their impact on child health, development, and well-being, pre- and post-program (Source: provider survey; n = 68 providers).

Figure 6

Comfort with discussion ACEs and ACE screening questions with patients, pre- and post-program (source: provider survey; n = 68 providers).

Figure 7

Number of patients with known risk status receiving/and or offered intervention by risk status, n = 7320 (Source: QIDA). Risk status was unknown for 196 patients; risk status was not reported/missing for 39 patients. Patients may receive more than one type of intervention.

Figure 8

Number of known high-risk patients receiving/attending follow up or referral (source: QIDA). Note: Patients may receive more than one type of intervention. TASIE used Cohort 1 to pilot referral tracking and only practices with established referral systems tracked referrals and follow-ups. It is likely for this reason that the data show Cohort 1 with greater success in offering follow-up and patients accessing services. The evaluation defined an INTERNAL referral as an in-practice support like internal behavioral health, case managers, or care coordinator; EXTERNAL referral was defined as a support offered outside the practice, including community-based behavioral health providers, support for social needs (e.g., housing, food, or legal aid), or another organization/resource, including virtual resources (e.g., mindfulness apps).

Figure 9

Relationship with provider after ACE screening (source: caregiver and adolescent survey, caregiver n = 210, adolescent n = 86).

Figure 10

Caregiver knowledge and attitudes (source: caregiver survey, n = 210).

Figure 11

Adolescent knowledge and attitudes (source: adolescent survey, n = 86).

Figure 12

Information received about the various Domains Of Wellness (source: caregiver and adolescent survey; caregiver n = 210, adolescent n = 86).