Childhood Stress – �Social Determinants and Adverse Childhood Experiences

Why Should We Screen and What Should We do?

Mark Minier, MD

Amanda Osta, MD

Stacy Laurent, DO

Anthony Heard, LCSW

Objectives

• Identify sources of stress in childhood
• Understand the link between childhood stress and health outcomes
• Gain confidence in our team’s ability to effectively identify, assess, and support stress in our patients
• Discuss new screening tool and roles we all play in getting this accomplished
• Review the referral process based on screening results

Sources of Stress for Children

• Adverse Childhood Experiences (ACEs)
• Unmet Social Needs (Social Determinants of Health)

Adverse Childhood Experiences Study

• Abuse
• Emotional
• Physical
• Sexual
• Neglect
• Emotional
• Physical

• Household Dysfunction
• Mother treated violently
• Household substance abuse
• Household mental illness
• Parental separation/divorce
• Incarcerated household member

Felitti, Am J Prev Med 1998

Note- Did not include other violence, poverty, bullying, loss of a parent

ACEs Score = Trauma “Dose”

• ACEs were common and tended to be grouped together

How does your ACE dose affect your health?

• ACE score of 6 or more led to a 20 year decrease in life expectancy
• Children with and ACE score of 4 or more had 4.5x increased risk of asthma
• 51% of children with ACE score of 4 or more have learning or behavior problems (compared to 3% of kids with ACE of zero)

Social Determinants of Health

• In Chicago, 1 in 3 children live in poverty
• Social Determinants of Health include:
• Parental employment
• Parental education and literacy
• Childcare
• Employment
• Food security
• Housing
• Legal aid
• Ability to pay utilities
• Data show that unmet social needs can have large impacts on health outcomes and health behaviors

Toxic Stress

• Long term exposure to “stressful” environments can lead to poor outcomes, including behavior and mental health issues
• Can lead to changes in your DNA and genes
• We need to identify and address “stressful” environments early
• If we don’t ask, we will never know

Clinical Manifestations

• Behavioral Outbursts
• Social withdrawal/Mood swings
• Irritability/mood swings
• Developmental delays
• Transient regression of behavior (bed wetting)
• School difficulties, underachievement
• Verbal/physical altercations
• Psychosomatic complaints

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Resilience

• Process of moving through a traumatic event utilizing protective factors for support
• Critical for successfully navigating through stressful events
• Serves as a buffer between the child and the events, possibly mitigating the negative effects

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• Again, if we don’t ask we won’t know about these toxic or stressful events
• Gives us the opportunity to identify protective factors for both the patient and the family as well as provide support

Assessing Social Key Questions for Health:�The ASK Questions For Health Study

A collaboration between:

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ASK Questions for Health: QI and Study

• Quality Improvement
• ASK Survey
• We will begin XXXXX
• ASK survey will be inserted in the WCC Patient Education packets
• ASK survey is in English and Spanish
• Study
• How common are unmet social needs and ACEs in our population
• What do parents think of this new screening tool
• What do YOU think about this new screening tool

Exclusion Criteria for Study Component

• Patients unaccompanied by a parent or guardian
• Patients whose parent or guardian is not able to read the ASK survey in English or Spanish

ASK Survey

ASK Study Packet – 4 items

Study Cover Letter

Information Sheet

#1

#2

ASK Study Packet – 4 items

Family Satisfaction Survey

Demographic Survey

#3

#4

Customer Service Representatives

• Hand out the WCC Patient Education packet for all patients coming in for a Well Child Check
• The packet will have the new ASK survey already included (both English and Spanish packets)

Medical Assistants

• Only for children presenting for a WCC in the COC clinic (this is only for resident COC patients, NOT FPG patients)
• Give the parent/caregiver a packet with the following items (4 items):
• Study Cover Letter
• Information Sheet
• Demographic Survey (to be completed by the parent in the waiting room or exam room before the visit)
• Family Satisfaction (to be completed at the end of the visit)
• Tell parent/caregiver that we are doing a study and if they would like to participate they can read the information on the cover letter and proceed. If any questions they can ask their provider.

Providers

• Resident physician will review the ASK and document any referrals needed on the ASK (bottom of the page) and will document the ASK results and follow-up in their Cerner note
• Resident physician will collect the Demographic Survey from the parent/caregiver
• Resident physician will collect the Family Satisfaction survey
• The following items will be placed in a secure lock-box in the attending room:
• Demographic survey (patient label)
• Family Satisfaction survey
• ASK questionnaire (patient label)

Referral Process

• If a referral is needed:
• Access resources here: http://go.uic.edu/ask

And/or

• Requires immediate social work consult
• Provider will communicate directly with SW regarding urgent concerns

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• We will be tracking SW referrals to see if there is a significant increase

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• Review the ASK
• Make necessary referrals or provider education from website
• Document at bottom of ASK and in Cerner
• Look to see if patient completed the ASK Study Packet
• Affix labels as appropriate
• Place all documents in the lockbox

• Hand the Family/Caregiver the ASK Study Packet
• Explain that they can read the cover letter and information sheet and fill out forms when they are in the waiting room/exam room before provider sees the patient
• Direct questions to the provider

• Give the Parent/Caregiver the WCC Patient Education packet (only for WCC appts)

In Review…

ASK Study Packet

Is this working? How is it affecting clinic flow?

ASK Screening Tool Started

6 months

Questions or Concerns

• If you have any concerns or questions please contact:
• Mark Minier, MD
• Amanda Osta, MD
• Stacy Laurent, DO
• Anthony Heard, LCSW