Screening for Adverse Childhood Experiences

In their recent commentary “Addressing Adverse Childhood Experiences in Family Medicine: A Multigenerational Approach,”1 Drs McKelvey and Edge recommend several helpful strategies that should precede “the initiation of screening” for adverse childhood experiences (ACEs). However, they do not address the important and vexing issue of whether to screen for ACEs even when a practice is adequately prepared. Many have advocated for routine ACE screening for adults and children, and the State of California is now encouraging ACE screening by reimbursing clinicians for each completed ACE screen.2 Before implementing widespread screening for ACEs, it should be rigorously reviewed using the accepted standards necessary for screening programs.

The potential benefits of reducing the negative health effects of ACEs are enormous. Unfortunately, no interventions have been demonstrated to improve outcomes in patients who report a high number of ACEs. While there are effective treatments for many of the sequelae of ACEs such posttraumatic stress disorder, panic disorder, and depression, they are not effective or appropriate to use with all patients with high ACEs, especially those who do not report any psychological distress. There is no consensus as to what events should be considered an ACE, and there are over a dozen different ACE questionnaires.3 The original ACE questionnaire was developed as a research tool and was never intended for clinical use. It provides population-based risk data that are not appropriate to apply to individual patients.

There are many potential harms of ACE screening. Patients may be retraumatized by screening. Children and adults with high ACE scores risk being labeled at high risk for psychological and physical health problems, which can result in psychological distress. Parents and teachers of children with high ACEs may look for and even create the predicted behavioral problems, the so-called “expectancy effect.” Most family physicians do not have adequate time to complete evidence-based clinical preventive services,4 such that few children and adults have received all the recommended services.5 Implementing an unproven screening program would only worsen this problem.

I agree with Drs McKelvey and Edge that family physicians should strengthen evidence-based screening programs for many of the consequences of ACEs, such as depression, substance abuse, and domestic violence, to assure that all of our patients receive these services. More research is needed on screening instruments, potential interventions, and the potential harms of ACE screening. However, it is premature to implement screening programs for ACEs until the effectiveness of such screening can be demonstrated.