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Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 19-25

Familiarity and screening practices for adverse childhood experiences: Contemporary considerations from providers in a high prevalence state

Department of Physician Assistant Studies, University of Kentucky, College of Health Sciences, Lexington, Kentucky, United States of America

Date of Submission08-Oct-2020
Date of Acceptance25-Nov-2020
Date of Web Publication7-May-2021

Correspondence Address:
Dr. Leslie N Woltenberg
900 S. Limestone Street, 207 Charles T. Wethington, Jr. Bldg., University of Kentucky, Lexington, KY 40536-0200
United States of America
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ehp.ehp_35_20

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Objective: The purpose of this exploratory study was to examine adverse childhood experiences (ACEs), knowledge, and screening practices. Methods: A convenience sample of pediatric primary care providers in a health-care system within a high-prevalence state were invited to participate. The original 12-item survey addressed familiarity, tools, barriers, and prevalence regarding ACEs. Results: Study participants reported familiarity with ACEs; however, only 23% reported the use of any screening tool(s). Primary barriers included time and lack of staff and/or knowledge/training. About 77% of respondents have encountered at least eight of the 10 major types of ACEs. Most frequently encountered ACEs included parental separation or divorce, substance abuse in the household, and mental illness in the household. About 73% expressed interest in continuing medical education. Conclusions: Provider knowledge/familiarity with ACEs does not imply systematic screening. An efficient and evidence-based standardization for screening merits consideration. Continued education and training may address barriers to both provider understanding and screening of ACEs.

Keywords: Adverse childhood experience, pediatrics, primary care, screening

How to cite this article:
Vance K, Budine L, Craft M, Hahn C, Merz N, Nave C, Woltenberg LN. Familiarity and screening practices for adverse childhood experiences: Contemporary considerations from providers in a high prevalence state. Educ Health Prof 2021;4:19-25

How to cite this URL:
Vance K, Budine L, Craft M, Hahn C, Merz N, Nave C, Woltenberg LN. Familiarity and screening practices for adverse childhood experiences: Contemporary considerations from providers in a high prevalence state. Educ Health Prof [serial online] 2021 [cited 2022 Aug 12];4:19-25. Available from: https://www.ehpjournal.com/text.asp?2021/4/1/19/315624

  Introduction Top

The landmark adverse childhood experiences (ACEs) study, by Kaiser Permanente and the Centers for Disease Control (CDC), revealed the association of ACEs with the development of toxic stress and subsequent negative health outcomes such as physical and psychological disease, including chronic health conditions, and decreased life expectancy.[1] Those researchers chose to use the term “Adverse Childhood Experiences,” or “ACEs,” to describe stressful or traumatic events that may have a lasting impact on health and well-being. These early experiences, which have various effects on cognitive, social, emotional, and biological functioning, can be put into three categories: abuse, neglect, and household challenges. This study exposed a national public health crisis that fundamentally challenged the way medical professionals understood trauma. The concept of ACEs provided clinicians with a new approach to practicing primary care, as well as a bridge between the medical and public health communities. Subsequent research has linked ACEs to specific behaviors and health conditions including learning difficulties, depression, illicit drug use, and substance abuse disorders.[2],[3],[4],[5],[6] A 2019 CDC report identified 60.9% of adults surveyed experienced at least one type of ACE and nearly 16% reported four or more ACEs in their lifetime.[7],[8]

Public health is significantly impacted by ACEs and health-care expenses are estimated at an annual societal cost of hundreds of billions of dollars.[9] Although critics claim insufficient evidence directly linking ACE screening and prevention of negative outcomes, tremendous support remains for trauma-informed care and ACE research.[10],[11] Given the substantial research linking ACEs with impact to the genetic predisposition of the emerging brain architecture, lifelong health outcomes, and the multigenerational effect of ACEs, screening for ACEs remains a critical opportunity to implement protective and preventive strategies.[12],[13] Barriers to screening include time, proper training, and comfort with engaging patients about ACEs; however, brief educational sessions (including mock ACE screenings) have demonstrated efficacy to overcome such barriers.[14],[15] If a pediatric provider fails to routinely screening patients for abuse and/or neglect, there is a critical chance these devastating experiences may be overlooked. Education among primary care providers remains essential in the prevention and treatment of ACEs.

Given the national prevalence, most health-care professionals will provide care to individuals affected by ACEs. Pediatric primary care providers are ideally positioned for early intervention. This exploratory study examined the awareness and prevalence of ACE screening among pediatric primary care providers in a major health-care system within a high prevalence state.

  Methods Top

This exploratory study surveyed a convenience sample of health-care providers in pediatric primary care employed by a major health system within a state with a high prevalence of ACEs. This study was reviewed by the University of Kentucky Institutional Review Board and approved as exempt status. Prospective participants were identified through the health system's public online directory. Electronic invitations to participate in the study were distributed to each prospective respondent and included a link to the online survey. Participation in the study was entirely voluntary with no compensation for participation.

A quantitative, cross-sectional design was employed in order to examine the awareness and prevalence of ACE screenings among pediatric primary care providers. The 12-item electronic survey was administered online through Qualtrics. The survey remained open for a period of 3 weeks and two E-mail reminders were deployed within that period to encourage response. The original CDC-Kaiser Permanente study served as a framework for the study, with reference to the three primary ACEs categories (abuse, neglect, and household challenges).[1] Variables in the survey instrument included knowledge of ACEs terminology, use of screening tools, and perceived prevalence of various ACEs as observed in practice. Profession, years in practice, and interest in continuing education opportunities regarding ACEs were also included to gain information regarding the respondent population. A copy of the original evaluation instrument, developed specifically for this exploratory study, is provided as Appendix A.

Data analysis was conducted through Qualtrics, Microsoft Excel, and SPSS version 26 (IBM SPSS Statistics for Windows, Version 26.0. (IBM Corp., Armonk, NY, USA). Descriptive statistics were calculated and reported to provide an essential summary of the data. Pearson's bivariate correlation examined relationships between provider attributes and ACEs knowledge or practices (statistical significance at P < 0.05).

  Results Top

Based on results from the health system directory and the inclusionary criteria, the electronic survey was distributed to 88 health care pediatric primary care providers. Of the 88 prospective participants, 22 completed the survey for a 25% response rate. Of those 22 respondents, data represented 11 physicians, 10 nurse practitioners, and 1 physician assistant. The median number of years practicing between those surveyed was 11.5 years with a range from 2 to 39 years. Although the response rate was modest, the sample studied for this exploratory research aligned with the overall provider composition of the health-care system.

Familiarity and screening practices

Study participants were first asked about their familiarity with ACEs. On a Likert scale from 1 (not at all familiar) to 5 (extremely familiar), the median response was 5, with a range of 3–5. Although more than half (55%) reported extreme familiarity with ACEs, only 23% reported using a specific screening tool in their practice. When asked which screening tool study participants used, primary responses included the clinic-specific (custom) intake forms with ACE-related questions or use of preexisting tools such as the Family Health History and Health Appraisal questionnaires (as used in the original CDC-Kaiser Permanente study), the Center for Youth Wellness Adverse Childhood Experiences Questionnaire, and Patient Health Questionnaire. Among the study participants who reported using an ACE screening tool, 80% reported that they administer the screening themselves, while 20% reported that other clinical staff administer the screening. When asked to whom the screening was administered, 40% reported administering the screening to the patient individually, 40% reported administering the screening to the patient together with their parent/guardian, and 20% reported administering the screening to the parent/guardian only. No statistically significant differences were identified on examination of provider type with familiarity nor screening practices.

Barriers to screening

Study participants who did not report the use of any screening tool for ACEs were asked to select, from a brief list, all barriers that prevent them from screening [Figure 1]. Time was the most frequently reported barrier to screening (59%), followed by lack of resources (29%), lack of training/knowledge (24%), and comfort/confidence level (12%). Other comments (41%) acknowledged limitations within the electronic health record and ACE screenings not required.
Figure 1: Barriers to screening

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Perceived prevalence of adverse childhood experiences

The study participants were asked to select all ACEs encountered in practice, irrespective of screening practices. [Table 1] lists the provided ACEs to choose from, which include the same ten ACEs reflected in the original CDC-Keiser Permanente study. Among respondents, 77% reported encountering at least eight of the ten types of ACEs listed in [Table 1] throughout the duration of their practice [Figure 2].
Table 1: Types of adverse childhood experiences

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Figure 2: Total number of adverse childhood experience types encountered per respondent

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The study participants were then asked to report the three most frequently encountered ACEs in their practice experience to-date [Figure 3]. Parental separation or divorce was the ACE most selected (77%), followed by substance abuse in the household (59%) and mental illness in the household (50%). All ACEs listed in [Table 1] were selected for this question by at least one study participant, with the exception of “mother treated violently.”
Figure 3: Types of adverse childhood experiences most frequently encountered in practice

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When asked whether study participants would be interested in receiving continuing medical education (CME) regarding ACE screening, 73% affirmed an interest in ACE-related CME. Results from Pearson's bivariate correlation indicated a moderate-high degree of correlation between dichotomous provider type physician providers versus non-physician providers (MD vs. non-MD) and interest in receiving ACEs-related CME (r = 0.504; P = 0.023). Nonphysician study participants (including nurse practitioner and physician assistant roles) were twice as likely to indicate an interest for CME as compared to their physician counterparts. Specific details of such education or training were not explored within the scope of this study.

  Discussion Top

Familiarity and screening practices

Although all study participants reported being at least somewhat familiar with ACEs, the prevalence of screening for ACEs within this population of pediatric primary care providers is sparse, with only 23% working in a practice that utilized some form of the screening tool. Based on the study findings, it is reasonable to infer that there is no standardized protocol for this secondary prevention strategy. Study participants reported the use of a range of screening tools from ACE-related questions on a patient intake form to a variety of established screening tools, and the patient may be screened individually or with a parent/guardian present. In some cases, the parent/guardian may be the only one to receive the screening. While it is commendable, some participants were both aware of and conducting a screen for ACEs; the information collected is at risk of being incomplete, biased, and/or misinterpreted without a standardized screening protocol in place.

Barriers to screening

The scarcity of screening in this population of providers may be attributed to a combination of perceived and systemic barriers. Study participants identified barriers of time and lack of resources, training, and/or comfort with screening for ACEs. These findings align with prior ACEs research among primary care providers which demonstrated that screening was not time-prohibitive after providers were given basic education and training, whereas others (without training intervention) reported patient visits to be extended by up to 15 min.[8],[9]

The findings of this study represent yet another population of primary care providers who perceive their time as restricted, further underscoring the need for an ACE screening tool that is effective, both sensitive and specific, as well as efficient for everyday use in a primary care setting. A promising study utilizing data from the Behavioral Risk Factor Surveillance System to measure the validity of a new 2-item ACE screening tool demonstrated sensitivity between 70% and 99% and a specificity between 66% and 94% as compared to an 11-item ACE screening tool for detecting ACEs related to abuse and household stressors – two primary categories identified from the original CDC-Kaiser Permanente Study.[10],[16] A valid, reliable screening tool with the ability to detect such ACEs with two questions may peak the interests of providers who appreciate the significance of ACEs on their patients' health but are hesitant to screen due to time constraints. A positive screening then provides valuable information regarding the social determinants of a patient's health – factors all primary care providers are trained to be aware of, look for, and especially consider for any given treatment plan.

Perceived prevalence of adverse childhood experiences

While screening for ACEs does not occur in all pediatric primary care practices, national data indicate near certainty for providers to encounter patients with them.[8] Study participants were asked to subjectively identify the ACEs they encounter in their practice to help characterize the types of challenges pediatric patients in a high prevalence state are facing. Unsurprisingly, 77% of respondents reported seeing at least eight of the ten ACEs from [Table 1] in their practice. These data are consistent with ongoing ACE research that reports the high prevalence of ACEs across various communities, further implicating the invaluable role of primary care providers in screening.

When study participants were asked to narrow their selected ACEs down to the three, they most frequently encountered in their practice, 77% reported parental separation and divorce, 59% reported substance abuse in the household, and 50% reported mental illness in the household. These three ACEs fall under the primary category of Household Challenges, which may be attributable to the sensitive nature of the other primary categories of abuse and neglect. Discussions of ACEs considered to be household challenges are often met with mutuality and trust – it is a sign to the patient that their provider is getting to know them better. Discussions of ACEs related to abuse and/or neglect, however, may be met with discomfort, shame, hostility, or other intense emotional triggering. Furthermore, reported instances of abuse and/or neglect of any kind likely depend heavily on whom the information is coming from (i.e., an abusive parent vs. an abused child), who is in the room when that information is being shared, and whether the patient feels safe disclosing sensitive information to their provider. In short, if a pediatric provider is not routinely screening their patient (individually or otherwise) for abuse and/or neglect, there is a critical chance these devastating experiences may be overlooked.

Irrespective of which ACEs are being encountered by the pediatric primary care providers in this study, children experience enough trauma to capture the attention of their pediatrician. It is not unreasonable to suggest that implementing a standardized screening tool for ACEs and referral management algorithm could have a significantly positive impact on the long-term health and wellness of children. The majority of participants in this study (73%) were interested in continuing education regarding ACEs. Strategic education could serve providers with updates on contemporary ACE research, bridge the present state of hesitation in ACE screening to a future where standardized screening is routinely administered by pediatricians across the state and/or nationally, and inform providers of appropriate steps in management for children who report any number of ACEs.


This 3-week exploratory study was, by design, small in scope and number in order to focus on a single health-care system within a high prevalence state. The focus was to explore pediatric primary care provider knowledge and screening practices of ACEs to establish a baseline of perception data among providers on the front lines with respect to the startling national data on ACEs prevalence. The most logical step in improving upon the statistical power of these data would be to replicate the study with a larger number of participants. To achieve greater external validity and generalizability, the research may be extended to pediatric providers outside of a single health-care system with a broader timeline in place to allow for more responses.

Although the convenience sampling method and small sample size may limit generalizability and pose difficulty in extrapolating findings to other populations, the results of this study provide opportunities to further ACEs research in hopes of identifying improved ways to provide optimal care to patients. Additional research is recommended to fully elucidate relationships among provider/practice attributes (i.e., provider type, practice setting, and geographic location) and encounters with ACEs as well as screening knowledge and behaviors. Further research may include continued feasibility studies for standardized ACE screenings,[17] integration with electronic medical record systems, and evidence-based management algorithms to guide providers when presented with a range of ACE scores. The delicate balance of factors which determine the feasibility of ACE screenings underpins its potential success.

  Conclusions Top

Subsequent research since the landmark CDC-Kaiser Permanente study has reinforced the idea that ACEs are pervasive throughout our nation, and the findings from this study further reinforce the studied state as high prevalence. In fact, most providers in this study reported seeing several ACEs of a wide variety in their practice. However, only a small percentage reported using a screening tool to infer that information, highlighting the need for the greater initiative in the implementation of ACE screenings. This study calls to action pediatric primary care providers to embrace the challenge of integrating a familiar, evidence-based secondary prevention strategy into their practice. Pediatricians represent one of the earliest points of contact for children unknowingly undergoing traumatic experiences within their own homes, making them the ideal professionals to administer this screening. As children represent an incredibly vulnerable, yet resilient population, the significance of their mental health cannot be understated. When provided the tools necessary to cope with any number of ACEs, there is great potential in avoiding some of the long-term negative outcomes. However, to reach the point of appropriately managing children with ACEs, providers must first take steps to collectively decide that screening should be incorporated into their practice, and then what it should look like – who receives the screening, how often, what questions get asked, and what to do with a positive screening. Findings from this study demonstrated provider awareness of the various ACEs of their patients and indicate a need for education and standardizing screening to effectively address concerns and overcome barriers.


The Institutional Review Board approval was obtained from the Office of Research Integrity at the University of Kentucky (protocol #55130). This research was conducted by Physician Assistant Studies students at the University of Kentucky, in collaboration with program faculty, in partial fulfillment of graduation requirements. The authorship team wishes to acknowledge the support of the University of Kentucky Department of Physician Assistant Studies and University of Kentucky Healthcare for support of this research.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  Appendix Top

Appendix A: Adverse childhood experiences survey

1. How familiar are you with the terminology adverse childhood experiences? Select one

  • Not at all familiar (1)
  • Slightly familiar (2)
  • Somewhat familiar (3)
  • Moderately familiar (4)
  • Extremely familiar (5)

2. Do you currently use any type of screening tool for ACEs?

  • Yes
  • No

3. What tools do you use? Check ALL that apply

  • Family Health History and Health Appraisal questionnaires (original ACE Study Questionnaire)
  • Center for Youth Wellness Adverse Childhood Experiences Questionnaire (CYW ACE-Q)
  • ACE-related questions included in pediatric intake form
  • I am not sure what tool my practice uses
  • Other, please explain:

4. When does screening occur? Check ALL that apply

  • Every patient every visit
  • Every patient annually
  • New patients only
  • When you have a concern
  • Other, please explain:

5. Who administers the screen? Check ALL that apply

  • Intake form
  • Clinical staff
  • Provider
  • Other, please explain:

6. To whom is the screen administered?

  • Patient individually
  • Parent/guardian individually
  • Patient and parent/guardian together
  • Other, please explain:

7. What are the barriers that keep you from screening? Check ALL that apply

  • Time
  • Comfort/confidence level
  • Lack of training/knowledge in this field
  • Lack of resources such as staff
  • Other, please explain

8. Select ALL ACEs from the following list that you have encountered in your practice:

  • Emotional abuse
  • Physical abuse
  • Sexual abuse
  • Mother treated violently
  • Substance abuse in household
  • Mental illness in household
  • Parental separation or divorce
  • Incarcerated household member
  • Emotional neglect
  • Physical neglect
  • Other, please explain:

9. Rank the top 3 most common ACEs you see in your practice

  • Emotional abuse
  • Physical abuse
  • Sexual abuse
  • Mother treated violently
  • Substance abuse in household
  • Mental illness in household
  • Parental separation or divorce
  • Incarcerated household member
  • Emotional neglect
  • Physical neglect
  • Other, please explain:

10. What is your profession?

  • Physician
  • Physician Assistant
  • Nurse Practitioner
  • Other, please explain

11. How many years have you been practicing? Please provide a numeric value (Example 8, not eight):

12. Are you interested in participating in continuing education regarding ACEs screening?

  • Yes
  • No

  References Top

Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 1998;14:245-58.  Back to cited text no. 1
Burke NJ, Hellman JL, Scott BG, Weems CF, Carrion VG. The impact of adverse childhood experiences on an urban pediatric population. Child Abuse Negl 2011;35:408-13.  Back to cited text no. 2
Dube SR, Felitti VJ, Dong M, Chapman DP, Giles WH, Anda RF. Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: The adverse childhood experiences study. Pediatrics 2003;111:564-72.  Back to cited text no. 3
Afifi TO, Henriksen CA, Asmundson GJ, Sareen J. Childhood maltreatment and substance use disorders among men and women in a nationally representative sample. Can J Psychiatry 2012;57:677-86.  Back to cited text no. 4
Hughes K, Bellis MA, Hardcastle KA, Sethi D, Butchart A, Mikton C, et al. The effect of multiple adverse childhood experiences on health: A systematic review and meta-analysis. Lancet Public Health 2017;2:e356-66.  Back to cited text no. 5
Schilling EA, Aseltine RH Jr., Gore S. Adverse childhood experiences and mental health in young adults: A longitudinal survey. BMC Public Health 2007;7:30.  Back to cited text no. 6
Merrick MT, Ford DC, Ports KA, Guinn AS. Prevalence of adverse childhood experiences from the 2011-2014 behavioral risk factor surveillance system in 23 states. JAMA Pediatr 2018;172:1038-44.  Back to cited text no. 7
Merrick MT, Ford DC, Ports KA, Guinn AS, Chen J, Kevens J, et al. Vital Signs: Estimated Proportion of Adult Health Problems Attributable to Adverse Childhood Experiences and Implications for Prevention: 25 States, 2015-2017. MMWR Morbidity and Mortality Weekly Report 2019;68:999-1005. Available from: https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6844-H.pd. [Last accessed on 2020 Aug 08].  Back to cited text no. 8
Centers for Disease Control and Prevention. Preventing Adverse Childhood Experiences (ACEs): Leveraging the Best Available Evidence. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Available from: https://www.cdc.gov/violenceprevention/acestudy/fastfact.html. [Last accessedon 2020 Aug 08].  Back to cited text no. 9
Campbell TL. Screening for adverse childhood experiences (ACEs) in primary care: A cautionary note. JAMA 2020;323:2379-80.  Back to cited text no. 10
Racine N, Killam T, Madigan S. Trauma-informed care as a universal precaution: Beyond the adverse childhood experiences questionnaire. JAMA Pediatr 2019;174:5-6.  Back to cited text no. 11
Jones CM, Merrick MT, Houry DE. Identifying and preventing adverse childhood experiences: Implications for clinical practice. JAMA 2019;323:25-6.  Back to cited text no. 12
Garner AS, Shonkoff JP; Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, Section on Developmental and Behavioral Pediatrics. Early childhood adversity, toxic stress, and the role of the pediatrician: Translating developmental science into lifelong health. Pediatrics 2012;129:e224-31.  Back to cited text no. 13
Kalmakis KA, Shafer MB, Chandler GE, Aponte EV, Roberts SJ. Screening for childhood adversity among adult primary care patients. J Am Assoc Nurse Pract 2018;30:193-200.  Back to cited text no. 14
Esden JL. Adverse childhood experiences and implementing trauma-informed primary care. Nurse Pract 2018;43:10-21.  Back to cited text no. 15
Wade R Jr., Becker BD, Bevans KB, Ford DC, Forrest CB. Development and evaluation of a short adverse childhood experiences measure. Am J Prev Med 2017;52:163-72.  Back to cited text no. 16
Glowa PT, Olson AL, Johnson DJ. Screening for adverse childhood experiences in a family medicine setting: A feasibility study. J Am Board Fam Med 2016;29:303-7.  Back to cited text no. 17


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]


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