Is screening for pediatric Adverse Childhood Experiences (ACEs) significant for 3-year-olds?

Pediatric ACEs Screening at Age 3: Clinical Significance and Recommendations

Screening for Adverse Childhood Experiences (ACEs) in 3-year-olds is not strongly supported by current evidence and may lead to inconsistent identification of at-risk children with potential system burden without clear pathways to improved outcomes.

Current Evidence on ACEs Screening in Young Children

The implementation of ACEs screening in pediatric populations has been increasing despite limited research establishing how these screening efforts impact healthcare systems and health outcomes 1. The evidence regarding ACEs screening specifically for 3-year-olds shows several important considerations:

• Significant heterogeneity exists in the proportion of respondents reporting ACEs across studies, with reported rates varying widely from 6% to 64% for 1+ ACEs and 0.01% to 40.7% for 4+ ACEs 1
• Young children have had less time to accumulate ACEs, making screening at age 3 potentially less sensitive than at older ages 1
• According to modeling data, children who experience ACEs at earlier ages are at higher risk for experiencing more ACEs later (a child with one ACE in their first year has a 53% chance of experiencing 4+ ACEs by age 18) 1

Clinical Impact and System Considerations

Implementing ACEs screening for 3-year-olds presents several challenges:

• There are significant gaps in the literature regarding appropriate cut-scores for referrals and referral completion rates 1
• Healthcare systems may experience variable impacts on service demand depending on screening implementation 1
• The PEdiatric ACEs and Related Life Event Screener (PEARLS) has shown that higher ACEs scores in children 0-11 years correlate with:
  • Poorer perceived general health
  • Worse executive functioning
  • Greater odds of specific health conditions like stomachaches and asthma 2

Screening Approaches and Considerations

If implementing ACEs screening for 3-year-olds, consider:

• Aggregate-level screening (reporting total number of exposures) may yield higher disclosure rates compared to item-level screening (specific responses to each question) 2
• Caregiver comfort varies with certain screening items, with sexual abuse, separation from caregiver, and community violence questions causing more discomfort 3
• Parents generally support ACEs screening when implemented with a trauma-sensitive, person-centered approach 4
• Parents see pediatricians as potential change-agents who can provide support to meet their parenting goals 4

Health Assessment Components When ACEs Are Identified

When ACEs are identified in 3-year-olds, a thorough health assessment should include:

• Physical evaluation: vital signs, growth parameters, skin examination for injuries, inflammatory/infectious consequences 5
• Developmental evaluation: screening for delays, learning difficulties, and executive functioning using validated tools like Ages and Stages Questionnaire 5
• Mental health evaluation: assessment for trauma responses including regression to earlier developmental behaviors, withdrawal, irritability, sleep disturbances 5

Intervention Approach

For 3-year-olds with identified ACEs:

• Focus on providing safety, calm, connection, self-efficacy, and hope during transitions 5
• Maintain continuity in key relationships and build resilience skills 5
• Recognize that the presence of at least one supportive relationship can significantly mitigate negative outcomes 5
• Consider cultural factors that influence both trauma expression and appropriate intervention approaches 5
• Schedule regular follow-up visits to monitor physical and mental health, reassess trauma symptoms, and track developmental progress 5

Pitfalls and Limitations

Important caveats to consider:

• ACEs screening may create healthcare system burden without clear pathways to improved outcomes 1
• There is limited evidence on the effectiveness of interventions specifically for 3-year-olds identified through ACEs screening 1
• Screening may lead to stigma or negative expectancies for children with high ACEs 1
• The healthcare system may have inadequate referral sources for behavioral health care and other resources to address identified adversities 1

Conclusion

While ACEs screening can identify children at risk for poor health outcomes, the specific benefit of screening at age 3 remains unclear. Healthcare providers should weigh the potential benefits of early identification against the limitations of current evidence and intervention pathways.