What score on the Adverse Childhood Experiences (ACEs) screener warrants attention and what referrals are recommended?

Pediatric ACEs Screening: Score Thresholds and Referral Recommendations

A score of 4 or more on the Adverse Childhood Experiences (ACEs) screener warrants immediate attention and referral to behavioral health services, while scores of 1-3 require follow-up when accompanied by symptoms. 1

Score Interpretation and Action Thresholds

Score of 4+ ACEs

• Represents a clinically significant threshold associated with substantially increased risk for negative health outcomes 2
• Children with 4+ ACEs have significantly higher odds of developing chronic diseases and behavioral health problems 2
• Requires immediate referral to behavioral health services regardless of current symptom presentation 1
• A child who experiences one ACE in their first year of life has a 53% chance of experiencing 4+ ACEs by age 18, while two ACEs in the first year increases this probability to 91% 3

Scores of 1-3 ACEs

• Considered clinically significant when accompanied by symptoms 1
• Require follow-up assessment and possible referral based on symptom presentation 1
• Even a score of 1 in infants may warrant referral to parenting programs, as demonstrated in studies where 47% of patients were referred when the infant had 1+ ACE 3

Assessment Protocol Following Positive Screen

For All Positive Screens (1+ ACEs)

1. Conduct thorough health assessment:

   • Physical evaluation (check for signs of neglect or abuse)
   • Developmental evaluation
   • Mental health evaluation
   • Growth parameters, vision, and hearing 1

2. Evaluate for current symptoms:

   • Behavioral changes
   • Developmental concerns
   • Physical symptoms (particularly stomachaches and asthma, which show increased odds with higher ACE scores) 4

For Scores of 4+ ACEs

• Immediate referral to behavioral health services regardless of symptom presentation 1
• Consider co-responder models where mental health professionals maintain confidentiality and make informed referrals 3

For Scores of 1-3 ACEs with Symptoms

• Provide psychoeducation about the connection between adversities and symptoms
• Make appropriate referrals based on identified needs
• Schedule regular follow-up visits to monitor physical and mental health 1

Referral Recommendations

Behavioral Health Services

• Implementation of ACEs screening and referral processes has been associated with a significant increase (from 4.33% to 32.48%) in receipt of behavioral health services within 90 days 5
• Referrals should be made within 90 days of a positive screen 5

Additional Support Services

• Parenting classes
• Social services
• Childcare resources 3
• Trauma-informed care approaches across systems 3

Important Clinical Considerations

Synergistic Effects

• Certain pairs of ACEs interact synergistically to significantly increase overall risk beyond the sum of individual ACEs 6
• Sexual abuse is the most synergistically reactive ACE across studies 6
• About 30-40% of variance in outcomes is accounted for by synergistic interactions between certain ACE pairs 6

Screening Method Impacts

• Aggregate-level screening (reporting total number of exposures) results in disclosure of approximately one additional adversity compared to item-level screening (specific item responses) 4
• Consider using aggregate-level screening for more accurate identification of at-risk children 4

Potential Pitfalls

1. Underestimating moderate scores: A score of 3 still indicates significant adversity requiring attention 1
2. Overreacting to ACEs: Not all children with ACEs develop problems; focus on symptom presence and protective factors 1
3. Cultural insensitivity: Consider cultural context when interpreting results 1
4. System burden: Ensure clear pathways to improved outcomes and adequate referral sources 1
5. Accrual over time: Children left in home following Child Protection Services investigation show precipitous increases in ACEs over time (average increase from 2.2 to 5.4 over three years) 7

Follow-Up Protocol

• Schedule regular follow-up visits to monitor physical and mental health
• Reassess trauma symptoms and track developmental progress
• Focus on providing safety, calm, connection, self-efficacy, and hope
• Maintain continuity in key relationships to build resilience skills 1