1. Why Should We Screen and What Should We do?
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

2. 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

3. Sources of Stress for Children
Adverse Childhood Experiences (ACEs)
Unmet Social Needs (Social Determinants of Health)

4. Adverse Childhood Experiences Study
Abuse
Emotional
Physical
Sexual
Neglect
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

5. ACEs Score = Trauma “Dose”
ACEs were common and tended to be grouped together
ACE Score
Prevalence
33% 1
26% 2
16% 3
10%
4 or more

6. 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)

7. 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

8. 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

9. 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

10. 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
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

12. Assessing Social Key Questions for Health: The ASK Questions For Health Study
A collaboration between:

13. 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

14. 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

15. ASK Survey
Social Needs
ACEs

16. ASK Study Packet – 4 items#1 #2
Study Cover Letter
Information Sheet

17. ASK Study Packet – 4 items#3 #4
Family Satisfaction Survey
Demographic Survey

19. 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)

20. 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.

21. 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)

22. Referral Process If a referral is needed:
Access resources here:
And/or
Requires immediate social work consult
Provider will communicate directly with SW regarding urgent concerns
We will be tracking SW referrals to see if there is a significant increase

23. In Review…
Give the Parent/Caregiver the WCC Patient Education packet (only for WCC appts)
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
ASK Study Packet
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

24. Is this working? How is it affecting clinic flow?
ASK Screening Tool Started
Staff Feedback Survey
Clinic flow
Wait times
Increased demands
Modifications made/Suggestions addressed
2 months
4 months
6 months

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