1 S CREENING FOR U NMET S OCIAL N EEDS ACES AND Do Pediatricians Ask About Adverse Childhood Experiences in Pediatric Primary Care? Bonnie D. Kerker, PhD; Amy Storfer-Isser, PhD; Moira Szilagyi, MD, PhD; Ruth E. K. Stein, MD; Andrew S. Garner, MD, PhD; Karen G. O’Connor, BS; Kimberly E. Hoagwood, PhD; Sarah M. Horwitz, PhD From the Nathan Kline Institute of Psychiatric Research, Orangeburg, NY (Dr Kerker); Department of Child and Adolescent Psychiatry, New York University School of Medicine, New York, NY (Drs Kerker, Hoagwood, and Horwitz); Statistical Research Consultants, LLC., , Schaumburg, Ill (Dr Storfer-Isser); University of California at Los Angeles, Los Angeles, Calif (Dr Szilagyi); Albert Einstein College of Medicine Bronx, NY (Dr Stein); Case Western Reserve University, School of Medicine, Cleveland, Ohio (Dr Garner); American Academy of Pediatrics, Elk Grove Village, Ill (Ms O’Connor); and New York State Office of Mental Health, Albany, NY (Dr Hoagwood) The authors declare that they have no conflict of interest. Address correspondence to Bonnie D. Kerker, PhD, Department of Child and Adolescent Psychiatry, New York University School of Medicine, [email protected] ). 1 Park Ave, 7th Floor, New York, NY 10016 (e-mail: Received for publication May 28, 2015; accepted August 1, 2015. BSTRACT A ACE study. Pediatricians who screened/inquired about ACEs BJECTIVE The stress associated with adverse childhood ex- O : usually asked about maternal depression (46%) and parental periences (ACEs) has immediate and long-lasting effects. The separation/divorce (42%). Multivariable analyses showed that objectives of this study were to examine 1) how often pediatri- pediatricians had more than twice the odds of usually asking cians ask patients’ families about ACEs, 2) how familiar pedia- about ACEs if they disagreed that they have little effect on influ- tricians are with the original ACE study, and 3) physician/ encing positive parenting skills, disagreed that screening for so- practice characteristics, physicians’ mental health training, cial emotional risk factors within the family is beyond the scope and physicians’ attitudes/beliefs that are associated with asking of pediatricians, or were very interested in receiving further ed- about ACEs. ucation on managing/treating mental health problems in chil- : ETHODS M Data were collected from 302 nontrainee pediatri- dren and adolescents. cians exclusively practicing general pediatrics who completed ONCLUSIONS C Few pediatricians ask about all ACEs. Pediat- : the 2013 American Academy of Pediatrics Periodic Survey. Pe- ric training that emphasizes the importance of social/emotional diatricians indicated whether they usually, sometimes, or never risk factors may increase the identification of ACEs in pediatric inquired about or screened for 7 ACEs. Sample weights were primary care. used to reduce nonresponse bias. Weighted descriptive and lo- gistic regression analyses were conducted. : ACE; adverse childhood experiences; pediatric K EYWORDS : ESULTS R Only 4% of pediatricians usually asked about all 7 primary care; screening ACEs; 32% did not usually ask about any. Less than 11% of pe- diatricians reported being very or somewhat familiar with the CADEMIC P EDIATRICS 2016;16:154–160 A 1 ’ S N EW Adverse experi- W HAT health and mental health (MH) problems. ences in early childhood have been linked to develop- Few pediatricians usually ask patients about all adverse mental delays and injuries in 4- and 5-year-olds, learning childhood experiences (ACEs). Pediatricians’ attitudes and behavioral disorders and high body mass index among and beliefs about ACEs are related to asking about children and adolescents, and poor MH in young them; physician/practice/training factors are not. Pedi- 2–4 children. The Adverse Childhood Experiences (ACEs) atric training that emphasizes the importance of so- study retrospectively examined the long-term impact of cial/emotional risk factors may increase identification adverse experiences, such as childhood abuse, neglect, in pediatric practices. and household dysfunction, and demonstrated that greater numbers of stressors experienced early in life were associ- ated with later-in-life risk taking and unhealthy lifestyles, 5 T with cumulative adverse HE STRESS ASSOCIATED as well as with disease. experiences in early childhood has immediate and long- Identifying ACEs in young children who are not yet in lasting effects, as it can disrupt developing brain circuits school can be difficult. However, most infants do receive 6 and increase levels of stress hormones, leading to adult well-child visits, and the American Academy of Pediatrics A CADEMIC P EDIATRICS Volume 16, Number 2 Copyright ª 2016 by Academic Pediatric Association 154 March 2016
2 HILDHOOD 155 C RIMARY P EDIATRIC P XPERIENCES IN E ARE C DVERSE A EDIATRICS P CADEMIC A atricians’ attitudes and beliefs about the impact of stress/ (AAP) recommends 7 well-child visits for children during adversity on child development (results not shown). None- the first year of life as well as frequent visits throughout early 7 theless, sample weights were created to reduce potential childhood. Given the frequency of contact with pediatri- nonresponse bias and ensure that the respondents were cians and the impact that ACEs can have on children’s health, representative of the AAP membership. Logistic regression pediatric offices may be a promising venue for identifying was used to estimate response propensity scores. The final and managing adverse experiences in early childhood. model included the 3-way interaction of age, sex, and re- The AAP recognizes that early life experiences can gion, as well as their 2-way interactions and main effects. impact long-term health outcomes and has consequently Ten groups were created using deciles of the response pro- made significant efforts to raise the awareness of ACEs pensity score distribution. The sample weights were the in- and their effects on early brain and child development 8,9 verse of the average propensity score for each group. The among pediatricians. For example, to identify children sample weights were rescaled such that the mean was unity at risk, it has encouraged pediatricians to implement and the sum was equal to the analytic sample size. routine screening to identify family- or community-level 9,10 factors that may adversely affect children. However, we know little about which pediatricians do and do not E ARIABLES XPOSURE AND O UTCOME V regularly identify ACEs among their patients. Sociodemographic factors included physician character- In 2013, the AAP included questions about identifying istics (eg, race/ethnicity, sex, age) and practice characteris- adverse experiences among children in its Periodic Survey tics (eg, years in practice, type of practice, patient (PS). Given these unique data, the goals of this study were insurance). Physicians were asked about their past child to: 1) examine how often pediatricians ask patients’ fam- MH-related residency and fellowship training (in develop- ilies about ACEs, 2) examine pediatricians’ familiarity mental/behavioral pediatrics, child psychiatry, adolescent with the original ACEs study, 3) assess pediatricians’ atti- medicine, and behavioral sciences), and their interest in tudes and beliefs about the impact of stress/adversity on future MH-related education, which was rated on a 3-point child development, and the role that parents and pediatri- ordinal scale (very, somewhat, not at all). Physicians were cians have in mitigating the effects of ACE, and 4) examine also asked how familiar they were with the original ACEs the associations of physician and practice characteristics, study (very, somewhat, vaguely, not at all familiar). Their MH training, and physician attitudes and beliefs with beliefs and attitudes about adverse experiences, the impact asking about ACEs. of ACEs on children, and the role that parents and providers play in mitigating the effects of ACEs were assessed using a M ETHODS 5-point Likert scale, ranging from strongly agree to strongly disagree. Responses were dichotomized such that strongly URVEY PS 85 S DMINISTRATION A agree and agree were compared to the other 3 categories The AAP has conducted a PS of pediatricians 3 or 4 for positively worded questions, and strongly disagree and times each year since 1987 to inform policy, to develop disagree were compared to the other 3 categories for nega- new initiatives, and/or to evaluate current projects. Data tively worded questions. collection for the PS 85 occurred between July and Using a 3-point ordinal scale (usually, sometimes, December 2013. The survey contained largely closed- never), pediatricians were asked how often they inquired ended questions asking about sociodemographic and about or routinely screened for 7 ACEs: maternal depres- practice characteristics, and it included questions about sion, parental separation/divorce, physical or sexual abuse, attitudes, training, and behaviors about child/adolescent hostile/rejecting parenting by mothers, domestic violence and maternal MH. The questionnaire was pretested and exposure, parental alcohol/drug use, and incarcerated rela- approved by the AAP institutional review board before tive. Although hostile/rejecting parenting by mothers was the mailings. Information about the survey is available on- not included in the original ACEs study, it is conceptually http://www.aap.org/en-us/professional-resources/Res line ( similar to emotional abuse, which was in the original study; earch/pediatrician-surveys/Pages/Periodic-Survey-of-Fell emotional abuse was not included in the PS 85. Pediatri- ows.aspx/ ). cians who reported usually inquiring about or routinely Of the 54,491 US nonretired AAP members, 1617 were screening for 1 or more ACEs (asking about any ACEs) randomly selected and asked to complete the PS 85. were compared to those who reported sometimes or never Although the sample represents the AAP membership on asking about any ACEs. age, sex, and region (data not shown), the response rate 594, 37%). Comparisons of re- was suboptimal (n ¼ S A TATISTICAL NALYSIS sponders and nonresponders showed that the former group Univariate and bivariate analyses were summarized P was significantly older (46.6 vs 43.7 years, < .001). using weighted percentages for categorical measures and Additional analyses examined differences between early weighted means and standard errors for continuous mea- and late responders, using late responders as a proxy for sures. Bivariate comparisons were assessed by the Rao- nonresponders. The groups were similar with respect to Scott chi-square test and weighted linear regression. how often pediatricians ask patients’ families about Weighted multivariable logistic regression was used to ACEs, familiarity with the original ACEs study, and pedi-
3 156 EDIATRICS P CADEMIC A ERKER ET AL K Physician and Practice Characteristics for Analytic Sam- Table 1. examine associations of physician characteristics, practice ple and Bivariate Associations With Pediatricians Usually Asking characteristics, and beliefs/attitudes with usually asking About One or More ACEs (Weighted %) about any ACEs. The results are summarized using odds Pediatrician Usually Asks ratios and 95% confidence intervals, and statistical signif- About One or More ACEs < P icance was set at .01. All analyses were performed by Analytic No Yes Sample SAS 9.3 (SAS Institute, Cary, NC). ¼ Characteristic (n (n (n ¼ 96) 302) ¼ 206) P Physician Characteristics Sex .5648 ESULTS R Female 30.8 69.2 68.1 Examination of the 321 nontrainee pediatricians who Male 31.9 34.2 65.8 Age, y, weighted 46.0 (0.6) 47.1 (1.3) 45.5 (0.7) .2597 exclusively practiced general pediatrics showed that 302 mean (SE) answered the majority of the ACEs questions and therefore Years in practice .0518 were included in the analytic sample. Pediatricians were 46 21.3 5 < 65.7 34.3 ). years old on average, and 68% were women ( Table 1 16.5 5–9 18.1 81.9 About half (51%) practiced in suburban settings, 53% 29.6 10–19 73.1 27.0 $ 58.6 41.4 32.6 20 worked in pediatric group practices, and 21% were in prac- .0107 Race/ethnicity tice for less than 5 years. Almost two-thirds saw fewer than 74.5 White 68.8 31.2 100 ambulatory visits per week (65%), and the majority of Asian 51.6 48.4 11.5 the patients served were white and 16% of physicians re- 19.3 Other 80.7 13.9 ported that at least 80% of their patients have public insur- Location of practice .5484 Urban 39.1 29.7 70.3 ance or Medicaid. About half of pediatricians completed 4 Suburban 34.5 65.5 50.7 or more weeks of a developmental/behavioral pediatrics 10.2 Rural 26.1 73.9 rotation in residency, and 70% completed 4 or more weeks Practice Characteristics of a residency rotation in some child MH area; very few Type of practice .7505 (2%) completed a fellowship in child MH. Nearly half 38.5 8.7 1 or 2 physician 61.5 33.9 52.7 66.1 Pediatric group attended a child MH lecture/conference in the past 2 years practice and were very interested in further education on child and 70.5 Multispecialty group 12.1 29.5 adolescent MH ( Table 2 ). 71.6 Medical school/ 28.4 7.2 Only 2% of pediatricians reported that they were very parent university familiar with the ACEs study, 9% were somewhat familiar, Other/unknown 19.3 26.1 73.9 Ambulatory visits per 13% were vaguely familiar, and 76% were not at all week .0694 familiar (results not shown). Approximately one-third < 28.4 71.6 100 65.2 (32%) of pediatricians reported that they did not usually 100 38.8 34.8 61.2 $ ask about any ACEs, while 4% reported usually asking .8051 Patient insurance Figure 1 ). The ACEs pediatricians usu- about all 7 ACEs ( 31.0 < 70.1 80% have 69.0 Medicaid/public ally asked about most often were maternal depression insurance ). Figure 2 (46%) and parental separation/divorce (42%) ( $ 31.7 15.8 80% have 68.3 The least commonly asked about ACEs were hostile/reject- Medicaid/public ing parenting by mothers (10%) and incarcerated relatives insurance (9%). A greater percentage of physicians who were very or Unknown 14.1 36.2 63.8 .4829 White patients somewhat familiar with the ACEs study usually asked 71.5 # 49% 41.4 28.5 about ACE compared to physicians who were vaguely or 66.1 50–74% 35.7 33.9 not at all familiar with the ACEs study (83.2% vs 66.2%, $ 63.5 36.5 22.9 75% P .04) (results not shown). Only 2% reported routinely ¼ ACE indicates adverse childhood experience. using a screening tool for child ACEs, 4% reported using the tool at times, 46% reported never using the screening to usually ask about ACEs compared to those who were tool, and 49% reported that they had never heard of the somewhat or not at all interested in further education on screening tool (results not shown). these topics ( Table 2 ). Unadjusted bivariate analyses showed that the only Pediatricians’ attitudes and beliefs are reported in physician characteristic associated with usually asking Table 3 . Most notably, only one-third of physicians about ACEs was race/ethnicity: significantly fewer Asian (34%) agreed that prolonged or excessive physiologic pediatricians usually asked about ACEs compared to white stress in childhood can result in epigenetic modification pediatricians or pediatricians of other race/ethnicity of the DNA, but almost all agreed that persistent physio- ( Table 1 ). No practice characteristics were associated logic stress in childhood can make children less capable with asking about ACEs. Physicians who were very inter- of coping with future stress (92%) and can disrupt brain ested in further education on identifying child and adoles- development an impair educational achievement (96%). cent MH problems and on managing/treating child and A great majority also indicated that stable and supportive adolescent MH problems were significantly more likely
4 A 157 P EDIATRIC P XPERIENCES IN E HILDHOOD C DVERSE RIMARY EDIATRICS P CADEMIC A C ARE MH Training and Bivariate Associations With Pediatricians Usually Asking About One or More ACE (Weighted %) Table 2. Pediatrician Usually Asks About One or More ACE No (n Characteristic 302) ¼ ¼ P 206) Analytic Sample (n ¼ Yes (n 96) Child/Adolescent MH training Completed $ 4 week residency rotation in DBP 45.0 33.9 66.1 .4879 No 69.8 30.2 55.0 Yes Completed 4 week residency rotation in child MH $ area 30.4 35.3 64.7 .3952 No Yes 30.4 69.6 69.6 Completed fellowship in child MH area No 97.7 33.1 66.9 .2450 2.3 Yes 13.0 87.0 Attended child MH lecture/conference in past 2 years .4884 No 55.7 33.8 66.2 Yes 44.3 30.0 70.0 Very interested in further education on identifying child and adolescent MH problems 60.9 No 47.6 39.1 .0097 25.0 75.0 52.4 Yes Very interested in further education on managing/ treating child and adolescent MH problems No 55.6 40.0 60.0 .0009 78.1 21.9 Yes 44.4 MH indicates mental health; ACE, adverse childhood experience; DBP, developmental/behavioral pediatrics. skills among patients’ parents and that screening for social adult relationships can mitigate the negative effects of emotional risk factors within the family is beyond the persistent childhood stress (84%). Most pediatricians dis- scope of the pediatric medical home were also positively agreed that positive parenting has little influence on a .001). associated with usually asking about ACEs ( P < child’s life-course trajectory (96%), that advice from pedi- Results from the multivariable logistic regression ana- atricians has little effect on influencing positive parenting lyses showed that those who disagreed that pediatricians skills (79%), and that screening for social emotional risk have little effect on influencing positive parenting skills factors within the family are beyond the scope of the pedi- among patients’ parents had a 2.2-fold increased odds of atric medical home (81%). usually asking about ACEs ( ). Similarly, pediatri- Table 4 Unadjusted bivariate associations of these attitudes and cians who disagreed that screening for social emotional beliefs with usually asking about ACEs are also shown in risk factors within the family is beyond the scope of the pe- Table 3 . Agreeing that prolonged or excessive physiologic diatric medical home had a 2.4-fold increased odds of usu- stress in childhood can result in epigenetic modification of ally asking about ACEs. Pediatricians who were very the DNA was positively associated with usually asking interested in receiving further education on managing/ about ACEs ( P ¼ .04). Disagreeing that advice from pedi- treating MH problems in children and adolescents had a atricians has little effect on influencing positive parenting 2.1-fold increased odds of usually asking about ACEs. Maternal depression Parental separa Ɵ on/divorce Physical or sexual abuse Domes Ɵ c violence exposure Parental alcohol/drug use Ɵ Incarcerated rela ve Ɵ Ɵ Hos ng by mothers Ɵ ng paren le/Rejec 0% 20% 100% 80% 60% 40% Some mes Never Usually Ɵ Frequency with which pediatricians reported asking Figure 2. Number of ACE pediatricians reported usually asking Figure 1. about (weighted %). about each child ACE (weighted %).
5 158 EDIATRICS ERKER ET AL K P A CADEMIC Table 3. Beliefs About the Effect of Stress/Adversity on Children and Bivariate Associations With Pediatricians Usually Asking About One or * More ACEs (Weighted % Shown) Pediatrician Usually Asks About One or More ACEs Analytic Sample No Yes 302) value (n (n ¼ 96) ¼ (n ¼ 206) P Prolonged or excessive physiologic stress in childhood can result in epigenetic modification of the DNA 35.4 66.3 Disagree .0393 64.6 33.7 23.7 76.3 Agree Persistent physiologic stress in childhood can make children less capable of coping with future stress .6660 Disagree 8.3 27.8 72.2 32.0 Agree 68.0 91.7 Prolonged or excessive physiologic stress in childhood can disrupt brain development and impair educational achievement .3554 Disagree 3.7 44.4 55.6 Agree 96.3 31.2 68.8 Brief periods of stress can have a positive effect on a child by serving to motivate and build resilience .6880 69.4 30.6 Disagree 42.8 57.2 32.8 67.2 Agree Parents who have experienced significant adversity in childhood have a harder time forming stable and supportive relationships with their children 34.6 41.7 Disagree .3951 65.4 58.3 29.9 70.1 Agree Stable and supportive adult relationships can mitigate the negative effects of persistent childhood stress 62.5 Disagree 16.4 37.5 .3809 69.0 31.0 Agree 83.6 Positive parenting has little influence on a child’s life-course trajectory 69.1 Disagree 95.6 30.9 .0921 46.6 53.4 4.4 Agree Advice from pediatricians has little effect on influencing positive parenting skills among patients’ parents 78.8 Disagree 73.3 26.7 .0005 49.9 50.1 21.2 Agree Screening for social emotional risk factors within the family are beyond the scope of the pediatric medical home 81.1 Disagree .0001 73.2 26.8 Agree 46.4 18.9 53.6 *“Disagree” includes neutral for the positively worded items, and “Agree” includes neutral for the negatively worded items. sample do not usually ask about any ACEs, and only 4% ISCUSSION D ask about all of them, representing a missed opportunity Our data suggest that most pediatricians surveyed have to address familial issues that may have a large impact never heard of the original ACEs study and do not under- on children’s development as well as on both physical stand the epigenetic effects of ACEs. Nevertheless, most and mental health. Additional training on the importance believe that childhood stressors can have a negative impact of identifying ACEs in pediatric practices is essential to on children, that pediatricians can help influence parenting, ensuring high-level care for all children. and that positive parenting can influence children’s trajec- The adverse experience most commonly asked about tories. Even so, almost one-third of pediatricians in our was maternal depression, yet less than half of pediatricians Odds of Pediatricians Usually Asking About One or More ACEs Table 4. Characteristic OR 95% CI P Advice from pediatricians has little effect on influencing positive parenting skills among patients’ parents .0095 Disagree vs agree 1.21, 3.97 2.19 * Screening for social emotional risk factors within the family is beyond the scope of the pediatric medical home .0061 Disagree vs agree * 1.29, 4.56 2.42 Interested in receiving further education on managing/treating mental health problems in children and adolescents 1.25, 3.65 .0058 2.13 Very vs somewhat or not at all ACEs indicates adverse childhood experiences; OR, odds ratio; CI, confidence interval. *Disagree includes disagree and strongly disagree; agree (reference group) includes neutral, agree, and strongly agree.
6 HILDHOOD 159 C RIMARY P EDIATRIC P XPERIENCES IN E ARE C DVERSE A EDIATRICS P CADEMIC A they lack the training to do so. We did not have data on reported usually asking about this condition. It is not sur- pediatricians’ feelings of competence in this area, but prising that maternal depression is asked about most often, 11,12 research in other areas suggests that if physicians do not given the focus of the AAP on this issue. Studies of the feel competent in a topic, they do not address it with their impact of maternal depression on children have 21–23 patients or their families. consistently demonstrated both short- and long-term Pediatric training programs 13–16 negative effects. should consider including practical approaches to not However, only 1 in 10 pediatricians only asking about but also discussing ACEs with usually asked about hostile/rejecting parenting, our families. Providers would likely be more comfortable study’s proxy for the original ACEs study’s emotional using screening tools if they had training on how to talk abuse. Although asking about this sensitive issue is with parents about sensitive subjects such as adverse certainly challenging, it seems critical that pediatricians experiences and what to do with the information they gather information about parenting practices, given collect. Further, it would be helpful for training to stress research suggesting that supportive parenting is ting screening tools and the importance of incorpora associated with positive changes in brain structure and 17–20 anticipatory guidance into practice. Future research fewer MH symptoms. The distribution of ACEs should examine more fully the barriers to having usually asked about suggests that although individual discussions about ACEs i n pediatric practice. adverse experiences may be salient with some These data are not without limitations. The survey had a pediatricians, as a whole, they have not embraced the suboptimal response rate, which is typical for surveys of concept of comprehensively identifying the social and 24,25 physicians. emotional factors that can impact children. However, extensive analysis of response The factors that were most strongly associated with usu- bias in AAP surveys, including periodic surveys, has 26 ally asking about ACEs were pediatricians’ attitudes and shown little nonresponse bias. Further, we found little dif- beliefs. Although most pediatricians believed that they ference among AAP members, providers who were can influence parenting, this attitude doubled the odds of randomly selected for the survey, and survey participants. pediatricians asking about ACEs, suggesting that training Additionally, early and late responders were similar with that emphasizes pediatricians’ ability to impact the lives respect to the primary outcomes of this study. Nonetheless, of their young patients, as well as strategies that pediatri- even though the results were weighted to reduce potential cians can use to help parents mitigate the impacts of stress- nonresponse bias, there may have been differences in un- ful situations at home, might increase identification. The measured variables. For example, pediatricians who were majority of pediatricians believed that addressing social very interested in the topic may have been more likely to 27 emotional issues is within the scope of pediatric practice, respond. There is also the possibility of response bias and those with this attitude also had twice the odds of for professionally desirable behaviors. If nonresponse or so- asking about ACEs. These findings suggest that learning cial desirability bias were present, we anticipate that our how social and environmental factors can influence health findings would overestimate the prevalence of physicians may be an important yet missing component of pediatric who usually ask about ACEs. Also, the 7 questions about training. Further, pediatricians who were very interested ACEs were conceptually similar to those used in the orig- in further MH education were twice as likely to ask about inal ACEs study, although the wording was not exactly ACEs as those who were not, suggesting that training is the same, and 2 of the original ACEs questions were not particularly important for pediatricians who are not inter- included in the AAP survey (physical neglect and emotional ested in MH issues. neglect). An additional ACE, emotional abuse, was exam- Our data also indicate that almost no pediatricians use a ined with a proxy, hostile/rejecting parenting. Further, the screening tool to assess adverse experiences in families, original study separated out physical and sexual abuse. If and almost half had never heard of such a tool. This is anything, we believe that these differences would overesti- not surprising given the lack of validated ACEs screening mate the number of ACEs that pediatricians usually ask tools available to pediatricians, although there are some about. Finally, these data are cross sectional, and therefore promising screening models available to gather data on in- the reported associations do not imply causality. dividual adverse events (eg, http://umm.edu/programs/ This national survey of pediatricians suggests that ). None- childrens/services/child-protection/seek-project although pediatricians seem to understand the importance theless, the field should invest in the development of vali- of childhood stressors to children’s health and develop- dated comprehensive, easy to use tools to help ment, most are not asking about all ACEs in their practice. pediatricians better assess their patients’ needs. Educating pediatricians about toxic stress became an AAP Identifying ACEs among young children may lead to educational goal around the same time that this survey was concrete steps to address family situations and mitigate administered, so it would be beneficial to repeat this survey the consequences of the event; additionally, conversations to see if recent efforts have made a difference in asking about ACEs with parents might encourage them to seek about ACEs. The 2013 survey showed that those who help, either as a result of an increased understanding of believe that pediatricians can influence parenting practices the importance of adverse events to their children’s health and those who believe that asking about social emotional or as a result of someone expressing interest in their dif- issues is within the scope of pediatric practice are more ficulties and validating their experiences. One reason pe- likely to ask about ACEs compared to those who do not diatricians do not ask about ACEs more often may be that hold such beliefs. These findings emphasize the need to
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