A Qualitative Study of Pediatricians' Adverse Childhood Experiences Screening Workflows

Adverse childhood experiences (ACEs) are associated with poor health outcomes over the life course. Interest in ACEs screening is growing, but standard ACEs screening workflows have yet to be established. We aimed to describe common workflow processes and variation among pediatricians who have successfully implemented ACEs screening and response protocols.

We conducted semi-structured interviews with members of the American Academy of Pediatrics who practiced in clinical pediatric settings that implemented standardized ACEs screening (n = 18 physicians). Interviews were coded and analyzed using thematic content analysis and clinical processes were examined for differences across ACEs screening workflow processes.

ACEs screening workflows varied considerably, hinging primarily on determination of a positive screen, the type of interventions recommended in response, and protocolization of the workflow. We identified 5 major theme domains related to ACEs screening workflows: 1) degree of protocolization of the workflow, 2) screening tool(s) used, 3) timing of screening, 4) clinic staff involvement, and 5) interventions recommended and/or initiated by the physician. Common workflow processes were identified and grouped based on determination of and thresholds for response to a positive screen. Clinicians used symptoms, ACE score, or a combination of the 2 as criteria for deciding when to intervene and to what degree, though protocolization of this approach varied.

ACEs screening workflow variability was largely driven by clinical feasibility and availability of ACEs intervention resources. This variability demonstrates that a one-size-fits-all standardized screening protocol may not be universally feasible or appropriate across practices.