Disparities in Screening for Adverse Childhood Experiences

Discussion

This study showed that the majority of California adults had not been screened for ACEs in the clinical setting, indicating wide room for policy and programmatic efforts to increase screening. These findings also provide a critical baseline for rates of screening, before new reimbursement policies for ACEs screening that will likely increase the uptake.¹³ However, as efforts to screen for ACEs expand, clinician reported barriers to screening, such as lack of mental health resources to refer patients to, insufficient time to screen, lacking confidence, fear of retraumatization, lack of appropriate screening tools, and beliefs that screening for ACEs does not have a positive impact^7,37,38 should be considered and addressed. One potential avenue to address these barriers would be to provide more clinicians training on screening, including working to increase self-efficacy and reducing fears around screening.

About half of Californians thought it was very important for clinicians to ask about ACEs, suggesting that a majority of the population sees some benefit to being asked about ACEs. This may be helpful as screening efforts increase in the future. However, just under half of California adults view clinicians asking about ACEs as important, meaning educational and social marketing efforts focusing on the reasons clinicians might want to know about their ACE experiences is important. In particular, the public might benefit from further education around the difference between a clinician asking a patient about ACEs to help diagnose a patient, as might occur in behavioral health settings, versus formally screening for ACEs that may occur in settings where no behavioral health condition has been diagnosed or suspected. Finally, satisfaction with efforts by clinicians to address the impacts of ACEs was low. Thus, clinicians and health care administrators may need to proactively increase their efforts to address ACEs, beyond merely asking about them, and they need to communicate with their patients what they have done about ACEs and why.

The present study showed important disparities in ACEs screening and related beliefs. In terms of screening, several socially marginalized groups, including racial and ethnic minorities and the uninsured, were less likely to be screened for ACEs. Given that many racial and ethnic minority groups are more likely to report ACEs,^25,39,40 and also have higher burden of disease, the decreased rates of ACEs screening present a challenge for efforts to expand screening. Namely, can screening efforts be expanded in such a way to target systematically marginalized communities who are less likely to be screened, but might also experience the biggest impact, positive or negative, from screening? However, some have cautioned against using ACEs screening to predict mental illness among some population subgroups, particularly among different gender and racialized groups.⁴¹ Thus, disparities in screening must be addressed in a way that does not overextend their use to try to predict disease. Importantly, individuals with private insurance and those that were uninsured, were less likely to be screened, relative to those on Medicaid, suggesting that Medicaid’s reimbursement of ACEs screening⁴² is promoting more screening. However, because the CHIS asks about lifetime ACE screening, we cannot know if participants were screened for ACEs on their current insurance. In addition, the findings showed that some medically vulnerable groups were more likely to be screened. In particular, higher burden of ACEs was associated with increased rates of being screened by a clinicians, suggesting that some higher risk groups are being screened.

Findings also highlight important disparities in beliefs about the importance of clinicians asking patients about ACEs. Here several communities that have a higher burden of ACEs, and/or who have marginalized identities, expressed higher rates of believing it was very important for clinicians to ask patients about ACEs. Latinx individuals, women, bisexual individuals, and non-US citizens all had beliefs that viewed asking about ACEs as more important than their respective counterparts. Given the higher burden of ACEs in several of these communities, these findings suggest that these communities understand the importance of having conversations about ACEs during a clinician encounter. Based on how CHIS asked this question, however, it is unclear if respondents view “asking about” ACEs as something that is distinct from screening for ACEs, thus further research is needed. Further, the belief that asking about ACEs is very important, does not directly address any other issues that may prevent utilization of health care, among individuals with a history of ACEs. In particular, a growing body of research has shown that people with a history of ACEs are less likely to get preventative care,^20,21 and also less likely to receive patient centered care.⁴³ Thus, positive attitudes around being asked by a clinician about ACEs will be less relevant if people with ACEs are less likely to get care, particularly high quality care.

When examining the disparities in satisfaction with efforts by clinicians to address ACEs, more marginalized and underserved groups tended to be less satisfied. In particular, racial and ethnic minorities and those with a higher burden of ACEs, were less satisfied with efforts to address ACEs, than their counterparts. Clinicians and health care administrators should investigate why these disparities exist, and take proactive efforts to address reasons for dissatisfaction, particularly among marginalized and underserved groups. Otherwise, patients may be alienated from health care based on the shortcomings that they observe and perceive. Importantly, those who had been screened for ACEs by a clinician, were far more likely to be satisfied with their clinician’s efforts to address ACEs, highlighting the need for research that investigates what benefits patients perceive from ACE screening. In addition, results showed that individuals who had higher educational attainment were less likely to be very satisfied with clinician efforts to address ACEs. Further research should examine if this is a function of education increasing knowledge of the impacts of ACEs.

Findings should be interpreted in light of several limitations. First, the CHIS is a California-specific survey, which has a policy environment that is more supportive of ACEs screening than other states in the US, potentially limiting generalizability. Second, because the CHIS is cross-sectional in nature, it is not possible to determine temporality of associations. Third, because data are self-reported, it is subject to recall bias. This can, for example, lead to inaccurate recall of whether or not a respondent has been screened for ACEs. Fourth, because the majority of the sample was not screened for ACEs, it is unclear what the level of satisfaction with clinician efforts to address the impacts of ACEs means for those who have not been formally screened. Future work should examine what people want clinicians to do to address ACEs.

The current study offers an important look at rates of screening, related beliefs and disparities that exist. Across study outcomes, several groups with higher ACEs burden were less likely to be screened and be satisfied with efforts to address ACEs. Policy makers, clinicians, health equity advocates and health care administrators should keep this in mind as efforts to promote ACEs screening in health care continue. In particular, efforts to promote screening should be done equitably, and examine if the benefits of screening are disproportionately experienced by groups in the population that occupy positions of relative advantage. Continued efforts to expand ACEs screening could provide an opportunity to promote health equity, if done carefully. In addition, as efforts to expand screening continue, there is a critical need to determine the health and health care utilization benefits of ACEs screening.