Running head: ASSESSING SUICIDE IN PEDIATRIC PRACTICE 1

Addressing Suicide in Pediatric Practice: Understanding Risk and Benefits of use of an

ACES Screening

Sara Jung, Cade Kerry, Amanda Van Mil, Shayna Mickenberg

University of Cincinnati
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Introduction

Well-Child Visits and Pediatric Suicide Risk

While well child visits have resulted in greater quality of life due to the elimination of

many previously deadly childhood diseases, there is a growing problem with concerns such as

“obesity, attention-deficit/hyperactivity disorder, behavior disorders, depression, and adolescent

risk behavior”​ ​(Schor, 2004, p.210) that is not currently being addressed by many pediatric

professionals during these scheduled appointments.

Tanner, Stein, Olson, Frintner, and Radecki (2009) determined that education, tools,

infrastructure within pediatric practices, and referral processes contribute to the “degree of

comfort in developmental surveillance and psychosocial counseling” (p.855)​ ​for pediatric

professionals. Pediatricians’ experience and comfort level and their awareness of outside

resources may limit their assessment of mental health conditions. However, the data suggest that

the suicide problem is a vital one for pediatricians to address. According to the CDC, the second

leading cause of death for both 10-14 and 15-24 year olds is suicide (Kochanek, Murphy, Xu,

Arias, 2017). Another startling piece of data about youth suicide is that over 80% of adolescents

who move from a suicide plan to a suicide attempt do so within one year of developing the

suicidal intent (Nock, et al., 2013, p.302). These data demonstrate the seriousness of addressing

this problem and doing so early.

Adverse Childhood Experiences (ACES) Explained

The Adverse Childhood Experiences Study, or ACEs, is a series of questions that ask

about differing forms of abuse such as physical, emotional, or sexual, forms of neglect such as
ASSESSING SUICIDE IN PEDIATRIC PRACTICE 3

physical and/or emotional, and forms of household dysfunction such as family/relative mental

illnesses, domestic abuse, substance abuse, divorce, and/or incarcerated relative. (Starecheski,

2015) Subsequent ACE studies also include racism, bullying, foster care, and other family

member abuse (​"Got Your ACE Score?",​ n.d.). The ACEs showed that there was a correlation

between higher test scores and risks such as chronic depression, alcoholism, perpetrating

domestic violence, liver disease, suicide attempt, use of antidepressant prescriptions, higher teen

sexual behavior, drug use, and smoking (Starecheski, 2015).​ ​The ACEs test is important because

it gives the practitioner a potential understanding of the causes of patients’ risk factor(s), and it

can alert the clinician of potential risk for those who score high early on (Faulkner, 2017).

Concerns with Use of Screeners

There are positives and negatives regarding the use of screeners. In using screeners in a

pediatric office, Tanner et al. (2009) found that these standardized questionnaires regarding

behaviors and development actually stimulated discussion about areas of need with parents and

helped guide treatment for specialized conditions. However, the authors also noted that the

questions may not be answered to the best of the parents’ ability in a waiting room or exam

room, and that direct observation may be better than pressured questions in an unfamiliar setting.

Setting is important to pay attention to in another regard as well. Finkelhor (2017) noted that it’s

important to attend to outside resources in the geographical area after screeners are distributed in

order to appropriately care for patient in regards to the treatment needs found. Addressing both

of these concerns may increase the effectiveness of using screeners across a clinical setting.
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Schor (2004) recognizes that practitioners don’t often have enough time and resources

within their visits with families to adequately assess families individual needs. His suggestion is

that “standardized paper-and-pencil or computerized screening can routinely be performed in the

office or at home home before the family sees the physician,” suggesting that effective

psychosocial screening tools are both useful and available for helping pediatricians meet the

diverse needs of their patients without taking in-office time to collect patient information.

Rationale for Use of an ACE Screener

People who fit the ACEs criteria have been well studied, and the adverse effects on their

quality of life have been proven and well documented. According to Mary Boullier and Mitch

Blair of the Journal of Paediatrics and Child Health (2018), “Those people who have experienced

four or more adverse childhood experiences (ACE) are at significantly increased risk of chronic

disease such as cancer, heart disease and diabetes as well as mental illness and health risk

behaviours” (p.132). There are numerous studies that confirm ACEs are a risk factor in various

physical and mental conditions, including suicide. The American Journal of Preventive Medicine

says, “Relationships between ACEs and alcohol abuse, illicit drug use, sexual promiscuity, and

suicide (which are related to causes of death that constitute a smaller fraction of total death)

exhibited strong, graded relationships across the ACE score” (Brown et al., 2009, p.395). In fact

studies show that those who have multiple ACEs are also more likely to use psychotropic

medications to manage mental health diagnoses (Boullier & Blair, 2018).

People with ACEs are far more likely to commit suicide and suffer from various mental

health conditions than those without. These concerns, among other reasons, are why an ACEs
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screener is an appropriate basis for assessing for complex trauma, and a necessary tool in

working with a pediatric population as they age.

Center for Youth Wellness ACES Screener

Choosing an ACES screener can be a difficult challenge for a pediatric practitioner.

Screeners vary in cost, effectiveness, and ease of deployment. There is often a significant

amount of training required to properly implement a screener. One strong contender is the

ACES screener developed by the Center for Youth Wellness in San Francisco. Developed by

Nadine Burke Harris (2015), one of the best-known voices in the application of ACES data, this

screener has many benefits. The screener is short - only one page - and could easily be deployed

online, alleviating some of the concerns with in-office screeners. The CYW screener requires

only a registration to implement, and is therefore free of cost (Burke Harris & Renschler, 2015).

Along with the screener itself, CYW has produced training and administration

information, which is also free, and includes relevant links to AAP recommendations to support

use of the screener. Finally, as noted in the administration guide, data show that ACES increase

yearly, so early detection is key (Bucci et al., 2015). While the questions about how to best

connect pediatric patients with outside services persists, this screener option does address many

of the concerns noted throughout this introduction in giving pediatricians a first-step option in

assessing for complex trauma as a suicide prevention strategy.

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References

Boullier, M., & Blair, M. (2018). Adverse childhood experiences.​ Paediatrics and Child Health,

28​(3), 132-137. doi:10.1016/j.paed.2017.12.008

Brown, David W., DSc, MScPH, MSc, Anda, Robert F., MD, MSc, Tiemeier, H., PhD, Felitti,

V. J., MD, Edwards, V. J., PhD, Croft, J. B., PhD, & Giles, Wayne H., MD, MSc. (2009).

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Preventive Medicine, 37(​ 5), 389-396. doi:10.1016/j.amepre.2009.06.021

Bucci M, Gutiérrez Wang L, Koita K, Purewal S, Silvério Marques S, Burke Harris N. Center for

Youth Wellness ACE-Questionnaire User Guide. San Francisco, CA: Center for Youth

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San Francisco, CA.

Faulkner, M. Adverse Childhood Experiences (ACE) Study: The evidence behind what we know

- Texas Institute for Child & Family Wellbeing. Retrieved from

https://txicfw.socialwork.utexas.edu/adverse-childhood-experiences-aces-study/

Finkelhor, D. (2017). Screening for adverse childhood experiences (ACEs): Cautions and

suggestions. ​Child Abuse & Neglect​. doi:10.1016/j.chiabu.2017.07.016

Got Your ACE Score?. (n.d.). Retrieved from ​https://acestoohigh.com/got-your-ace-score/

Kochanek KD, Murphy SL, Xu JQ, Arias E. Mortality in the United States, 2016. NCHS Data

Brief, no 293. Hyattsville, MD: National Center for Health Statistics. 2017.
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Nock, M. K., Green, J. G., Hwang, I., McLaughlin, K. A., Sampson, N. A., Zaslavsky, A. M., &

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earn-what-it-does-and-doesnt-mean

Tanner, J. L., Stein, M. T., Olson, L. M., Frintner, M. P., & Radecki, L. (2009). Reflections on

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