Using simulation to increase resident comfort discussing social determinants of health.

BACKGROUND: Social determinants of health (SDoH) play an important role in pediatric health outcomes. Trainees receive little to no training on how to identify, discuss and counsel families in a clinical setting. The aim of this study was to determine if a simulation-based SDoH training activity would improve pediatric resident comfort with these skills. METHODS: We performed a prospective study of a curricular intervention involving simulation cases utilizing standardized patients focused on four social determinants (food insecurity, housing insecurity, barriers to accessing care, and adverse childhood experiences [ACEs]). Residents reported confidence levels with discussing each SDoH and satisfaction with the activity in a retrospective pre-post survey with five-point Likert style questions. Select residents were surveyed again 9-12 months after participation. RESULTS: 85% (33/39) of residents expressed satisfaction with the simulation activity. More residents expressed comfort discussing each SDoH after the activity (Δ% 38-47%; all p < .05), with the greatest effect noted in post-graduate-year-1 (PGY-1) participants. Improvements in comfort were sustained longitudinally during the academic year. More PGY-1 participants reported engaging in ≥ 2 conversations in a clinical setting related to food insecurity (43% vs. 5%; p = .04) and ACEs (71% vs. 20%; p = .02). DISCUSSION: Simulation led to an increased resident comfort with discussing SDoH in a clinical setting. The greatest benefit from such a curriculum is likely realized early in training. Future efforts should investigate if exposure to the simulations and increased comfort level with each topic correlate with increased likelihood to engage in these conversations in the clinical setting.

Association between cumulative exposure to adverse childhood experiences and childhood obesity.

BACKGROUND: Exposure to adverse childhood experiences (ACEs) is associated with many childhood diseases and poor health outcomes in adulthood. However, the association with childhood obesity is inconsistent. We investigated the association between reported cumulative ACE score and body mass index (BMI) in a large sample of patients at a single institution. METHODS: This cross-sectional study included children aged 2-20 years that were screened in a general pediatrics clinic for ACEs utilizing the Center for Youth Wellness ACEs questionnaire between July 2017 and July 2018. Overall ACE score was categorized as 'no exposure' (score = 0), 'low exposure' (score = 1), and 'high exposure' (score≥ 2). BMI was categorized as overweight/obese (BMI percentile ≥ 85) or non-obese (BMI percentile < 85). The association between ACEs score and obesity was determined using univariate and multivariable logistic regression. RESULTS: Of the 948 patients included in the study, 30% (n = 314) were overweight/obese and 53% (n = 504) had no ACE exposure, 19% (n = 179) had low ACE exposure, and 28% (n = 265) had high ACE exposure. High ACE exposure was associated with increased odds of obesity (OR = 1.47, 95%CI = 1.07-2.03, p = 0.026). However, after adjusting for age, race/ethnicity, insurance type, and birth weight, the association attenuated and was null (OR = 1.01, 95%CI = 0.70-1.46, p = 0.97). CONCLUSION: The study findings may suggest an association between ACE and childhood obesity. However, the association attenuated after adjusting for age, race/ethnicity, insurance type, and birth weight. Larger prospective studies are warranted to better understand the association.

Implementing Standardized Screening for Adverse Childhood Experiences in a Pediatric Resident Continuity Clinic.

INTRODUCTION: Exposure to adversity in childhood has been shown to impact the development of children and increase their risk of poor early childhood mental health and chronic medical conditions in young children, and developing chronic diseases, mental health disorders, and substance abuse disorders as adults. The recognition of adverse childhood experiences (ACEs) and provision of behavioral-based interventions can help children build resilience. We implemented a screening method to help providers better assess patients' exposure to adversity. Our goal was to increase the screening for ACEs utilizing a standardized ACEs screening tool from 0% to 80% of children presenting for annual well-child visits within 1 year. METHODS: We implemented a screening tool to determine a child's exposure to ACEs within our general pediatrics clinic. A variety of interventions, including resident, faculty, and staff-focused educational lectures, simulation, and process changes were performed to increase screening. Also, we surveyed resident physicians and faculty about their experiences with ACEs screening. RESULTS: Over 1 year, we screened 1,206 patients for exposure to ACEs and increased screening from 0% to 60%. Provider comfort with discussing abuse with patients and familiarity with resources for children exposed to ACEs did not change significantly. CONCLUSIONS: Patients can successfully be screened in a resident-led, general pediatric clinic using a standardized ACEs screening tool. Such an approach can successfully identify patients with high-risk ACE scores. Additionally, education on and implementation of the tool may improve provider comfort with screening for ACEs.