Screening for Adverse Childhood Experiences (ACEs) before age 3: Evidence for the Family Map Inventory


Engaging and supporting parents as key nurturers of children is a hallmark objective of Early Head Start (EHS) and other high quality childhood education programs (U.S. Department of Health and Human Services, 2018, 2022). In particular, two-generation programs like EHS are tasked with supporting children’s optimal development directly, through educational programming, and indirectly, through collaboration with parents (or other caregivers). EHS programs are mandated to support parents in efforts to reduce child risks of poor development through partnership with parent in the use of educational services, supportive interventions, and referrals to community services. To be successful in this goal, educators require supportive training on developing partnerships with families and tools to systematically and accurately assess the environment while building a productive, goal directed relationship with the parent (U.S. Department of Health and Human Services, 2018, 2022).

Our growing understanding of the widespread negative impacts of Adverse Childhood Experiences (ACEs) on children’s development highlights the import of interventions that support the parenting environment (Centers for Disease Control and Prevention, 2019; Shonkoff et al., 2012). An array of studies has demonstrated that early experiences are consistently associated with adult emotional, social and health outcomes. These range from concurrent disruptions in development in early childhood to early adolescent behavior concerns to serious illness in adulthood such as cancer, diseases of the heart, lungs, and liver (American Academy of Pediatrics, 2014; Chanlongbutra, Singh, & Mueller, 2018; Gilgoff, Singh, Koita, Gentile, & Marques, 2020; Hunt, Slack, & Berger; Jimenez et al., 2017; McKelvey et al., 2015; McKelvey, Edge, Mesman, Whiteside-Mansell, & Bradley, 2018; McKelvey, Edge, Fitzgerald, Kraleti, & Whiteside-Mansell, 2017; McKelvey, Whiteside-Mansell, McKelvey, Saccente, & Selig, 2019).

Even though these studies underscore the need for screening and provisions for early intervention, there is a lack of consensus on the best method for concurrent screening during childhood. In particular in the context of building a collaborative partnership with parents, the choice of a screening tool is difficult. Specific indicators of ACEs vary but are generally reports of traumatic events experienced in childhood, including direct experiences of maltreatment, for example, physical, sexual, or emotional abuse/neglect. Indicators also includes parent/family characteristics associated with less optimal parenting such as incarceration of a family member, domestic violence, mental illness (Shonkoff et al., 2012). The 1998 seminal study of adults reporting retrospectively identified 10 key indicators of ACEs (Felitti et al., 1998). In this seminal work, the assessment of ACEs was a self-report assessment from adults reflecting on their childhood before age 18 (Stevens, 2012). Studies of the exposure to individual adverse experiences as well as the cumulative effect of the number of experiences (i.e. sum of indicators) has consistently indicated
increased risk of poor outcomes as the number of adverse experienced increases (Anda et al., 2006; Brown et al., 2009). The tool used in the Felitti et al study (Kaiser-ACEs), is direct in the presentation of items used to assess abuse and neglect and has been excluded in some cases from research studies for that reason (Health Resources and Services Administration, 2015).

The selection of a screening tool should depend on the expected use of the information (Bethell et al., 2017). Most are reworded versions of the Kaiser-ACE tool (Burke, Hellman, Scott, Weems, & Carrion, 2011) or leave out the potential offensive constructs of neglect or abuse (Bethell, Newacheck, Hawes, & Halfon, 2014). The California Department of Health Care Services (DHCS) has adopted a screening tool for the pediatric setting. The goal of the s pediatric screen is so that ‘providers can better determine the likelihood a patient is at increased health risk due to a toxic stress response’ (“Trauma Informed Care,” 2021). The DHCS uses PEARLS, the Pediatric ACEs and Related Life-events Screener (State of California Department of Health Care Services, 2022; Thakur et al., 2020; “Trauma Informed Care,” 2021). The PEARLS, like many ACE screening tools, is based on the Kaiser-ACEs tool reworded for the young child as the target of the screen. It has shown to be useful in the pediatric and research context (Bethell et al., 2017). However, when the intent is to provide support or intervention on specific parenting or home environmental risk for adverse experiences and is reported by parents in face-to-face interviews with educators in child education programs, screeners like the PEARLS and Kaiser-ACE may be inconsistent with the goals of supportive collaboration. An important challenge is that the parent will most often the key informant and is likely reluctant to admit the existence of illegal or stigmatized behavior, such as child maltreatment, and drug use or abuse (McKelvey, Selig, & Whiteside-Mansell, 2017). Further, affirmative responses to questions about these exposures may require child welfare reporting. Finally, the direct questions used for adults may disrupt rapport building with the child’s caregiver, making the link to resources or intervention difficult.

The FMI system takes a different approach. The FMI-ACEs are proxies for the constructs identified (Kaiser-ACE) in adult retrospective reporting (Anda et al., 2006; McKelvey, Conners Edge, et al., 2017; McKelvey et al., 2016) but appropriate for preschool children. For example, the FMI asks if the parent spanks with objects, rather than asking about confirmed physical abuse. The FMI is family-friendly and was developed in collaboration with EHS parents, educators and administrators to strengthen parent-provider relationships (Whiteside-Mansell, et al., 2013; Whiteside-Mansell, et al., 2007). The FMI implementation includes training in the use of the tool to enhance the parent-educator partnership. ACEs assessed using the Family Map Inventory (FMIACE) have been shown to be associated with concurrent parenting attitudes and behavior (McKelvey, Whiteside-Mansell, Conners-Burrow, Swindle, & Fitzgerald, 2016) and early physical and behavioral health indicators (McKelvey, Conners Edge, Fitzgerald, Kraleti, & Whiteside-Mansell, 2017). Like the Kaiser-ACE, these validation studies indicate that reduction in the number of FMI-ACEs is associated with less developmental concerns for children. However, previous validation studies were conducted based on data from home visitor interviews with families and used a paper and pencil version of the tool.

Since the examination by McKelvey and colleagues (McKelvey, Conners Edge, et al., 2017; McKelvey et al., 2016), the FMI transitioned from a paper to an online educator-parent interview portal (eFMI). Like other electronic systems, eFMI allows for easy access to information for educators, detailed reports of the interview that guide the EHS staff toward productive intervention efforts, document progress toward family goals, and make administrative supervision easier. On the other hand, similar to the concern for disruption of communication between medical provider and patient with the introduction of the use of electronic medical records (EMR), there is a concern that the transition to an electronic system will disrupt the parent-educator partnership (Alcocer Alkureishi et al., 2016).
The advantage of addressing potential ACEs as early as possible is obvious in the protection to
children. Further, addressing exposure to ACEs is in line with EHS goals. For example, EHS programs have goals related to supporting parents with depressive symptoms to receive treatment. In addition, while treatment is sought, EHS programs support parents during depressive episodes to protect children from the inconsistent parenting typically seen during depression. With these services focused on environmental conditions, children should see a reduction in the number of exposures.

We had two goals in this study. First, we aimed to validate the FMI-ACE captured through the electric system (eFMI-ACE) in the EHS context. To achieve this goal, we analyzed the association between eFMI-ACE and parental warmth, mirroring the validation study of the original paper version FMI-ACE (pFMI-ACE) used in home visiting programs (McKelvey, Conners Edge, et al.,2017; McKelvey et al., 2016). Preliminary support for the validity for the electronic version has been conduct in older preschool children. In a study of families with children 3 to 5 years of age, the number of ACEs recorded through eFMI-ACE showed a distribution similar to those recorded through Kaiser-ACE (Whiteside-Mansell et al., 2019).

Our second goal was to produce evidence that EHS programs are using the FMI effectively as an intervention tool. The FMI is designed so that educators using the FMI electronic system correctly will focus on support to families related to the constructs including in the FMI-ACE and reduce the number of exposures for children. We examined the change in the number of ACEs reported by families whose children are enrolled in EHS programs recorded through eFMI-ACE. We hypothesize that on average, EHS enrolled children whose educators use eFMI-ACE experienced a reduction in the number of ACEs.


Comments are closed.