The Journal of the Arkansas Medical Society Med Journal Sept 2019 FInal 2 | Page 13

AFMC: A CLOSER LOOK AT QUALIT Y
TABLE 1. Characteristics of children distributed by primary caregiver ACE score
0 1-3 4 or more
19 (31%) 25 (40%) 18 (29%)
9.5 years old 9.4 years old 9.8 years old
Gender distribution 57% female, 43% male 72% female, 28% male 52% female, 48% male
Ethnicity/race 79% White,
21% African American 80% White,
20% African American 95% White,
5% African American
Average diabetes duration 3.9 years 3.9 years 4.1 years
Average HbA1c (last 4 visits) 8.3% 8.3% 8.2%
Percentage of patients in diabetic ketoacidosis at diagnosis 42% 48% 52%
Average number of diabetes clinic visits per year since diagnosis 3.1 3.0 3.1
Caregiver ACE Score
Number (percent) of caregivers
Average age
of zero, one to three, or four or more.
We found no significant difference
in the average HbA1c, the average
number of diabetes clinic visits, or the
frequency of diabetic ketoacidosis
(DKA) at diagnosis.
Families of children with T1DM
have an exceptional burden of care.
Peer relations and family dynamics
play a critical part in adherence to
care and diabetes control. Psychoso-
cial factors and family stressors need
to be evaluated on a routine basis,
as they are linked to poorer glycemic
control. It is vital that the diabetes
team be aware of needs for mental
health or resource referrals. Social
workers and certified diabetes edu-
cators play a crucial role in screening
patients and connecting them to
appropriate resources during clinic
visits. ACEs scores are not part of the
current screening process.
This study did not show a signifi-
cant link between primary caregiver’s
ACE scores and child’s T1DM control.
However, a surprising number of
caregivers were found to have high
ACE scores, compared to the aver-
age number of ACEs experienced in
Arkansas: 69 percent of caregivers
reported at least one ACE; 29 percent
reported four or more ACEs. Con-
sidering the well-established rela-
tionship between higher ACE scores
and adverse health outcomes at the
individual and generational levels, it
is imperative to analyze the long-term
consequences of these findings in
longitudinal studies. Almost a third of
caregivers, with an ACE score of four
or more, are themselves at higher risk
of adverse health effects and may
benefit from additional resources.
Another study finding is that the
percent of patients who presented in
DKA was higher (but not statistically
significant) with higher primary care-
giver ACE scores. We cannot conclude
if the caregiver’s ACE score was a
contributing factor to the severity of
DKA; however, the effect of ACEs on
the caregiver’s ability to recognize
signs and symptoms of diabetes may
be examined. Following diagnosis,
there was no notable difference
between groups in diabetes-related
ED visits or hospital admissions for
DKA. Conclusions based on the results
of this study cannot be made given
the study’s small sample size, but
additional exploration is warranted.
A fine balance needs to be met
regarding the level of caregiver
involvement in their child’s diabetes
management. Over-involvement can
lead to stress, burnout and potentially
poor control. Under-involvement can
lead to increased acute or chronic dia-
betes-related complications. Protocols
are in place for screening patients and
families for depression, understand-
ing family dynamics, stressors, and
roles in responsibility of care, disor-
dered eating and poor social adjust-
ment. However, the focus of these
tools is the child, not the caregiver.
The ACE screening questionnaire may
serve as an adjunct tool to alert the
health care team to a family’s need for
increased social support. s
The authors work in the Division of
Diabetes and Endocrinology, Arkansas
Children’s Hospital.
REFERENCES:
• Psychological aspects of diabetes care: Effect-
ing behavioral change in patients. Chew BH,
Shariff-Ghazali S, Fernandez A. World J Diabe-
tes. 2014 Dec 15;5(6):796-808. doi:10.4239/
wjd.v5.i6.796. Review.
• Association of Parental Adverse Childhood
Experiences and Current Child Adversity. Ran-
dell KA, O’Malley D, Dowd MD. JAMA Pediatr.
2015;169(8):786-787. doi:10.1001/jamapediat-
rics.2015.0269
Visit afmc.org/ACEs for more
information about the 2019 Arkansas
Adverse Childhood Experiences and
Resilience Summit.
AFMC WORKS COLLABORATIVELY WITH PROVIDERS,
COMMUNITY GROUPS AND OTHER STAKEHOLDERS TO
PROMOTE THE QUALITY OF CARE IN ARKANSAS THROUGH
EDUCATION AND EVALUATION. FOR MORE INFORMATION
ABOUT AFMC QUALITY IMPROVEMENT PROJECTS,
CALL 1-877-375-5700 OR VISIT AFMC.ORG.
SEPTEMBER 2019
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SEPTEMBER 2019 • 61