The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis

Threat, Emotion Dysregulation, and Parenting in a Clinical Sample of Children with Disruptive Behaviour

Early-life adversity is associated with the development of internalizing and externalizing problems in children. Despite this, there is a need to understand the mechanisms linking these experiences to psychopathology, especially in clinical samples. This cross-sectional study tested emotion dysregulation as a mechanism linking early-life threat to psychopathology in a clinical sample of children with disruptive behavior problems. We also explored parental positive reinforcement as a protective factor in these pathways. A clinical sample of 606 children aged 6-12 years, referred to a mental healthcare hospital, were included. Parent-reported child threat, and parent- and teacher-reported child emotion dysregulation and psychopathology, were collected. Path analysis was used to explore the mediating effect of emotion dysregulation in the relation between threat and psychopathology. The moderating effects of parental positive reinforcement were explored through moderated-mediation analyses. Emotion dysregulation partially mediated the association between threat and both internalizing (β = .18, P = .006) and externalizing (β = .19, P = .002) problems. Positive reinforcement did not buffer the association between threat and emotion dysregulation (β = .09, P = .62) or the association between emotion dysregulation and internalizing (β = - .003, P = .20) or externalizing (β = - .002, P = .35). Poor emotion regulation may be a transdiagnostic mechanism linking early-threat with internalizing and externalizing problems in clinic-referred children with disruptive behaviors. Factors aside from parental positive reinforcement should be explored as protective factors in these pathways, including those directly implicated in the purported mechanisms linking these factors over time.

The Association Between a Neighborhood Adverse Childhood Experiences Index and Body Mass Index Among New York City Youth

Background: The role of neighborhood factors in the association between adverse childhood experiences (ACEs) and body mass index (BMI) has not been widely studied. A neighborhood ACEs index (NAI) captures neighborhood environment factors associated with ACE exposure. This study examined associations between BMI and an NAI among New York City (NYC) youth. An exploratory objective examined the NAI geographic distribution across NYC neighborhoods. Methods: Data for students attending NYC public general education schools in kindergarten-12th grade from 2006-2017 (n = 1,753,867) were linked to 25 geospatial datasets capturing neighborhood characteristics for every census tract in NYC. Multivariable hierarchical linear regression tested associations between BMI and the NAI; analyses also were conducted by young (<8 years), school age (8-12 years), and adolescent (>12 years) subgroups. In addition, NAI was mapped by census tract, and local Moran's I identified clusters of high and low NAI neighborhoods. Results: Higher BMI was associated with higher NAI across all sex and age groups, with largest magnitude of associations for girls (medium NAI vs. low NAI: unstandardized β = 0.112 (SE 0.008), standardized β [effect size]=0.097, p < 0.001; high NAI vs. low NAI: unstandardized β = 0.195 (SE 0.008), standardized β = 0.178, p < 0.001) and adolescents (medium NAI vs. low NAI: unstandardized β = 0.189 (SE 0.014), standardized β = 0.161, p < 0.001, high NAI vs. low NAI: unstandardized β = 0.364 (SE 0.015), standardized β = 0.334, p < 0.001 for adolescent girls; medium NAI vs. low NAI: unstandardized β = 0.122 (SE 0.014), standardized β = 0.095, p < 0.001, high NAI vs. low NAI: unstandardized β = 0.217 (SE 0.015), standardized β = 0.187, p < 0.001 for adolescent boys). Each borough of NYC included clusters of neighborhoods with higher and lower NAI exposure, although clusters varied in size and patterns of geographic dispersion across boroughs. Conclusions: A spatial index capturing neighborhood environment factors associated with ACE exposure is associated with higher BMI among NYC youth. Findings complement prior literature about relationships between neighborhood environment and obesity risk, existing research documenting ACE-obesity associations, and the potential for neighborhood factors to be a source of adversity. Collectively, evidence suggests that trauma-informed place-based obesity reduction efforts merit further exploration as potential means to interrupt ACE-obesity associations.

A hybrid digital parenting programme to prevent abuse of adolescents in Tanzania: statistical analysis plan for a pragmatic cluster randomised controlled trial

BACKGROUND

Globally, violence against children poses substantial health and economic challenges, with estimated costs nearing USD 7 trillion. This prompts the urgent call for effective evidence-based interventions in preventing and mitigating violence against children. ParentApp is a mobile, open-source application designed to offer a remote version of the Parenting for Lifelong Health (PLH) programme. ParentApp is the first digital parenting intervention for caregivers of adolescents aged 10-17 years to be tested in low- and middle-income settings.

METHODS

This study is a pragmatic, two-arm, cluster-randomised trial in Mwanza, Tanzania's urban and peri-urban areas. Assessments are set for baseline, 1 month post-intervention, and 12 months post-intervention. We randomised 80 clusters, each with about 30 caregiver-adolescent dyads, with a 1:1 ratio stratified by urban or peri-urban location. Both arms receive an entry-level smartphone preloaded with Kiswahili apps-ParentApp for intervention and WashApp control. The primary method of analysis will be generalised linear mixed-effects models with adjustment for person-level characteristics and multiple imputation. In three-level models, measurement waves are nested within a person, nested within a sub-ward. Regressions will constrain groups to be equal at baseline and include covariates for stratification, percentage of male caregivers, and individual-level characteristics.

DISCUSSIONS

Preparations for the trial began in December 2022, including community mobilisation and sensitisation. Rolling recruitment, baseline data collection, and implementation onboarding took place between April and September 2023. One-month post-test data collection began in August 2023 and thus far achieved 97% and 94% retention rates for caregivers and adolescents respectively. Final post-test data collection will begin in September 2024, anticipated to run until April 2025. This SAP was submitted to the journal before the interim analysis to preserve scientific integrity under a superiority hypothesis testing framework.

TRIAL REGISTRATION

The trial was registered on the Open Science Framework on 14 March 2023: https://doi.org/10.17605/OSF.IO/T9FXZ . The trial protocol was published in Trials 25, 119 (2024): Baerecke, L., Ornellas, A., Wamoyi, J. et al. A hybrid digital parenting programme to prevent abuse of adolescents in Tanzania: study protocol for a pragmatic cluster-randomised controlled trial. Trials 25, 119 (2024). https://doi.org/10.1186/s13063-023-07893-x .

The Association between Adverse Childhood Experiences and Frailty: A Systematic Review

OBJECTIVE

Based on life-course theory, adverse childhood experiences (ACEs) have emerged as risk factors for health in later life. This study aimed to explore the association between ACEs and frailty.

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

Frail older adults who have experienced ACEs.

METHODS

We searched 7 databases: PubMed, Cochrane Library, Embase, Web of Science, Scopus, PsycINFO, and China National Knowledge Infrastructure (CNKI). The last searched date was October 27, 2023. Included studies should have investigated the association between exposure to at least 1 ACE and frailty. Two researchers independently assessed the risk of bias in the included studies using the Newcastle-Ottawa Scale (NOS) and an adapted version of the NOS scale and also extracted relevant characteristics and outcomes of the included studies.

RESULTS

A total of 14 studies were finally included. Consistent associations with increased risk of frailty were only shown in studies that assessed family members with mental illness, low neighborhood quality, emotional abuse, sexual abuse, and combinations of ACEs. In addition, women exposed to ACEs were more likely to be at risk for frailty than men, and greater numbers or types of exposure to ACEs were associated with higher odds of frailty. The results of the quality assessment showed a moderate risk of bias in half of the studies.

CONCLUSIONS AND IMPLICATIONS

This study summarizes for the first time the evidence for an association between ACEs and frailty. Considered collectively, increased attention to ACEs may be one way to prevent frailty, and unhealthy lifestyles resulting from ACEs may serve as a breakthrough in developing interventions.

Allostasis, health, and development in Latin America

The lifespan is influenced by adverse childhood experiences that create predispositions to poor health outcomes. Here we propose an allostatic framework of childhood experiences and their impact on health across the lifespan, focusing on Latin American and Caribbean countries. This region is marked by significant social and health inequalities nested in environmental and social stressors, such as exposure to pollution, violence, and nutritional deficiencies, which critically influence current and later-life health outcomes. We review several manifestations across cognition, behavior, and the body, observed at the psychological (e.g., cognitive, socioemotional, and behavioral dysfunctions), brain (e.g., alteration of the development, structure, and function of the brain), and physiological levels (e.g., dysregulation of the body systems and damage to organs). To address the complexity of the interactions between environmental and health-related factors, we present an allostatic framework regarding the cumulative burden of environmental stressors on physiological systems (e.g., cardiovascular, metabolic, immune, and neuroendocrine) related to health across the life course. Lastly, we explore the relevance of this allostatic integrative approach in informing regional interventions and public policy recommendations. We also propose a research agenda, potentially providing detailed profiling and personalized care by assessing the social and environmental conditions. This framework could facilitate the delivery of evidence-based interventions and informed childhood-centered policy-making.

The effectiveness of interventions to prevent and reduce child maltreatment in high-income countries: An umbrella review

BACKGROUND

In recent decades, many interventions targeting the occurrence (primary prevention) or the recurrence (secondary prevention) of child abuse and neglect have been tested. Findings have been synthesized in several meta-analyses and systematic reviews. However, the range of interventions addressed in these studies is very broad, and an integrative assessment of this large spectrum is lacking.

OBJECTIVE

Focusing on high-income countries, we ask (i) what is known about the effectiveness of interventions to prevent or reduce child abuse and neglect and (ii) how robust this evidence is.

METHODS

A systematic review of systematic reviews, called an umbrella review, was conducted. Ten databases on OvidSP and Web of Science were searched up until April 2023. Narrative synthesis was used to document the publications' findings.

RESULTS

44 publications were included in the umbrella review. We did not find that any type of intervention had a clear, consistent, and robust track record of preventing or reducing the occurrence of child abuse and neglect. Rather, publications examining the effectiveness of interventions in all areas frequently reported non-existent, small or inconsistent effects. However, positive effects for particular interventions in specific settings did emerge. Research methodologies showed several and often severe problems.

CONCLUSIONS

We suggest several measures to improve the quality of research and call on practitioners to be persistent in developing more effective interventions.

Association Between Adverse Childhood Experiences and Opioid Use-Related Behaviors: A Systematic Review

As opioid use-related behaviors continue at epidemic proportions, identifying the root causes of these behaviors is critical. Adverse childhood experiences (ACEs) are shown to be an important predictor of opioid initiation, opioid dependence, and lifetime opioid overdose. The purpose of this systematic review is to examine the association between ACEs and opioid use-related behaviors later in life and to discuss implications for policy, practice, and research regarding ACEs and opioids. Five databases (PubMed, PsycINFO, CINAHL, Medline, and Scopus) were used to identify studies investigating the association between ACEs and opioid use-related behaviors. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, 20 studies out of the initial 428 met the inclusion criteria for this review. Among the included 20 studies, 15 focused on the relationship between ACEs and lifetime opioid use-related behaviors, and five focused on current opioid use-related behaviors. All studies found statistical associations between ACEs and lifetime or current opioid use-related behaviors. Five studies found a significant gradient effect; that is, as the number of ACEs increased, the risk of opioid use-related behaviors also increased. A significant dose-response relationship exists between ACEs and opioid use-related behaviors. Hence, it is essential for clinicians to screen for ACEs before prescribing opioid medications, for opioid treatment to incorporate trauma-informed methods, and for messaging around opioid use interventions to include information about ACEs. The current review points to a critical need to implement standardized ACE screening instruments in clinical and research settings.

A Scoping Review of Factors Associated With the Mental Health of Young People Who Have "Aged Out" of the Child Welfare System

Young people who grow up in care and then exit care around the age of 18 (care-leavers) are a particularly vulnerable group, at increased risk for mental health problems even relative to other care-experienced groups. Yet, little is understood about the factors underpinning this association. We used scoping review methods to synthesize the quantitative and qualitative literature on factors that are associated with mental health problems for care-leavers. Following rigorous methods, we systematically searched three scientific databases spanning psychology and social care and identified 23 peer-reviewed studies for inclusion. This review highlights the heterogeneity of this research, in terms of methodology and topics investigated. Topics included are as follows: pre-care maltreatment, care-related experiences, psychological factors (emotion regulation), social support, education, and adult functioning (e.g., housing, finances, employment). We found mixed and inconsistent findings across research studies. The strongest evidence-base is around the influence of social support upon the mental health of recent care-leavers, though methodological problems are discussed. The field benefits from several large-scale observational and longitudinal research studies. However, there is an over-reliance upon retrospective reporting, and the use of unvalidated measures is common. It is apparent that there are significant gaps in our current understanding of the mental health of care-leavers, in particular around modifiable factors. We discuss potential directions for future empirical research, both in terms of methodology and factors investigated.

Global trends and differences in the burden of alcohol use disorders attributable to childhood sexual abuse by sex, age, and socio-demographic index: Findings from the Global Burden of Disease Study 2019

BACKGROUND

Childhood sexual abuse (CSA) is a severe global problem associated with alcohol use disorder (AUD). Previous studies have confirmed this relationship; however, there is a lack of research on the disease burden of AUD attributable to CSA.

OBJECTIVE

To analyze global spatiotemporal trends and differences in the disease burden of AUD attributable to CSA and its relationship with age, sex, and the sociodemographic index (SDI).

PARTICIPANTS AND SETTING

Data from the Global Burden of Disease 2019 Public Database.

METHODS

Summary exposure value (SEV) was used to evaluate CSA. Disability-adjusted life year (DALY), years lived with disability (YLD), years of life lost (YLL), and their annual rates of change were used to evaluate disease burden. Cluster analysis based on Ward's method was used to examine the global burden associated with age, sex, and SDI. A 95 % uncertainty intervals (UI), excluding 0, was considered statistically significant.

RESULTS

In 2019, 1.63 million (95 % UI 0.23-3.90 million) DALYs of AUD were caused by CSA and the age-standardized rates (ASRs) of DALY was 19.77 (95 % UI 2.78-47.46) globally. Annual rates of change in DALY of people over 65 years of age increased from 1990 to 2019 in all regions except the High-middle SDI regions. The ASRs of DALY of females in High SDI regions, were always at a much higher level than other SDI regions, and showed an upward trend from 1990 to 2019 (DALY 1990: 20.38 [95 % UI 2.87-47.77], 2019: 23.61 [95 % UI 3.55-54.94]).

CONCLUSIONS

Substantial geographical differences were observed in the burden of AUD attributable to CSA. The level of CSA exposure was inconsistent with the related burden of AUD in different regions according to the sociodemographic index. The burden of disease increased in the elderly population and in females in high sociodemographic index regions.

Elevated risk for psychiatric outcomes in pediatric patients with Multisystem Inflammatory Syndrome (MIS-C): A review of neuroinflammatory and psychosocial stressors

Multisystem Inflammatory Syndrome in Children (MIS-C) is a secondary immune manifestation of COVID-19 involving multiple organ systems in the body, resulting in fever, skin rash, abdominal pain, nausea, shock, and cardiac dysfunction that often lead to hospitalization. Although many of these symptoms resolve following anti-inflammatory treatment, the long-term neurological and psychiatric sequelae of MIS-C are unknown. In this review, we will summarize two domains of the MIS-C disease course, 1) Neuroinflammation in the MIS-C brain and 2) Psychosocial disruptions resulting from stress and hospitalization. In both domains, we present existing clinical findings and hypothesize potential connections to psychiatric outcomes. This is the first review to conceptualize a holistic framework of psychiatric risk in MIS-C patients that includes neuroinflammatory and psychosocial risk factors. As cases of severe COVID-19 and MIS-C subside, it is important for clinicians to monitor outcomes in this vulnerable patient population.

Early adolescent perceived friendship quality aids affective and neural responses to social inclusion and exclusion in young adults with and without adverse childhood experiences

Friendships increase mental wellbeing and resilient functioning in young people with childhood adversity (CA). However, the mechanisms of this relationship are unknown. We examined the relationship between perceived friendship quality at age 14 after the experience of CA and reduced affective and neural responses to social exclusion at age 24. Resilient functioning was quantified as psychosocial functioning relative to the degree of CA severity in 310 participants at age 24. From this cohort, 62 young people with and without CA underwent functional Magnetic Resonance Imaging to assess brain responses to social inclusion and exclusion. We observed that good friendship quality was significantly associated with better resilient functioning. Both friendship quality and resilient functioning were related to increased affective responses to social inclusion. We also found that friendship quality, but not resilient functioning, was associated with increased dorsomedial prefrontal cortex responses to peer exclusion. Our findings suggest that friendship quality in early adolescence may contribute to the evaluation of social inclusion by increasing affective sensitivity to positive social experiences and increased brain activity in regions involved in emotion regulation to negative social experiences. Future research is needed to clarify this relationship with resilient functioning in early adulthood.

Trends in the dose-response relationship between adverse childhood experiences and maladaptive metacognitive beliefs: A cross-sectional study

BACKGROUND

Since the publication of the major research on adverse childhood experiences (ACE) at the turn of the millennium, our knowledge about the prevalence and physical and mental consequences of childhood adversities has increased substantially. In parallel, research on metacognition, which plays an important role in understanding our mental functioning, has also been on the rise. Although the adverse effects of ACEs on mental processes and the role of metacognitive deficits in the development of mental disorders are widely known, hardly any research into the interaction between these two areas has been conducted; this is what triggered our investigation.

METHODS

Our research was carried out as a cross-sectional study on a sample of 304 members of the general population. We measured ACEs with the 10-item Adverse Childhood Experiences Questionnaire and maladaptive metacognitions-positive and negative metacognitive beliefs, cognitive confidence, cognitive self-consciousness, and need to control thoughts- using the Meta-Cognitions Questionnaire. The closeness of the relationship between the ACE score and metacognitions was measured using Pearson's linear correlation coefficient, while the association of ACE accumulation with metacognitive beliefs was assessed using generalized linear models.

RESULTS

The most common ACE in our sample turned out to be emotional neglect (44.74%). All the examined maladaptive metacognitive beliefs correlate mildly to moderately with the number of suffered ACEs (r = 0.13-0.34), with an increase in the ACE score leading to a rise in the salience of maladaptive metacognitive beliefs. Moreover, a dose-response relationship was seen between increases in ACE scores and the overall values of metacognition, negative metacognitive beliefs, and the maladaptive metacognitive belief of the need to control thoughts.

CONCLUSIONS

Our results suggest that the more ACEs were experienced in childhood, the more pronounced the dysfunctional metacognitive beliefs are. Therefore, our findings emphasize the importance of further research into the topic.

Relational skill training for patient engagement and the creation of a trauma-informed critical care

Patients and families in critical care have a high likelihood of previous and re-experienced trauma. Unaddressed, physical, and psychological impacts of these traumas can worsen outcomes for patients and families. A trauma-informed care approach has been proposed for critical care; however, training programs do not include relational competencies or de-escalation techniques, risking the re-traumatization of patients and families in critical care and negatively impacting clinicians. This article describes a strategy that can be adopted by critical care teams towards the creation of a trauma-informed critical care unit including the use of a framework for relational training. Principles of relationship management and de-escalation are discussed with the use of a fictional exemplar scenario. Key messages include a call to action for relational training for care teams to enhance skilled relational engagement of patients and families. This article also highlights the foundational importance of policies supporting a trauma-informed approach in critical care.

Associations between child maltreatment and hospital admissions for alcohol and other substance use-related disorders up to 40 years of age: Results from the Childhood Adversity and Lifetime Morbidity study

BACKGROUND AND AIMS

Evidence on the associations between child maltreatment (CM), alcohol use disorders (AUDs) and other substance use disorders (SUDs) comes largely from retrospective studies. These rely on self-reported data, which may be impacted by recall bias. Using prospective CM reports to statutory agencies, we measured associations between CM notifications and inpatient admissions for AUDs and SUDs up to 40 years of age.

DESIGN, SETTING AND PARTICIPANTS

Observational study linking administrative health data from Queensland, Australia to prospective birth cohort data comprising both agency-reported and substantiated notifications of CM.

MEASUREMENTS

Outcomes were inpatient admissions for AUDs and SUDs based on ICD-10-Australian modification (AM)-coded primary diagnoses. Unadjusted and adjusted logistic regression analyses were undertaken.

FINDINGS

Ten per cent (n = 609) of the cohort had a history of agency-reported or substantiated CM notifications before age 15. These individuals had higher adjusted odds of being admitted for AUDs and SUDs. For AUDs, the adjusted odds of inpatient admission were 2.86 [95% confidence interval (CI) = 1.73-4.74] greater where there was any previous agency-reported CM and 3.38 (95% CI = 1.94-5.89) greater where there was any previous substantiated CM. For SUDs, the adjusted odds of inpatient admission were 3.34 (95% CI = 2.42-4.61) greater where there was any previous agency-reported CM and 2.98 (95% CI = 2.04-4.36) greater where there was any previous substantiated CM.

CONCLUSIONS

People with a history of child maltreatment appear to have significantly higher odds of inpatient admissions for alcohol use disorders and other substance use disorders up to 40 years of age compared to people with no history of child maltreatment.

Early life adversity and obesity risk in adolescence: a 9-year population-based prospective cohort study

BACKGROUND

There are few prospective studies of factors that mediate the association between exposure to adverse childhood experiences (ACEs) and obesity in adolescence. Our aim was to address this limitation.

METHODS

We used prospective data from the Growing up in Ireland cohort study, with measurements at 9, 13, and 18 years old. The exposures were 14 adverse experiences before age 9. The main outcome was body mass index (BMI) at 18 years. Mediators were daily activity, diet quality, self-image and behavioural difficulties at 13 years.

RESULTS

Among the 4561 adolescents in the final cohort, 77.2% experienced any adversity, 50.5% were female and 26.7% were overweight/obese at 18 years. BMI Z was higher at ages 9 (0.54 vs 0.43, p < 0.05, 95% CI of difference: -0.22, -0.01) and 13 years (0.50 vs 0.35, p < 0.05, 95% CI of difference: -0.25, -0.06), in those exposed to an ACE, compared to those unexposed. Structural equation models revealed that behavioural difficulties (β = 0.01; 95% CI: 0.007-0.018, p < 0.001) and self-concept (β = 0.0027; 95% CI: 0.0004-0.0050, p = 0.026) indirectly mediate the association between exposure to ACEs and BMI at 18 years.

CONCLUSIONS

The association between ACEs and BMI in adolescence is mediated by behavioural difficulties and self-concept.

IMPACT

In a previous study, we found modest associations between exposure to a range of adverse childhood experiences and weight gain at 13 years of age. The strength of the association between adverse childhood experiences and weight gain was lower at 18 years of age compared to the association observed at 13 years and was no longer significant after controlling for confounding and including possible mediators. The association between adverse childhood experiences and BMI in adolescence is indirectly mediated by behavioural difficulties and self-concept.

Understanding forms of childhood adversities and associations with adult health outcomes: A regression tree analysis

BACKGROUND

Empirical studies have demonstrated associations between ten original adverse childhood experiences (ACEs) and multiple health outcomes. Identifying expanded ACEs can capture the burden of other childhood adversities that may have important health implications.

OBJECTIVE

We sought to identify childhood adversities that warrant consideration as expanded ACEs. We hypothesized that experiencing expanded and original ACEs would be associated with poorer adult health outcomes compared to experiencing original ACEs alone.

PARTICIPANTS

The 11,545 respondents of the National Longitudinal Surveys (NLS) and Child and Young Adult Survey were 48.9 % female, 22.7 % Black, 15.8 % Hispanic, 36.1 % White, 1.7 % Asian/Native Hawaiian/Pacific Islander/Native American/Native Alaskan, and 7.5 % Other.

METHODS

This study used regression trees and generalized linear models to identify if/which expanded ACEs interacted with original ACEs in association with six health outcomes.

RESULTS

Four expanded ACEs-basic needs instability, lack of parental love and affection, community stressors, and mother's experience with physical abuse during childhood -significantly interacted with general health, depressive symptom severity, anxiety symptom severity, and violent crime victimization in adulthood (all p-values <0.005). Basic needs instability and/or lack of parental love and affection emerged as correlates across multiple outcomes. Experiencing lack of parental love and affection and original ACEs was associated with greater anxiety symptoms (p = 0.022).

CONCLUSIONS

This is the first study to use supervised machine learning to investigate interaction effects among original ACEs and expanded ACEs. Two expanded ACEs emerged as predictors for three adult health outcomes and warrant further consideration in ACEs assessments.

Child and Adolescent Exposure to Sexual Harassment: Relationship to Gender, Contact Sexual Abuse, and Adult Psychological Symptoms

In contrast to adults, there is considerably less research on childhood or adolescent exposure to sexual harassment (CAESH), its lasting psychological correlates, and whether such experiences should be included in definitions of childhood sexual abuse. The current study examined the prevalence and symptomatic sequels of unwanted flirting, being "checked out" sexually, unwanted sexual attention, sexual comments, propositions, and related noncontact behaviors that occurred before age 18, as well as the multivariate relationship between CAESH and contact child sexual abuse (C-CSA) in a diverse online sample of 528 individuals. CAESH was very common, with over 95% of women and 64% of men reporting at least one experience of noncontact sexual harassment before age 18. When childhood sexual abuse was operationalized as the presence of either C-CSA or a total CAESH score of 18 or higher (corresponding to an average score of "3-5 times" prior to age 18), the prevalence was 67% for women and 26% for men, more than three times higher than C-CSA alone. This expanded definition was associated with significantly more anxiety, depression, and posttraumatic stress relative to C-CSA alone. These results suggest that CAESH is a significant source of symptoms in adults and support the emerging perspective that childhood sexual abuse may be best understood as including both contact and noncontact events.

Leveraging biosocial methods to examine and address structural determinants of health and promote health equity

BACKGROUND

Biosocial approaches in nursing research have largely focused on the ways that social determinants of health influence individual-level outcomes, including symptom management, family and social support, and educational interventions.

PURPOSE

Theoretical, methodological, and practical strategies are needed to expand current biosocial methods for nursing science and focus on upstream, structural determinants of health and the policies that underlie health inequities.

METHODS

This paper summarizes presentations given at the 2023 Council for the Advancement of Nursing Science Advanced Methods Conference, Biosocial Methods to Advance Health Equity, in a panel titled "Individual, community, systems and policy related to biosocial methods."

DISCUSSION

Nurses are uniquely positioned to examine upstream, structural determinants of health by leveraging expertise in biosocial methods, collaborating with interdisciplinary researchers and community members, and advocating for policy change. By conducting theory-grounded biosocial research, nurse researchers can significantly advance scientific knowledge and promote health equity for individuals and communities.

CONCLUSION

Nurse scientists are conducting research using biosocial methods and provide recommendations for expansion of this approach in the field.

A Scoping Review of Parenting Programs for Preventing Violence Against Children in Low- and Middle-Income Countries

Violence against children affects their well-being globally, with a greater burden in low-and middle-income countries (LMICs). This scoping review aimed to summarize the available evidence on parenting programs for reducing violence against children in LMICs and identify knowledge gaps in this area. Six English databases and gray literature were systematically searched to identify studies in LMICs that examined the efficacy of parenting programs to prevent violence against children, before April 15, 2023. A total of 4,183 independent studies were identified, of which 31 met the inclusion criteria. The majority were conducted in Africa and Asia, delivered by trained local community/childcare workers and lay workers, and targeted younger children aged <10 years. Although the core modules varied in terms of number of group sessions and age of the children, the majority emphasized the importance of building a positive relationship with children and nonviolent discipline strategies. The vast majority demonstrated intervention efficacy in reducing general maltreatment and physical and emotional abuse, and improving positive parenting. Ineffective programs for violence tended to be characterized by self-designed programs, small sample sizes, and low corporal punishment levels in the baseline assessment. In conclusion, parenting programs are promising for preventing and reducing the risk factors for violence in LMICs. Future intervention studies should expand to low-income countries outside Eastern Africa with more trials targeting older children, utilizing direct observational assessments, designing core modules relevant to child neglect, involving more male caregivers, and conducting long-term follow-up assessments.

Caregiver preferences for physically harsh discipline of children in rural Uganda

Purpose

Physically harsh discipline is associated with poor developmental outcomes among children. These practices are more prevalent in areas experiencing poverty and resource scarcity, including in low- and middle-income countries. Designed to limit social desirability bias, this cross-sectional study in rural Uganda estimated caregiver preferences for physically harsh discipline; differences by caregiver sex, child sex, and setting; and associations with indicators of household economic stress and insecurity.

Method

Three-hundred-fifty adult caregivers were shown six hypothetical pictographic scenarios depicting children whining, spilling a drink, and kicking a caregiver. Girls and boys were depicted engaging in each of the three behaviors. Approximately half of the participants were shown scenes from a market setting and half were shown scenes from a household setting. For each scenario, caregivers reported the discipline strategy they would use (time out, beating, discussing, yelling, ignoring, slapping).

Results

Two thirds of the participants selected a physically harsh discipline strategy (beating, slapping) at least once. Women selected more physically harsh discipline strategies than men (b = 0.40; 95% confidence interval [CI], 0.26 to 0.54). Participants shown scenes from the market selected fewer physically harsh discipline strategies than participants shown scenes from the household (b = -0.51; 95% CI, -0.69 to -0.33). Finally, caregivers selected more physically harsh discipline strategies in response to boys than girls. Indicators of economic insecurity were inconsistently associated with preferences for physically harsh discipline.

Conclusions

The high prevalence of physically harsh discipline preferences warrant interventions aimed at reframing caregivers' approaches to discipline.

Sex, Adverse Childhood Experiences, and Substance Use Disorders in US Military Veterans: Results From the National Health and Resilience in Veterans Study

OBJECTIVES

US veterans report more adverse childhood experiences (ACEs) than nonveterans, and a greater number of ACEs has been linked to substance use disorders (SUDs). To date, however, no study has examined whether specific ACEs may be linked to SUDs in this population in a sex-related fashion.

METHODS

We analyzed data from the National Health and Resilience in Veterans Study, a nationally representative survey of 4069 US veterans. ACEs, current alcohol use disorder (AUD), and current drug use disorder (DUD) were assessed using validated self-report measures.

RESULTS

Being raised in a household with people with SUDs was independently associated with current AUD. Childhood sexual abuse and having an incarcerated family member were independently associated with current DUD. Sex moderated associations with specific ACEs. Specifically, female veterans who had experienced physical neglect in childhood or were raised with a mentally ill family member in the home were more likely to endorse current AUD and DUD, whereas male veterans who experienced sexual abuse in childhood or who were raised in a home with someone who used substances were more likely to endorse current AUD and DUD.

CONCLUSIONS

Results underscore the importance of targeted and sex-sensitive interventions in addressing potentially unresolved childhood traumas as part of treatment efforts for SUDs in veterans.

Childhood adversity and adolescent acting-out behaviors: the mediating role of mentalizing difficulties and epistemic vigilance

Childhood adversity is a well-established risk factor for adolescent acting-out behaviors such as self-harm, bingeing, substance abuse, and aggressive behavior. From a mentalizing perspective, acting-out behaviors are understood as resulting from a combination of impairments in mentalizing and epistemic vigilance that are a consequence of childhood adversity. Yet, few studies have investigated these assumptions. The current study investigated the potential mediating role of mentalizing impairments and epistemic vigilance in the relationship between childhood adversity and acting-out behaviors in adolescents, oversampled for risk status for psychopathology (N = 451, mean age = 15.40 years). Structural equation modeling showed a strong, direct relationship between childhood adversity and acting-out behaviors, confirming the importance of traumatic childhood experiences for adolescent acting-out behaviors. This relationship was partially mediated by both mentalizing difficulties and epistemic vigilance, explaining about 40% of the total variance. These results support the importance of focusing on strengthening mentalizing abilities and lowering epistemic hypervigilance in psychotherapeutic work with adolescents who have experienced childhood trauma.

Adverse Childhood Experiences and Trajectories of Firearm Exposure in Childhood

OBJECTIVE

To examine the longitudinal relationship between exposure to adverse childhood experiences (ACEs) in early life and trajectories of firearm exposure from early to middle childhood (ages 5-9 years old).

STUDY DESIGN

Data from the Longitudinal Studies of Child Abuse and Neglect (LOGSCAN) study were used. The LONGSCAN study was a prospective study in the United States and contained data from 1354 children from age 4 to age 18 years old. Exposure to ACEs was measured through the wave 1 interview (age 5 years old) and trajectories of firearm exposure were created using data from waves 1 (age 5 years old) and two (age 9 years old).

RESULTS

Two trajectories of firearm exposure in childhood were identified: a low exposure group and a group with persistently-high firearm exposure from ages 5 to 9 years old. ACEs were associated with membership in the high exposure group and children with four or more ACEs had over twice the odds of membership in the high exposure group compared with children with zero ACEs.

CONCLUSION

ACEs exposure in early childhood is associated with persistently-high exposure to firearms from early to middle childhood. This finding highlights the need for pediatricians to consider screening for both ACEs and firearm exposure in routine examinations, as well as the need for future research to identify and evaluate interventions intended to address exposure to adversity and firearms.

Adverse Childhood Experiences and Autism: A Meta-Analysis

Evidence suggests that autistic children have a higher probability of experiencing adverse childhood experiences (ACEs) compared to their non-autistic peers. This meta-analysis (PROSPERO: CRD42022262635) aimed to quantify the association of autism and ACEs. Eight databases and Google Scholar were searched for studies that reported dichotomous outcomes regarding the associations between ACEs and autistic individuals, compared to non-autistic individuals. A random-effects model was used to calculate the average Odds Ratio (OR) of the relationship between a diagnosis of autism and ACEs. A total of 40 studies with 5,619,584 participants were included, generating an overall average OR 2.11 (CI 1.61, 2.77). Significant differences in the magnitude of association were found across studies with regards to the type of ACEs studied, comparison groups, and population type. Overall, moderate certainty evidence (downgraded for bias) indicates that autistic individuals are at greater risk of experiencing ACEs, compared to non-autistic individuals. Appropriate support for autistic individuals and their families are required to prevent ACEs and treat the impact of ACEs.

Trajectories of risk and resilience: The role of empathy and perceived social support in the context of early adversity

BACKGROUND

Evidence overwhelmingly suggests that adverse childhood experiences (ACEs) is a risk factor for poor mental health outcomes. However, the specific mechanisms via which ACEs confer an increased risk of psychopathology are less well understood.

OBJECTIVE

The study modelled the effect of empathy and perceived social support (PSS) on mental health outcomes in a mixed clinical and non-clinical population, within the context of exposure to ACEs.

PARTICIPANTS AND SETTING

A total of 575 participants (comprising a treatment-receiving and community-based sample), aged 18 to 65 completed self-report measures assessing early adversity, PSS, empathy, and mental health outcomes.

METHODS

Multiple mediation analyses were used to investigate whether empathy and PSS mediated the relationship between self-reported ACEs and mental health outcomes, and whether affective and cognitive empathy affected differentially the link between emotional neglect and psychological distress.

RESULTS

Results revealed a statistically significant indirect effect of ACEs on adult mental health through affective empathy and PSS. Emotional neglect was the only type of adversity significantly correlated with both dimensions of empathy. The indirect effect of emotional neglect on mental health outcomes via cognitive and affective empathy was also statistically significant.

CONCLUSIONS

Study results highlight the role of affective empathy and PSS as transdiagnostic mechanisms influencing the pathway between early adversity and adult mental health, and the importance of taking these into account when designing interventions aiming to promote well-being among those who have experienced childhood adversity.

Maternal, prenatal and postnatal risk factors for early child physical abuse: a French nationwide cohort study

Background

Identifying risk factors for early child physical abuse (CPA) is crucial for understanding its mechanisms and defining effective preventive interventions. We aimed to identify maternal, prenatal and postnatal factors associated with early CPA.

Methods

This cohort study was based on comprehensive data from the Mother-Child EPI-MERES nationwide register and included all infants born alive in France between 2010 and 2019. Factors associated with early CPA (before age 1) were identified with a multilevel Cox regression model with random intercepts at the regional level.

Findings

Among the 6,897,384 included infants, 2994 (40/100,000) had a diagnosis of early CPA, at a median age of 4 months. Independent factors most strongly associated with early CPA were maternal low financial resources (adjusted hazard ratio [aHR] 1.91; 95% confidence interval [95% CI] 1.67-2.18), maternal age <20 years versus 35-40 years (aHR 7.06; 95% CI 6.00-8.31), maternal alcohol use disorder (aHR 1.85; 95% CI 1.48-2.31), opioid use disorder (aHR 1.90; 95% CI 1.41-2.56), intimate partner violence (aHR 3.33; 95% CI 2.76-4.01), diagnosis of a chronic mental disorder (aHR 1.50; 95% CI 1.14-1.97) or somatic disorder (aHR 1.55; 95% CI 1.32-1.83), hospitalisation for a mental disorder (aHR 1.88; 95% CI 1.49-2.36), very preterm birth (aHR 2.15; 95% CI 1.68-2.75), and diagnosis of a chronic severe neurocognitive disorder in the infant (aHR 14.37; 95% CI 11.85-17.44).

Interpretation

Independent risk factors of early CPA identified at the national level in France may help in understanding CPA mechanisms and developing effective prevention programs including risk-stratification tools to optimise the allocation of parenting interventions to parents who could most benefit from them.

Funding

Ile-de-France regional council, L'Oréal-UNESCO For Women In Science France Young Talent Award, French National Observatory for Child Protection [ONPE], French Association of Ambulatory Paediatrics [AFPA], HUGO university hospitals network, Mustela Foundation and Sauver la Vie prizes.

The trajectory of anxiety in therapy: The role of ACEs

The connection between adverse childhood experiences (ACEs) and anxiety disorders is well-documented. Additionally, therapy has been shown to be effective at reducing anxiety symptoms. Yet more needs to be known about how ACEs may shape the process of therapy and the trajectory of anxiety symptoms. This study was designed to compare the trajectory of improvement in anxiety symptoms over the course of 12 sessions of therapy in adults (N = 472), who reported more (greater than four) and fewer (fewer than four) ACEs using a multigroup latent growth curve analysis. Data were drawn from the Marriage and Family Therapy Practice Research Network database. Results suggested that the rate of improvement in those with more and fewer ACEs was not significantly different; however, those with more ACEs had a significantly higher average starting point of anxiety symptoms.

Patterns of Adverse Childhood Experiences and Neurocognitive Development

Importance

Early life adversity is associated with higher risk of many adult health problems, including mental illness, substance abuse, suicide attempt, and chronic diseases. Many previous studies investigated adversities one at a time or investigated the health toll associated with the cumulative number of adversities.

Objective

To examine the co-occurrence of adversities among children and how specific patterns of adversities are associated with neurocognitive development.

Design, Setting, and Participants

This cohort study used data from the Collaborative Perinatal Project (CPP), which enrolled a national sample of women during pregnancy and followed their offspring to ages 7 to 8 years, between 1959 and 1974. The CPP was a community-based study conducted in 12 US medical centers. The CPP sample was ascertained through prenatal clinics and is diverse with respect to race and socioeconomic status. Data analysis was performed from August 2023 to March 2024.

Exposures

A latent class analysis was conducted of 12 adverse childhood experiences that occurred between birth and 7 years to identify common patterns of childhood adversities.

Main Outcomes and Measures

Five neurocognitive tests were used to measure children's visual-motor, sensory-motor, auditory-vocal, intelligence quotient, and academic skills.

Results

The analysis sample included 49 853 offspring (25 226 boys [50.6%]); 24 436 children (49.0%) had low probability of experiencing any adversity, whereas the remaining half were classified into 5 groups reflecting distinct patterns of childhood adversities: parental harshness and neglect, 1625 children (3.3%); parental separation and poverty, 8731 children (17.5%); family instability, 3655 children (7.3%); family loss, instability, and poverty, 1505 children (3.0%); and crowded housing and poverty, 9901 children (19.9%). Children in 4 of these groups had lower neurocognitive scores than children with a low probability of experiencing adversity, with standardized mean differences ranging from -0.07 (95% CI, -0.11 to -0.03) to -0.86 (95% CI, -1.06 to -0.65).

Conclusions and Relevance

These findings suggest that adverse childhood experiences are associated with deficits in children's neurocognitive functions. It is important to understand the complexity in children's exposure to adversity and the resulting developmental consequences, as well as the underlying mechanisms, to help support children exposed to adversity and foster healthier and resilient trajectories of development.

Multi-level factors associated with psychological resilience in the face of adverse childhood experiences among Chinese early adolescents

BACKGROUND

Adverse childhood experiences (ACEs) are pervasive and exert enduring negative effects on health throughout one's life. A better understanding of resilience among adolescents with ACEs exposure is crucial to enhance their mental health; however, comprehensive and multifaceted analyses of its associated factors are limited.

OBJECTIVE

This study aimed to investigate multi-level correlates of psychological resilience in Chinese early adolescents exposed to ACEs.

PARTICIPANTS AND SETTING

In a sample of 5724 middle school students, 65.5 % (n = 3749; 49.1 % females; Mage = 13.57, SD = 0.96) reported ACEs during their primary school period and were finally included in this study.

METHOD

Both linear regression and network models were conducted to explore correlates of capacity- and outcome-oriented resilience at the individual (i.e., five personality traits, emotional release, and loneliness), family (i.e., family support and relationships with the mother and father), and school levels (i.e., peer support, teacher support, and relationships with classmates and teachers).

RESULTS

Linear regression analysis revealed that all correlates were associated with capacity- (β ranged from -0.271 to 0.503, PFDR < 0.001 for all) and outcome-oriented resilience (β ranged from -0.516 to 0.229, PFDR < 0.001 for all). Similarly, network analysis revealed that neuroticism, conscientiousness, loneliness, emotional release, extraversion, and the relationship with the mother were directly associated with both capacity- (weights ranged from 0.029 to 0.179) and outcome-oriented resilience (weights ranged from 0.024 to 0.396). However, openness, peer and family support, and relationships with classmates and teachers were directly associated with capacity-oriented resilience (weights ranged from 0.020 to 0.201).

CONCLUSIONS

This study identified the shared and unique associated factors for capacity- and outcome-oriented resilience in the face of ACEs and demonstrated the complex interactions between these factors, which can guide tailored interventions to enhance resilience among Chinese early adolescents with ACEs exposure. Further longitudinal studies may endeavor to confirm our results.

Gender differences in the association between adverse childhood experiences and premature mortality: A prospective population study

BACKGROUND

Birth cohort studies have shown that adverse childhood experiences (ACEs) are associated with all-cause mortality. The effect of ACEs on premature mortality among working-age people is less clear and may differ between the genders.

OBJECTIVE

In this prospective population study, we investigated the association of ACEs with all-cause mortality in a working-age population.

PARTICIPANTS AND METHODS

In a representative Finnish population study, Health 2000, individuals aged 30 to 64 years were interviewed in 2000, and their deaths were registered until 2020. At baseline, the participants (n = 4981, 2624 females) completed a questionnaire that included 11 questions on ACEs and questions on tobacco smoking, alcohol abuse, self-reported health and sufficiency of income. All-cause mortality was analysed by Cox regression analysis.

RESULTS

Of the ACEs, financial difficulties, parental unemployment and individual's own chronic illness were associated with mortality. High number (4+) of ACEs was significantly associated with all-cause mortality in females (HR 2.11, p < 0.001), not in males. Poor health behaviour, self-reported health and low income were the major predictors of mortality in both genders. When the effects of these factors were controlled, childhood family conflicts associated with mortality in both genders.

CONCLUSIONS

Among working-age people, females seem to be sensitive to the effects of numerous adverse childhood experiences, exhibiting higher premature all-cause mortality. Of the individual ACEs, family conflicts may increase risk of premature mortality in both genders. The effect of ACEs on premature mortality may partly be mediated via poor adult health behaviour and low socioeconomic status.

WHAT IS ALREADY KNOWN

In birth cohort studies, adverse childhood experiences (ACEs) have been associated with all-cause mortality. In working-age people, the association of ACEs with premature mortality is less clear and may differ between the genders.

WHAT THIS STUDY ADDS

In working-age people, high number of ACEs associate with all-cause premature mortality in females, not in males. The effect of ACEs on premature mortality may partly be mediated via poor adult health behaviour, self-reported health and low socioeconomic status.

Impact of family and caregiver factors on development and behaviours in maltreated young children

Introduction

This study aimed to evaluate the prevalence of developmental and emotional/ behavioural concerns in maltreated children and to examine the impact of adverse family/caregiver risk factors on these outcomes.

Method

We analysed family demographic and baseline data of 132 maltreated children and their caregivers from a family support programme in Singapore. We examined the associations of 3 main risk factors (i.e., caregiver mental health, educational attainment, and family socio-economic status [SES]) with developmental/behavioural outcomes using multivariable logistic regression, controlling for caregiver relationship to the child. Caregiver mental health was assessed using the Patient Health Questionnaire 9 (PHQ-9) and General Anxiety Disorder 7 (GAD-7) tools. Developmental/behavioural outcomes were assessed using the Ages and Stages Questionnaires (ASQ-3), ASQ-Social-Emotional (ASQ-SE), and the Child Behaviour Checklist (CBCL).

Results

The children ranged in age, from 2 months to 3 years 11 months (median age 1.7 years, interquartile range [IQR] 0.9-2.6). Among caregivers, 86 (65.2%) were biological mothers, 11 (8.3%) were biological fathers, and 35 (26.5%) were foster parents or extended family members. Low family SES was associated with communication concerns on the ASQ-3 (adjusted odds ratio [AOR] 3.04, 95% CI 1.08-8.57, P=0.04). Caregiver mental health concerns were associated with increased behavioural concerns on the CBCL (AOR 6.54, 95% CI 1.83-23.33, P=0.004) and higher scores on the ASQ-SE (AOR 7.78, 95% CI 2.38-25.38, P=0.001).

Conclusion

Maltreated children with caregivers experiencing mental health issues are more likely to have heightened emotional and behavioural concerns. Those from low SES families are also at increased risk of language delay, affecting their communication.

Adverse childhood experiences (ACEs), resilience, and outcomes in older adulthood: A scoping review

BACKGROUND

Previous research has demonstrated a dose-response relationship between exposure to adverse childhood experiences (ACEs) and adverse outcomes in adulthood. Despite widely known associations, previous reviews have primarily focused on outcomes in younger and middle-aged adults exposed to ACEs to the exclusion of older adults and do not consider the potential role of resilience for understanding outcomes in older adulthood.

OBJECTIVE

The present scoping review aimed to examine the extent and nature of existing literature on the influence of ACEs and resilience on the cognitive, physical, mental, and social health outcomes among older adults.

METHODS

We conducted a search of five electronic databases (CINAHL, MEDLINE, PsycINFO, AgeLine, Scopus) using the following keywords: adversity, resilience, aging, and older adults. We limited our inclusion criteria to works published in English or French after 1998 as Felitti et al. published the first study describing ACEs in this year.

RESULTS

Of the 4926 studies screened, 27 studies met the inclusion criteria. Overall, results from the included studies indicated that exposure to adversity during childhood was associated with worse outcomes in older adulthood. Additionally, we found that resilience and resiliency-related factors (e.g., problem-focused coping strategies) mitigated or reduced harms associated with ACEs to improve outcomes in older adulthood.

CONCLUSIONS

Exposure to ACEs is associated with reduced functioning in later adulthood. Findings from this review indicate a need for further exploration into the role of ACEs, and the potential effects of resilience, on health outcomes in older adults to develop better individual- and population-level interventions for this group.

Co-design workshops with families experiencing multiple and interacting adversities including parental mental health, substance use, domestic violence, and poverty: intervention principles and insights from mothers, fathers, and young people

BACKGROUND

Clustering and co-occurring of family adversities, including mental health problems, substance use, domestic violence and abuse, as well as poverty can increase health and behavioural risks for children, which persist throughout the life course. Yet, interventions that acknowledge and account for the complex interactive nature of such risks are limited. This study aimed to develop intervention principles based on reflections from mothers, fathers, and young people who experience multiple and interacting adversities. These principles will show how family members perceive an intervention may bring about positive change and highlight key insights into design and delivery.

METHODS

A series of six co-design workshops with mothers, fathers, and young people who experienced multiple and interacting adversities (n = 41) were iteratively conducted across two regions in England (London and North-East) by four researchers. Workshop content and co-design activities were informed by advisory groups. Data from facilitator notes and activities were analysed thematically, resulting in a set of intervention principles.

RESULTS

The intervention principles highlighted that: (1) to reduce isolation and loneliness parents and young people wanted to be connected to services, resources, and peer support networks within their local community, particularly by a knowledgeable and friendly community worker; (2) to address feelings of being misunderstood, parents and young people wanted the development of specialised trauma informed training for practitioners and to have the space to build trusting, gradual, and non-stigmatising relationships with practitioners; and (3) to address the needs and strengths of individual family members, mothers, fathers, and young people wanted separate, tailored, and confidential support.

CONCLUSIONS

The current study has important implications for practice in supporting families that experience multiple and interacting adversities. The intervention principles from this study share common characteristics with other intervention models currently on offer in the United Kingdom, including social prescribing, but go beyond these to holistically consider the whole families' needs, environments, and circumstances. There should be particular focus on the child's as well as the mothers' and fathers' needs, independently of the family unit. Further refinement and piloting of the developing intervention are needed.

Association between adverse childhood experiences and type 2 diabetes mellitus in later life: A case-control study

Adverse childhood experiences (ACEs) are potentially traumatic events that occur before 18 years of age. Studies emphasize the importance of childhood adversity as a risk factor for developing non-communicable diseases, including type-2 diabetes mellitus (T2DM) in adulthood. This case-control study involved 137 patients with T2DM and 134 non-diabetic adults of both genders (mean age 46.9 and 45.7 years, respectively). In addition to collecting socio-demographic, behavioral, and anthropological data, a 10-item ACE scale was utilized to gather information regarding childhood adversities, while perceived stress was assessed using the perceived stress scale-4. Fasting and 2-hour post glucose load blood sugar levels, HbA1c, and fasting lipid profiles were measured. Both univariable and multivariable binary logistic regression analyses were performed to investigate whether ACE is a potential risk factor for T2DM, with a significance level of 0.05. Around two-thirds of T2DM patients reported having ACE scores of 4 or higher, with the mean ACE score significantly higher in the case group than in the control group (3.96 vs. 3.34; p<0.0001). The logistic regression analysis found that T2DM was linked to female gender, hypertension, dyslipidemia, family history of DM, higher perceived stress, and a higher ACE score of 4 and above. After adjusting for confounding factors, individuals with an ACE score of 4 or higher had a significantly greater risk of developing T2DM (OR: 2.24; 95% CI 1.238-4.061). The study revealed a significant association between higher ACE scores and an increased risk of developing T2DM. As a recommendation, further investigation into the epigenetic mechanisms underlying this relationship is warranted.

Promotive and protective effects of community-related positive childhood experiences on adult health outcomes in the context of adverse childhood experiences: a nationwide cross-sectional survey in Japan

OBJECTIVE

Although adverse childhood experiences (ACEs) are associated with poor health in adulthood, positive childhood experiences (PCEs) can reduce the risk of negative health outcomes. This study aimed to investigate whether PCEs in the community (CPCEs, ie, trusted adults other than parents, supportive friends, belongingness to school, or community traditions) would have an independent effect on better health outcomes and moderate the association between ACEs and adult illnesses.

DESIGN

Cross-sectional survey.

SETTING

Data were gathered from a nationwide, cross-sectional internet survey conducted in Japan in 2022.

PARTICIPANTS

This study included 28 617 Japanese adults aged 18-82 years (51.1% female; mean age=48.1 years).

PRIMARY AND SECONDARY OUTCOME MEASURES

The associations among self-reported ACEs, CPCEs before the age of 18 years and current chronic diseases (eg, cancer and depression) were investigated using multivariable logistic regression models.

RESULTS

CPCEs were associated with lower odds of adult diseases (such as stroke, chronic obstructive pulmonary disease (COPD), chronic pain, depression, suicidal ideation and severe psychological distress) after adjusting for ACEs. More CPCEs weakened the association between ACEs and adult diseases. Specifically, among those with ACEs, ≥3 CPCEs (vs 0-2 CPCEs) lowered the adjusted prevalence by ≥50% for stroke (2.4% to 1.2%), COPD (2.2% to 0.7%) and severe psychological distress (16.4% to 7.4%).

CONCLUSION

CPCEs could reduce ACE-related risk of poor physical and mental health in later life. Early-life interventions that enhance PCEs in schools and/or neighbourhoods are recommended.

Intriguing connection between diminished ovarian reserve and childhood traumatic experiences, a prospective case-control study

INTRODUCTION

Diminished ovarian reserve (DOR) presents a complex challenge in the field of infertility, with factors like age and genetics traditionally under scrutiny. However, the potential influence of adverse childhood experiences on ovarian reserve remains a relatively unexplored area. This research aims to contribute novel insights to the understanding of diminished ovarian reserve etiology, shedding light on previously unexplored risk factors and their potential implications.

DESIGN

This case-control study was conducted at an Assisted Reproductive Technology (ART) Center of a university hospital. Infertile patients admitted to the ART center were enrolled in the study. The case group consisted of 102 infertile women diagnosed with diminished ovarian reserve, and the control group consisted of 103 healthy women with male factor infertility. An interview lasting approximately 30 min was held in a separate room with those who volunteered to participate in the study. Due to the sensitivity of the research subject, the data was collected anonymously. The Childhood Trauma Questionnaire was used to measure adverse childhood experiences, and the Hospital Anxiety and Depression Scale (HADS) was used to assess anxiety and depression in the study. The results were compared between the case and the control groups.

RESULTS

Overall, the total score of the Childhood Trauma Questionnaire and all subscale scores were higher in the case group (38.28 ± 9.86) than in the control group (35.10 ± 9.52). According to HADS, the total score was 15.92 ± 7.98 in the case group and 14.22 ± 6.87 in the control group.

CONCLUSIONS

Our pioneering study is designed to investigate a previously unexplored risk factor in low ovarian reserve. Considering our data and other studies in the literature examining childhood traumas as a risk, it makes us think that the issue is worth examining.

Persistent physical symptoms: definition, genesis, and management

Persistent physical symptoms (synonymous with persistent somatic symptoms) is an umbrella term for distressing somatic complaints that last several months or more, regardless of their cause. These symptoms are associated with substantial disability and represent a major burden for patients, health-care professionals, and society. Persistent physical symptoms can follow infections, injuries, medical diseases, stressful life events, or arise de novo. As symptoms persist, their link to clearly identifiable pathophysiology often weakens, making diagnosis and treatment challenging. Multiple biological and psychosocial risk factors and mechanisms contribute to the persistence of somatic symptoms, including persistent inflammation; epigenetic profiles; immune, metabolic and microbiome dysregulation; early adverse life experiences; depression; illness-related anxiety; dysfunctional symptom expectations; symptom focusing; symptom learning; and avoidance behaviours, with many factors being common across symptoms and diagnoses. Basic care consists of addressing underlying pathophysiology and using person-centred communication techniques with validation, appropriate reassurance, and biopsychosocial explanation. If basic care is insufficient, targeted psychological and pharmacological interventions can be beneficial. A better understanding of the multifactorial persistence of somatic symptoms should lead to more specific, personalised, and mechanism-based treatment, and a reduction in the stigma patients commonly face.

Detecting and preventing child maltreatment in primary care and PHNs' role-a cross-sectional study

BACKGROUND

Child maltreatment is a global problem that puts children at risk of mental illness, substance abuse, and premature death. Interdisciplinary collaboration is important in preventing and detecting child maltreatment. In Norway, children undergo universal preventive health assessments and receive complimentary follow-up care from specialized public health nurses in child and family health clinics. These nurses conduct regular check-ups and home visits to monitor children for signs of maltreatment.

OBJECTIVE

The objective of this study is to describe how public health nurses at child and family health clinics follow the National Clinical Guidelines to prevent and detect child maltreatment, with a particular focus on clinical procedures and interdisciplinary collaboration. Furthermore, we aim to determine factors that are associated with identification of child maltreatment.

DESIGN

A cross-sectional online survey was conducted among public health nurses working in primary care between October 24th and December 31st, 2022. Public health nurses who worked with children aged 0-5 years and had consultations with families were eligible to participate, resulting in 554 responses. The study employed descriptive analysis, including frequency, percentage and mean, as well as a two-step logistic regression analysis. The study was approved by the relevant authority, and informed consent was obtained through questionnaire completion.

RESULTS

The public health nurses in this study displayed strong adherence to the guidelines and utilized various comprehensive assessment procedures to monitor child well-being, growth, and development. However, there was limited and infrequent collaboration with other professionals, such as child protection services, general practitioners, and hospitals. Most public health nurses reported occasional suspicion of child maltreatment, with age and years of experience in child and family clinics influencing these suspicions. Older public health nurses were more likely to suspect physical violence, while those with less than two years of experience reported less experience in suspecting maltreatment. Additional education increased the probability of suspecting sexual violence.

CONCLUSIONS

This study provides insights into the practices of public health nurses in Norway regarding the detection and prevention of child maltreatment in child and family clinics. While adherence to guidelines is strong, suspicion of maltreatment is relatively rare. Collaboration across agencies is crucial in addressing child maltreatment. Age and experience may influence the detection of maltreatment. Improved collaboration, targeted guidelines, and ongoing professional development are needed to enhance child protection.

Childhood Adversities and the ATTACHTM Program's Influence on Immune Cell Gene Expression

OBJECTIVE

To determine whether maternal Adverse Childhood Experiences (ACEs) are (a) associated with increased inflammatory gene expression in mother-child dyads and (b) whether a parenting intervention (ATTACH™) moderates the association between maternal ACEs and mother and/or child inflammatory gene expression.

METHODS

Twenty mother-child dyads, recruited from a domestic violence shelter in Calgary, AB, Canada, were randomized into an ATTACH™ parenting intervention group (n = 9) or a wait-list control group (n = 11). Maternal ACEs were assessed. The mothers and children each provided one non-fasting blood sample after the intervention group completed the ATTACH™ program, which was assayed to quantify the Conserved Transcriptional Response to Adversity (CTRA) score, indicating inflammatory gene expression profile. Mixed-effect linear models were used, separately in mothers and children, to examine the associations between CTRA score, maternal ACEs, and the ACEs-by-intervention group interaction term. The covariates were age, sex, ethnicity, and maternal medication use.

RESULTS

Higher maternal ACEs were associated with higher child CTRA scores (b = 0.123 ± SE 0.044, p = 0.005), indicating an increased pro-inflammatory gene expression profile. The ATTACH™ parenting intervention moderated this association between maternal ACEs and child CTRA scores (b = 0.328 ± SE 0.133, p = 0.014). In mothers, the ACEs-by-intervention interaction terms were insignificant (p = 0.305).

CONCLUSIONS

Maternal ACEs could exert an intergenerational impact on child inflammatory activity, and this association could be moderated by participating in the ATTACH™ parenting intervention.

Supporting Ontario public health units to address adverse childhood experiences in pandemic recovery planning: A priority-setting exercise

BACKGROUND

Adverse childhood experiences (ACEs) are potentially traumatic exposures experienced during childhood, for example, neglect. There is growing evidence that the coronavirus disease 2019 (COVID-19) pandemic and related socioeconomic conditions contributed to an increased risk of ACEs. As public health programs/services are re-evaluated and restored following the state of emergency, it is important to plan using an ACEs-informed lens. The aim of this study was to identify and prioritize initiatives or activities that Public Health Ontario (PHO) could undertake to support Ontario public health units' work towards ACEs-informed pandemic recovery plans.

METHODS

The Child Health and Nutrition Research Initiative method was adapted to conduct a priority-setting exercise (May-October 2022). Two online surveys were administered with members of the Healthy Growth and Development (HGD) Evidence Network, comprised of public health unit staff working in child and family health/HGD from Ontario's 34 public health units. In the first survey, participants were asked to propose activities or initiatives that PHO could undertake to support Ontario public health units' work towards ACEs-informed planning. In the second survey, participants were asked to score the final list of options against pre-determined prioritization criteria (for example, relevance). Responses were numerically coded and used to calculate prioritization scores, which were used to rank the options.

RESULTS

In all, 76% of public health units (n = 26) responded to the first survey to identify options. The 168 proposed ideas were consolidated into a final list of 13 options, which fall under PHO's scientific and technical support mandate areas (data and surveillance, evidence synthesis, collaboration and networking, knowledge exchange and research). A total of 79% of public health units (n = 27) responded to the follow-up survey to prioritize options. Prioritization scores ranged from 76.4% to 88.6%. The top-ranked option was the establishment of a new provincial ACEs community of practice.

CONCLUSIONS

Over three quarters of public health units contributed to identifying and ranking 13 options for PHO to support public health units in considering and addressing ACEs through pandemic recovery planning. In consultation with the ACEs and Resilience Community of Practice, recently formed on the basis of this exercise, PHO will continue to use the ranked list of options to inform work-planning activities/priorities.

Poverty trajectories and child and mother well-being outcomes in Ireland: findings from an Irish prospective cohort

BACKGROUND

Poverty is associated with poor outcomes, yet exposure to distinct poverty trajectories in early childhood is not well understood.

OBJECTIVE

To understand the prevalence of different trajectories of household poverty and their association with mid-childhood and mother indicators of physical health and psychopathology in Ireland.

METHODS

We used a nationally representative, prospective cohort (Growing Up in Ireland-Infant Cohort). Household poverty included lowest third income decile, subjective poverty and material deprivation when children were aged 9 months, and 3, 5, 9 years. We used group-based multitrajectory cluster modelling to classify trajectories of poverty. Using multivariable logistic regression, adjusted with separate child and mother confounders, we assessed the association of poverty trajectories from 9 months to 9 years with child outcomes (overweight, any longstanding illness and psychopathology) at age 9 years and the same poverty trajectories over the same 9-year period with mother outcomes (overweight, any longstanding illness and depression).

RESULTS

Of 11 134 participants, 4 trajectories were identified: never in poverty (43.1%), material/subjective>monetary poverty (16.1%), monetary>material poverty (25.6%) and persistent poverty (15.2%). Children in persistent poverty compared with those in never in poverty experienced higher odds of being overweight at 9 years (adjusted OR (aOR) 1.70, 95% CI 1.34, 2.16), having a longstanding illness (aOR 1.51, 95% CI 1.20, 1.91), and psychopathology (aOR 2.06, 95% CI 1.42, 2.99). The outcomes for primary parents (99.7% were mothers) were as follows: having higher odds of being overweight (aOR 1.49, 95% CI 1.16, 1.92), having a longstanding illness (aOR 2.13, 95% CI 1.63, 2.79), and depression (aOR 3.54, 95% CI 2.54, 4.94).

CONCLUSIONS

Any poverty trajectory was associated with poorer psychopathology and physical well-being in late childhood for children and their mothers in Ireland.

Childhood Environmental Instabilities and Their Behavioral Implications: A Machine Learning Approach to Studying Adverse Childhood Experiences

Adverse childhood experiences (ACEs) include a range of abusive, neglectful, and dysfunctional household behaviors that are strongly associated with long-term health problems, mental health conditions, and societal difficulties. The study aims to uncover significant factors influencing ACEs in children aged 0-17 years and to propose a predictive model that can be used to forecast the likelihood of ACEs in children. Machine learning models are applied to identify and analyze the relationships between several predictors and the occurrence of ACEs. Key performance metrics such as AUC, F1 score, recall, and precision are used to evaluate the predictive strength of different factors on ACEs. Family structures, especially non-traditional forms such as single parenting, and the frequency of relocating to a new address are determined as key predictors of ACEs. The final model, a neural network, achieved an AUC of 0.788, a precision score of 0.683, and a recall of 0.707, indicating its effectiveness in accurately identifying ACE cases. The model's ROC and PR curves showed a high true positive rate for detecting children with two or more ACEs while also pointing to difficulties in classifying single ACE instances accurately. Furthermore, our analysis revealed the intricate relationship between the frequency of relocation and other predictive factors. The findings highlight the importance of familial and residential stability in children's lives, with substantial implications for child welfare policies and interventions. The study emphasizes the need for targeted educational and healthcare support to promote the well-being and resilience of at-risk children.

Longitudinal description and prediction of physical inactivity among patients with borderline personality disorder and personality-disordered comparison subjects

BACKGROUND

The physical and psychological benefits of physical activity are well-known, and physical activity has been proven to be a helpful adjunct to psychotherapeutic treatment for many symptomatic disorders, including mood and anxiety disorders. The current study explores physical inactivity levels in patients with borderline personality disorder (BPD). The first aim of this study is to describe the 12-year course of physical inactivity in patients with BPD. The second aim is to examine predictors of physical inactivity, including adversity experiences, comorbid symptomatic (formerly axis I) disorders, medical disorders, and demographic factors.

METHODS

Two hundred and forty-five patients with BPD were interviewed seven times over 12-years of prospective follow-up as part of the McLean Study of Adult Development (MSAD). Patients were categorized as ever-recovered (i.e., patient had experienced a symptomatic and psychosocial recovery from BPD) or never-recovered. At each follow-up, patients reported physical activity levels (minutes of exercise per week) via a semi-structured interview- the Medical History and Services Utilization Interview (MHSUI). Data was collected from June 1992 to December 2018.

RESULTS

Never-recovered patients with BPD were significantly more inactive than their ever-recovered counterparts (p < 0.001). These rates of inactivity remained stable over time for both groups. Two significant multivariate predictors of inactivity were found: obesity (p = 0.003) and PTSD (p < 0.001).

CONCLUSIONS

Non-recovered BPD patients are more likely to be inactive than patients who have recovered. Both clinical and medical factors appear to contribute to inactivity levels in patients with BPD.

Social protection as a strategy for HIV prevention, education promotion and child marriage reduction among adolescents: a cross-sectional population-based study in Lesotho

BACKGROUND

Lesotho's government has shown consistent efforts to implement social protection programmes. However, while recent evidence established a positive causal relationship between some of these programmes and food security there is little evidence on the extent to which these initiatives are associated with better educational and sexual and reproductive health outcomes among vulnerable adolescents in Lesotho.

METHODS AND FINDINGS

The study uses cross-sectional, nationally representative data from the 2018 Lesotho Violence Against Children and Youth Survey. Our research examined the association between social protection receipt and educational and sexual and reproductive health outcomes among adolescents and young people (13-24 years) living in poverty. We employed multivariate logistic regression controlling for age, orphanhood, HIV status and sex. Social protection receipt was defined as household receipt of financial support from a governmental, non-governmental, or community-based program that provides income. Additionally, we fitted a marginal effects model by sex. Among the 3,506 adolescent females and males living in the two lowest poverty quintiles, receipt of social protection was associated with improvements in multiple adolescent outcomes: higher odds of consistent condom use (aOR 1.64, 95% CI 1.17-2.29), educational attainment (aOR 1.79, 95% CI 1.36-2.36), and school enrolment (aOR 2.19, 95% CI 1.44-3.34). Stratified analyses by sex showed that social protection receipt was also associated with reduced likelihood of child marriage among females (aOR 0.59, 95% CI 0.42-0.83) and higher odds of educational attainment and school enrolment among males (aOR 2.53, 95% CI 1.59-4.03 and aOR 3.11, 95% CI 1.56-6.19, respectively).

CONCLUSIONS

Our study provides evidence that social protection programs are associated with improved educational, sexual and reproductive health and child marriage prevention outcomes among adolescents living in poverty. Implementing and expanding such social protection initiatives could prove instrumental in improving the well-being of vulnerable adolescents.

CONTRIBUTIONS

Social protection programs have been increasing in sub-Saharan African countries, playing a pivotal role in poverty reduction, with Lesotho being no exception. Despite the optimistic outlook brought about by the implementation of the National Social Protection Strategy Lesotho I (2014-19) and II (2021-2031), the impact of these programs on some specific outcomes that concern the lives of the most vulnerable adolescents in Lesotho remains to some extent unexplored. Additionally, Lesotho grapples with high rates of HIV, adolescent pregnancy, child marriage and early school dropout, which can further contribute to poor long-term health and social outcomes among adolescents. In this study, we used data from the 2018 Lesotho Violence Against Children and Youth Survey (VACS) to examine the association between receiving social protection and multiple adolescent outcomes: educational, sexual and reproductive. The findings revealed that social protection programs, particularly the existing government-provided cash transfers, are significantly associated with multiple better outcomes among adolescents living in the poorest households in Lesotho. Such cash transfer schemes in Lesotho are associated with improved sexual and reproductive health outcomes for adolescent females, including reduced child marriage rates, and improved educational outcomes for males. These findings indicate that government-led social protection programmes are positively associated with favourable outcomes that can improve the quality of life for adolescents in resource-limited settings.

Adverse childhood experiences and deviant peer affiliation among Chinese delinquent adolescents: the role of relative deprivation and age

Background

Deviant peer affiliation is considered a potential risk factor for adolescent delinquency. Due to the serious situation of adolescent delinquency in China, it is necessary to investigate the mechanisms by which adolescents associate with deviant peers.

Objectives

The purpose of this study was to examine the association between adverse childhood experiences (ACEs) and deviant peer affiliation, the mediating effect of relative deprivation, and the moderating effect of age in a sample of Chinese delinquent adolescents.

Methods

Five hundred and forty-two Special School students aged 11-18 years were interviewed and completed questionnaires, including demographics, adverse childhood experiences, deviant peer affiliation, and relative deprivation.

Results

(1) After controlling for gender, adverse childhood experiences and deviant peer affiliation were significantly and positively associated among delinquent adolescents. (2) The effect of ACEs on deviant peer affiliation was mediated by relative deprivation. (3) Age played a moderating role not only in the relationship between ACEs and relative deprivation, but also in the indirect relationship in which ACEs influence deviant peer affiliation through relative deprivation; specifically, the indirect effect of ACEs influencing deviant peer affiliation through relative deprivation was stronger in early adolescence compared with late adolescence.

Conclusion

Overall, early ACEs play an important role in deviant peer affiliation among delinquent adolescents and relative deprivation is an important mediating variable. The results of the present study emphasize the importance of cognitive interventions for delinquent adolescents who experience ACEs in early adolescence, which may be instructive for the prevention of adolescent delinquency.

Did childhood adversity increase the vulnerability of university students to the negative mental health impact of the COVID-19 pandemic?

OBJECTIVE

To examine a potential synergistic effect of history of childhood adversity and COVID-19 pandemic exposure on the association with mental health concerns in undergraduate students. Participants: We used U-Flourish Survey data from 2019 (pre-pandemic) and 2020 (during-pandemic) first-year cohorts (n = 3,149) identified at entry to a major Canadian University.

METHODS

Interactions between childhood adversity (physical and sexual abuse, and peer bullying) and COVID-19 pandemic exposure regarding mental health concern (depressive and anxiety symptoms, suicidality, and non-suicidal self-harm) were examined on an additive scale.

RESULTS

We found a positive additive interaction between physical abuse and pandemic exposure in relation to suicidality (combined effect was greater than additive effect (risk difference 0.54 vs. 0.36)). Conversely, less than additive interactions between peer bullying and pandemic regarding depression and anxiety were observed.

CONCLUSIONS

Childhood adversities have diverse reactions to adult stressor depending on the nature of the childhood adversity and the mental health outcomes.

Prevalence of smartphone addiction and its relation with psychological distress and internet gaming disorder among medical college students

Background

The incidence of smartphone addiction has been widely studied, but the research on the relationship between smartphone addiction and psychological distress and internet gaming disorder is limited. This study investigated the characteristics and prevalence of smartphone addiction and its relation with psychological distress and internet gaming disorder. Furthermore, it provides the scientific basis for intervention measures in schools, families, and society.

Methods

A random cluster sampling method was applied to investigate 656 medical students from grades 1 to 4 at Wannan Medical College in Anhui province, People's Republic of China. The questionnaire consisted of general information, a smartphone addiction scale, an Internet gaming disorder scale, and a Kessler 6-item psychological distress test. The obtained results were first summarized using descriptive statistics. The Chi-square test was used to compare the status of smartphone addiction. Binary logistic regression was used to analyze the relationship between smartphone addiction and various variables.

Results

Our results showed that the prevalence of smartphone addiction in medical students was 49.5% (325/656). Psychological distress (p < 0.001), internet gaming disorder (p < 0.001), and childhood trauma (p = 0.001) were highly correlated with smartphone addiction in medical students. Psychological distress, and internet gaming disorder were positively associated with smartphone addiction (p < 0.000).

Conclusion

The prevalence of smartphone addiction is high among medical students in Chinese. Smartphone addiction is highly related to related to internet gaming disorder and psychological distress.

The specialist community practitioner district nurse's role in optimising COPD

Chronic obstructive pulmonary disease (COPD) is a long-term condition affecting all aspects of an individual's life. Specialist Community practitioner district nurses (SCPDN) manage patients with multiple co morbidities on their caseload, and as such require an extensive clinical knowledge base. COPD is a highly prevalent and complex disease; therefore, individualised holistic assessments are required to ensure patients receive personalised and evidence-based care. Care delivery must include an awareness of health interventions encompassing, screening, health promotion and prevention. The SCPDN's consideration of the physical, mental and social determinants which adversely affect the health of the individual with COPD is imperative to deliver high quality care to the individuals, families and communities.

Exploring the Relationship between Adverse Childhood Experiences (ACEs) and Mental Health in Low Birthweight Children

Low birthweight is associated with poor health, developmental, and social outcomes throughout the lifespan. Exposure to adverse childhood experiences (ACEs) is also associated with negative mental and physical health outcomes in adulthood. The aims of this study were to explore the relationship between low birthweight (LBW), exposure to ACES, and subsequent utilization of mental health service. Data analysis was conducted using a subset of data from children ages 6-17 years from the National Survey of Children's Health (NSCH) for 2018-2019 (n = 40,656). Welch ANOVA, Pearson's chi-square, and logistic regression investigated the relationship between LBW, ACEs, and mental health. LBW children in this sample had higher exposure to ACEs when compared to not low birthweight (NBW) children. LBW children also had a higher reported incidence of identified mental health (MH) issues. There was no significant association between birthweight and unmet MH service needs. LBW children with an ACE score or two or more were more likely to have an unidentified MH issue and/or an unmet MH service need. The results demonstrate LBW children experience higher levels of adversity. Children with ACE scores of two or more and those with unidentified MH issues have a higher likelihood of unmet MH needs. Professionals working in the health, education, and social service sectors can use this information to raise awareness of the increased vulnerability and more effectively meet the mental health needs of LBW children.