Adverse Childhood Experiences in Non-Westernized Nations: Implications for Immigrant and Refugee Health

Defining and distinguishing early life stress, trauma, adversity, toxic and chronic stress and allostatic load: a descriptive review

AIMS

Various concepts are used to study the impact of stress on childhood development. These concepts are often used inconsistently or interchangeably. Our main objectives were to determine how selected stress concepts (chronic stress, toxic stress, allostatic load, early life stress, childhood adversity, childhood trauma and adverse childhood experiences; ACEs) are defined, operationalized and described, and to provide a theoretical context to aid the choice for a preferred concept in public health research.

METHODS

For this descriptive review, we systematically searched for literature published before 4 August 2021, on PubMed, Embase and PsycInfo. Two independent reviewers included studies. Exclusion criteria were: no systematic review, not peer reviewed, not published in English, selected stress concepts were no predetermined variable or a substantial topic in the discussion, full text was unobtainable or study described non-human or non-childhood populations. Data extraction forms were used. Descriptives were gathered, publication fields were identified through Journal Citation Reports categories, and verbatim descriptions were ordered in text and Venn diagrams.

RESULTS

Of 264 screened studies, 124 were included. ACEs, childhood adversity and childhood trauma were used most. ACEs were the main concept used most frequently (47.6%). A total of 11 of 14 public and environmental health journals used ACEs. All concepts refer to prolonged, repeated, interpersonal stress from 0 to 18 years, that can alter physiological systems. Four concepts were stressor oriented, two concepts focused on stress response and effect and one on the state of challenged homeostasis.

CONCLUSIONS

ACEs seem most fitting for public health setting, due to their operationalizability, large set of core experiences and widespread use.

Adverse Childhood Experiences and Health Outcomes Among Sexual and Gender Minorities: A Systematic Review

Current research indicates a strong association between adverse childhood experiences (ACEs) and adverse health outcomes. Participants in frequently cited ACE research are predominantly heterosexual and cis gendered; the extent to which ACEs affect health outcomes among sexual and gender minorities (SGMs) is unclear. This systematic review examined the frequency of, and relationship between, ACEs and negative health outcomes among SGM. CINAHL, MEDLINE, PsycARTICLES, PsycINFO, Scopus, and PubMed databases were searched with no date restriction. After eliminating duplicates, titles and abstracts were reviewed resulting in 22 articles to be critiqued using the Joanna Briggs Institute Critical Appraisal Checklist for Analytical Cross-Sectional Studies. A total of 22 studies met final inclusion criteria. The frequency of reporting at least one ACE among SGMs ranged from 51.4 to 91.6%, while the frequency of reporting four or more ACEs ranged from 18.1 to 60.7%. SGMs reported a higher frequency of ACEs than non-SGM. ACEs were associated with poorer mental and physical health outcomes, as well as increased risky behavior among SGMs. SGMs report a high frequency of ACEs, but current studies did not include data regarding ongoing stigma and adversities that may further contribute to their negative health outcomes. Further research is needed to fully understand the impact of adversities experienced due to the sexual and/or gender orientation of this minority group.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40653-023-00576-4.

A cross-cultural examination of adverse childhood experiences in low-and middle-income countries and their relation with adolescent educational aspirations

BACKGROUND

Adverse Childhood Experiences (ACEs) are potentially traumatic events that occur before the age of 18. Researchers have examined the negative associations between adversity and adolescent and adult outcomes, such as education and physical health. However, research on ACEs, and their association with other outcomes in non-western contexts is sparse.

OBJECTIVE

The present study aims to increase our understanding of the prevalence of ACEs - and their association with educational aspirations - in low- and middle-income country contexts.

PARTICIPANTS AND SETTING

We utilize data from the Family Migration and Early Life Outcomes (FAMELO) project, a multi-site survey project that collected data from families in historically high-migration contexts. ACEs and educational aspirations were measured in children aged 11 to17 years in Mexico (n = 853), Mozambique (n = 651), and Nepal (n = 1180).

METHODS

We use Poisson regressions to examine the prevalence of ACEs in multiple cultures, and then use multinomial logistic regressions to examine whether ACEs are associated with educational aspirations, as a practical application of the utility of the ACEs framework in cross-cultural contexts.

RESULTS

Our results suggest that adolescents in Mozambique have a higher average number of ACEs (2.7) than adolescents in Mexico (1.4) and Nepal (1.3). Female adolescents reported fewer ACEs, while socioeconomic vulnerabilities (low-income and low parental education) were associated with higher exposure to ACEs, with differences by country. Lastly, ACEs were associated with lower educational aspirations in Mexico and Nepal.

CONCLUSIONS

Our study attempted to heed the call of many scholars who have pushed for an expansion of research on ACEs in non-western, low- and middle-income country contexts.

Examining relationships between adverse childhood experiences and coping during the cost-of-living crisis using a national cross-sectional survey in Wales, UK

OBJECTIVES

Adverse childhood experiences (ACEs) can affect individuals' resilience to stressors and their vulnerability to mental, physical and social harms. This study explored associations between ACEs, financial coping during the cost-of-living crisis and perceived impacts on health and well-being.

DESIGN

National cross-sectional face-to-face survey. Recruitment used a random quota sample of households stratified by health region and deprivation quintile.

SETTING

Households in Wales, UK.

PARTICIPANTS

1880 Welsh residents aged ≥18 years.

MEASURES

Outcome variables were perceived inability to cope financially during the cost-of-living crisis; rising costs of living causing substantial distress and anxiety; and self-reported negative impact of rising costs of living on mental health, physical health, family relationships, local levels of antisocial behaviour and violence, and community support. Nine ACEs were measured retrospectively. Socioeconomic and demographic variables included low household income, economic inactivity, residential deprivation and activity limitation.

RESULTS

The prevalence of all outcomes increased strongly with ACE count. Perceived inability to cope financially during the cost-of-living crisis increased from 14.0% with 0 ACEs to 51.5% with 4+ ACEs. Relationships with ACEs remained after controlling for socioeconomic and demographic factors. Those with 4+ ACEs (vs 0 ACEs) were over three times more likely to perceive they would be unable to cope financially and, correspondingly, almost three times more likely to report substantial distress and anxiety and over three times more likely to report negative impacts on mental health, physical health and family relationships.

CONCLUSIONS

Socioeconomically deprived populations are recognised to be disproportionately impacted by rising costs of living. Our study identifies a history of ACEs as an additional vulnerability that can affect all socioeconomic groups. Definitions of vulnerability during crises and communications with services on who is most likely to be impacted should consider childhood adversity and history of trauma.

Association of adversities and mental health among first- and second-generation Arab American young adults

The prevalence of mental health problems among young adults is widely recognized. However, limited research has examined the mental health of Arab American young adults specifically. To address this gap in the literature, this study aimed to investigate the effects of multiple stressors including adverse childhood experiences (ACEs), discrimination, and bullying victimization on the mental health of first- and second-generation Arab American young adults. The participants (N = 162) were recruited from a Midwest university using online and in-person methods. They were screened and completed a demographic questionnaire and self-report measures of ACEs, discrimination, bullying victimization, and mental health. Hierarchical multiple regression analysis was conducted to examine the effect of psychosocial stressors on mental health and the moderating effect of generation (first vs. second) on that relationship. Female gender, increased perceived discrimination, and more ACEs were associated with lower mental health scores (β = -0.316, p < 0.001, β = -0.308, p < 0.001, and β = -0.230, p = 0.002, respectively). There was a significant negative relationship between victimization and mental health for first-generation Arab Americans (β = -0.356, p = 0.010). However, that association all but disappeared for second-generation participants (β = 0.006, p = 0.953). The results highlight the impact of multiple adversities on Arab American young adults' mental health and indicate important nuances related to their generation in the association between bullying victimization and mental health. Implications for practice and future research are discussed.

Current and Cumulative Stress Experiences: A Model for Arab American Young Adults

BACKGROUND

The effect of multiple stressors on immigrant young adults' endocrine functioning and health outcomes has not been comprehensively investigated.

AIMS

This study tested a theoretical model of cumulative and current stressor effects on the hypothalamic-pituitary-adrenocortical (HPA) axis functioning and health-related quality of life (HRQL) among Arab American young adults.

METHODS

Using a cross-sectional design, we recruited 160 participants, ages 18 to 24 years, from an urban university in the Midwest. Cumulative stress was assessed by self-report measures of childhood adversity, bullying victimization, and perceived ethnic discrimination. Current perceived stress was measured using the Perceived Stress Scale (PSS) while cortisol levels were measured in participants' hair. Structural equation modeling tested the effects of cumulative and current stress on cortisol and HRQL.

RESULTS

Cumulative stress was negatively associated with HRQL (standardized path coefficient = -.51, p < .05). Interestingly, however, cumulative stress was inversely associated with hair cortisol level (standardized path coefficient = -.51, p < .05). Current stress was positively associated with cortisol level (standardized path coefficient = .43, p < .05) and negatively associated with the mental HRQL (standardized path coefficient < -.37, p < .05).

CONCLUSION

Cumulative stress exhibited a different effect on HPA functioning from current perceived stress. Mental health was significantly impaired by both cumulative and current perceived stress. Implications for mental health nursing practice and research among Arab Americans are discussed.

Parenting-related positive childhood experiences, adverse childhood experiences, and mental health-Four sub-Saharan African countries

BACKGROUND

Adverse Childhood Experiences (ACEs) are associated with poor mental health outcomes and risk-taking behaviors. Positive childhood experiences (PCEs) may mitigate these negative impacts.

OBJECTIVE

This study 1) assessed the associations between ACEs and negative health outcomes and risk-taking behaviors among young adults, and 2) evaluated whether - and which - PCEs moderate the association between ACEs and these outcomes in sub-Saharan Africa.

METHODS

This multi-country analysis combined cross-sectional representative survey data from young adults, ages 18-24 years, from the 2019 Kenya, 2018 Lesotho, 2019 Mozambique, and 2019 Namibia Violence Against Children and Youth Surveys. The association between experiencing any ACEs and each health outcome was assessed using Wald's chi-square tests. Multivariable logistic regression analyses assessed the association between each PCE and each outcome of interest.

RESULTS

Females who experienced any ACEs had higher odds of experiencing moderate to severe mental distress (aOR = 2.7, 95%CI: 1.9, 3.9). Males who experienced any ACEs had higher odds of experiencing suicidal/self-harm behaviors (aOR = 6.7, 95%CI: 2.8, 16.0) and substance use (aOR = 2.5, 95%CI: 1.4, 4.2). In females, strong mother-child relationship was protective against moderate to severe mental distress (aOR = 0.7, 95%CI: 0.6, 0.9), suicidal/self-harm behaviors (aOR = 0.6, 95%CI: 0.4, 0.9), and substance use (aOR = 0.6, 95%CI: 0.4, 0.9). For males, a strong mother-child relationship was protective against suicidal/self-harm behaviors (aOR = 0.5, 95%CI: 0.2, 0.9), and a strong father-child relationship was protective against suicidal/self-harm behaviors (aOR = 0.4, 95%CI: 0.2, 0.7) and substance use (aOR = 0.6, 95%CI: 0.4, 0.8).

CONCLUSIONS

Strong parenting programs may likely play an important role in improving the psychosocial health of young adults.

ACE-IQ extended version validation and ACE's frequency in Mexican adolescents

BACKGROUND

Adverse Childhood Experiences (ACEs) may have short, middle, and long-term consequences on people's development and physical and mental health. There is a need for information on this subject in low- and middle-income countries and a need to reduce recall bias in ACEs research worldwide.

OBJECTIVE

Hence our objectives were to translate, adapt and validate the Adverse Childhood Experiences extended version and to determine ACEs frequencies in a sample of Mexican adolescents.

PARTICIPANTS AND SETTING

A convenience sample of 5835 schooled Mexican adolescents (age: M = 16.13, SD = 1.32; 61.01 % females) from 20 states in Mexico completed a survey.

METHOD

A cross-sectional study was conducted with an extended version of the ACE-International Questionnaire (ACE-IQ), which assesses 23 ACEs organized into five categories: situations that cause household dysfunction, exposure to violence, violence from parents or guardians, interpersonal violence, and sociodemographic context.

RESULTS

Evidence of construct validity and reliability of the questionnaire was obtained, and 16 ACEs were included in the final ACE-IQ version. 90 % of adolescents had one or more ACEs. Neglect was the most experienced ACE reported by 73.30 % of the participants, with no significant difference by age, sex, or geographic region.

CONCLUSION

ACE-IQ questionnaire is a reliable and valid instrument to recommend its use for generating information on ACEs in studies on Mexican adolescents. The results on the frequency of ACEs revealed that 90 % of this schooled Mexican adolescent sample had experienced one or more ACEs, and about a third had experienced six or more.

Childhood maltreatment and health in the UK Biobank: triangulation of outcome-wide and polygenic risk score analyses

BACKGROUND

Childhood maltreatment is common globally and impacts morbidity, mortality, and well-being. Our understanding of its impact is constrained by key substantive and methodological limitations of extant research, including understudied physical health outcomes and bias due to unmeasured confounding. We address these limitations through a large-scale outcome-wide triangulation study.

METHODS

We performed two outcome-wide analyses (OWAs) in the UK Biobank. First, we examined the relationship between self-reported maltreatment exposure (number of maltreatment types, via Childhood Trauma Screener) and 414 outcomes in a sub-sample of 157,316 individuals using generalized linear models ("observational OWA"). Outcomes covered a broad range of health themes including health behaviors, cardiovascular disease, digestive health, socioeconomic status, and pain. Second, we examined the relationship between a polygenic risk score for maltreatment and 298 outcomes in a non-overlapping sample of 243,006 individuals ("genetic OWA"). We triangulated results across OWAs based on differing sources of bias.

RESULTS

Overall, 23.8% of the analytic sample for the observational OWA reported at least one maltreatment type. Of 298 outcomes examined in both OWAs, 25% were significant in both OWAs and concordant in the direction of association. Most of these were considered robust in the observational OWA according to sensitivity analyses and included outcomes such as marital separation (OR from observational OWA, ORo = 1.25 (95% CI: 1.21, 1.29); OR from genetic OWA, ORg = 1.06 (1.03, 1.08)), major diet changes due to illness (ORo = 1.27 (1.24, 1.29); ORg = 1.01 (1.00, 1.03)), certain intestinal diseases (ORo = 1.14 (1.10, 1.18); ORg = 1.03 (1.01, 1.06)), hearing difficulty with background noise (ORo = 1.11 (1.11, 1.12); ORg = 1.01 (1.00, 1.01)), knee arthrosis (ORo = 1.13 (1.09, 1.18); ORg = 1.03 (1.01, 1.05)), frequent sleeplessness (ORo = 1.21 (1.20, 1.23); ORg = 1.02 (1.01, 1.03)), and low household income (ORo = 1.28 (1.26, 1.31); ORg = 1.02 (1.01, 1.03)). Approximately 62% of results were significant in the observational OWA but not the genetic OWA, including numerous cardiovascular outcomes. Only 6 outcomes were significant in the genetic OWA and null in the observational OWA; these included diastolic blood pressure and glaucoma. No outcomes were statistically significant in opposite directions in the two analyses, and 11% were not significant in either OWA.

CONCLUSIONS

Our findings underscore the far-reaching negative effects of childhood maltreatment in later life and the utility of an outcome-wide triangulation design with sensitivity analyses for improving causal inference.

Adverse Childhood Experiences and Mental Distress Among Adolescents and Youth in Zimbabwe

Adverse childhood experiences (ACEs) are a global public health crisis associated with physical and poor mental health outcomes. The current study examined the prevalence and association between individual and cumulative ACEs with mental distress among adolescents and youth in Zimbabwe. Data from the 2017 Violence Against Children and Youth Survey were utilized (13-25 years old, n = 8,715). Bivariate analysis was conducted using chi-square tests to obtain the prevalence estimates. Two sets of logistic regression models were conducted to determine significant associations between independent variables (i.e., experiencing childhood physical, emotional, and sexual violence; witnessing intimate partner violence (IPV) and community violence; orphan status; and cumulative ACE exposure) and the dependent variable (i.e., mental distress in the past 30 days as measured by Kelser 6). 28.4% of the adolescents and youth reported experiencing mental distress in the past 30 days. Regarding ACEs, cumulative ACE exposure (34.7%; adjusted odds ratio [AOR] = 2.13) and individual ACEs (i.e., experiencing childhood physical violence [39.3%; AOR = 1.41], emotional violence [55.8%; AOR = 2.67], sexual violence [50.8%; AOR = 2.00], witnessing community violence [47.3%; AOR = 1.52], witnessing IPV [43.1%; AOR = 1.47], and being orphaned during childhood [33.6%; AOR = 1.24]) were significantly associated with higher prevalence rates and odds of experiencing mental distress in the past 30 days among adolescents and youth in Zimbabwe. These findings show that ACEs are highly prevalent and increases the risk of mental distress for vulnerable adolescents and youth in Zimbabwe. Effective interventions to reduce violence exposure in families, schools, and communities are essential to mitigate the negative consequences of ACEs and mental distress of adolescents and youth in Zimbabwe. Strengthening child protection policies and involving social workers, psychologists, and mental health workers are also crucial for safeguarding vulnerable children who might be impacted by ACEs in Zimbabwe. Implications for future research are further discussed.

The association between adverse childhood experiences and sensory impairment in middle-aged and older adults: Evidence from a nationwide cohort study in China

BACKGROUND

Sensory impairment (SI), as prevalent condition among the elderly, presents a substantial public health burden.

OBJECTIVES

To investigate the association of cumulative and individual adverse childhood experiences (ACEs) with SI.

METHODS

Chinese residents aged 45 years and above were recruited from the China Health and Retirement Longitudinal Study 2011-2018, using stratified random sampling. The number of ACEs was classified into "0 ACE", "1 to 3 ACEs", and "≥4 ACEs". SI was assessed with self-rated visual or hearing status. SI categories included single sensory impairment (SSI), which can be divided into single vision impairment and single hearing impairment. Possessing both vision impairment and hearing impairment was considered as dual sensory impairment (DSI). Longitudinal SI progression encompassed "maintained no SI", "no SI to SSI", "no SI to DSI", "maintained SSI", "SSI to DSI", and "maintained DSI". Logistic regression and restricted cubic splines models were used for analysis.

RESULTS

A total of 6812 participants entered the cross-sectional analysis and 5299 entered the longitudinal analysis. Compared to 0 ACE, ≥4 ACEs had a positive association with DSI (OR = 1.57, 95 % CI = 1.20-2.06) but not with single vision impairment (OR = 1.17, 95 % CI: 0.88-1.55) or single hearing impairment (OR = 1.10, 95 % CI: 0.71-1.70), and this association was observed only in females (OR = 1.73, 95 % CI = 1.20-2.51). A linear association was found between cumulative ACEs and both single vision impairment (p = 0.044) and DSI (p < 0.001). Compared to 0 ACE, ≥4 ACEs was associated with a higher risk of progression from SSI to DSI (OR = 1.71, 95 % CI = 1.03-2.84), and the maintained DSI (OR = 2.23, 95 % CI =1.37-3.65).

CONCLUSION

ACEs were found to be associated with an increased risk and more severe progression of SI later in life. It is imperative to address different types of ACE and incorporate sex-specific measures to mitigate the enduring sensory impact of ACEs.

Maternal adverse childhood experiences on child growth and development in rural Pakistan: An observational cohort study

Maternal adverse childhood experiences (ACEs) have significant impacts on the next generation with links to negative birth outcomes, impaired cognitive development, and increased socioemotional problems in children. However, not all types or levels of adversity are similarly deleterious and research from diverse contexts is needed to better understand why and how intergenerational transmission of adversity occurs. We examined the role of maternal ACEs on children's growth, cognitive, and socioemotional development at 36 months postpartum in rural Pakistan. We used data from 877 mother-child dyads in the Bachpan Cohort, a birth cohort study. Maternal ACEs were captured using an adapted version of the ACE-International Questionnaire. Outcomes at 36 months of age included child growth using the WHO growth z-scores, fine motor and receptive language development assessed with the Bayley Scales of Infant and Toddler Development, and socioemotional and behavioral development measured with the Ages and Stages Questionnaire: Socioemotional and Strengths and Difficulties Questionnaire. To estimate the associations between maternal ACEs and child outcomes, we used multivariable generalized linear models with inverse probability weights to account for sampling and loss to follow-up. Over half of mothers in our sample (58%) experienced at least one ACE. Emotional abuse, physical abuse, and emotional neglect were the most commonly reported ACEs. We found null relationships between the number of maternal ACEs and child growth. Maternal ACEs were associated with higher fine motor and receptive language development and worse socioemotional and behavioral outcomes. Maternal ACE domains had similarly varying relationships with child outcomes. Our findings highlight the complexity of intergenerational associations between maternal ACEs and children's growth and development. Further work is necessary to examine these relationships across cultural contexts and identify moderating factors to mitigate potential negative intergenerational effects.

Adverse childhood experiences and adult outcomes using a causal framework perspective: Challenges and opportunities

BACKGROUND

Research on the effect of adverse childhood experiences (ACEs) on adult outcomes has typically relied on retrospective assessment of ACEs and cumulative scores. However, this approach raises methodological challenges that can limit the validity of findings.

OBJECTIVE

The aims of this paper are 1) to present the value of directed acyclic graphs (DAGs) to identify and mitigate potential problems related to confounding and selection bias, and 2) to question the meaning of a cumulative ACE score.

RESULTS

Adjusting for variables that post-date childhood could block mediated pathways that are part of the total causal effect while conditioning on adult variables, which often serve as proxies for childhood variables, can create collider stratification bias. Because exposure to ACEs can affect the likelihood of reaching adulthood or study entry, selection bias could be introduced via restricting selection on a variable affected by ACEs in the presence of unmeasured confounding. In addition to challenges regarding causal structure, using a cumulative score of ACEs assumes that each type of adversity will have the same effect on a given outcome, which is unlikely considering differing risk across adverse experiences.

CONCLUSIONS

DAGs provide a transparent approach of the researchers' assumed causal relationships and can be used to overcome issues related to confounding and selection bias. Researchers should be explicit about their operationalization of ACEs and how it is to be interpreted in the context of the research question they are trying to answer.

Exploring the link between adverse childhood experiences and mental and physical health conditions in pregnant Palestine refugee women in Jordan

OBJECTIVES

Adverse childhood experiences (ACEs) are linked to negative pregnancy outcomes. However, little is known about the prevalence of ACEs and their relationship to mental and health outcomes among pregnant Palestine refugee women.

STUDY DESIGN

This was a cross-sectional study.

METHODS

Data were collected from 772 pregnant Palestine refugee women with a median (interquartile range) age of 27 (23, 32) years, attending five antenatal clinics in Jordan between February and June 2021. The modified 33-item ACE International Questionnaire was used to assess eight domains of ACEs: (1) marriage and family, (2) relationship with parents, (3) neglect, (4) household dysfunction/domestic violence, (5) abuse, (6) peer violence, (7) community violence, and (8) collective violence. Multivariate logistic regression was used to examine the association between ACEs and mental and health outcomes. The ethical approval was obtained from United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) Research Review Board in May 2020.

RESULTS

Eighty-eight percent of women experienced at least one type of ACE, and 26% of women experienced ≥4 types of ACEs. Compared with women with 0-3 types of ACE exposure, those with ≥4 types of ACEs had 1.58 (95% confidence interval [CI] 1.10-2.28) times higher prevalence of obesity before pregnancy, 3.28 (95% CI 1.79-6.03) times higher prevalence of depression during pregnancy, and 2.01 (95% CI 1.39-2.91) times higher prevalence of ever been smoking cigarettes or hookah.

CONCLUSIONS

Exposure to ACEs is prevalent among pregnant Palestine refugee women. Exposure to multiple types of ACEs was associated with obesity, mental health conditions, and smoking.

Risk clustering and psychopathology from a multi-center cohort of Indian children, adolescents, and young adults

Developmental adversities early in life are associated with later psychopathology. Clustering may be a useful approach to group multiple diverse risks together and study their relation with psychopathology. To generate risk clusters of children, adolescents, and young adults, based on adverse environmental exposure and developmental characteristics, and to examine the association of risk clusters with manifest psychopathology. Participants (n = 8300) between 6 and 23 years were recruited from seven sites in India. We administered questionnaires to elicit history of previous exposure to adverse childhood environments, family history of psychiatric disorders in first-degree relatives, and a range of antenatal and postnatal adversities. We used these variables to generate risk clusters. Mini-International Neuropsychiatric Interview-5 was administered to evaluate manifest psychopathology. Two-step cluster analysis revealed two clusters designated as high-risk cluster (HRC) and low-risk cluster (LRC), comprising 4197 (50.5%) and 4103 (49.5%) participants, respectively. HRC had higher frequencies of family history of mental illness, antenatal and neonatal risk factors, developmental delays, history of migration, and exposure to adverse childhood experiences than LRC. There were significantly higher risks of any psychiatric disorder [Relative Risk (RR) = 2.0, 95% CI 1.8-2.3], externalizing (RR = 4.8, 95% CI 3.6-6.4) and internalizing disorders (RR = 2.6, 95% CI 2.2-2.9), and suicidality (2.3, 95% CI 1.8-2.8) in HRC. Social-environmental and developmental factors could classify Indian children, adolescents and young adults into homogeneous clusters at high or low risk of psychopathology. These biopsychosocial determinants of mental health may have practice, policy and research implications for people in low- and middle-income countries.

A Multi-Country Study of Risk and Protective Factors for Emotional and Behavioral Problems Among Early Adolescents

PURPOSE

Early adolescence (ages 10-14) is a critical period for psychosocial development, but few studies have focused on risk and protective factors for emergent psychosocial challenges among youth living in low- and middle-income countries. This study explored the contribution of social environmental factors to patterns of emotional and behavioral problems among early adolescents across four low- and middle-income countries.

METHODS

Participants were drawn from the Global Early Adolescent Study, and included 10,437 early adolescents from six low-resource urban settings in the Democratic Republic of Congo, Malawi, Indonesia, and China. Multivariate latent class regression was used to examine the associations between distinct patterns of emotional and behavioral problems and risk and protective factors across the family, peer, school, and neighborhood levels.

RESULTS

Across countries, childhood adversity, peer bullying behaviors, and a perceived lack of school safety were consistently associated with emotional and behavioral problems. With some contextual variability, peer substance use and a perceived lack of neighborhood safety also emerged as significant risk factors. The magnitude of these associations was generally greatest among a subgroup of early adolescents with co-occurring emotional and behavioral problems.

DISCUSSION

The overall consistency of findings across countries is suggestive of the generalizability of risk factors in early adolescence and indicates that interventions bolstering psychosocial adjustment among this age group may have applicability in diverse cross-national settings. Given the significance of peer bullying behaviors and school safety, multicomponent school-based interventions may be an especially applicable approach.

Using Implementation Mapping to develop protocols supporting the implementation of a state policy on screening children for Adverse Childhood Experiences in a system of health centers in inland Southern California

Adverse Childhood Experiences (ACEs) are defined as traumatic events occurring before age 18, such as maltreatment, life-threatening accidents, harsh migration experiences, or violence. Screening for ACEs includes asking questions about an individual's early exposure to these types of events. ACEs screenings have potential value in identifying children exposed to chronic and significant stress that produces elevated cortisol levels (i.e., toxic stress), and its associated physical and mental health conditions, such as heart disease, diabetes, depression, asthma, ADHD, anxiety, and substance dependence. However, ACEs screenings are seldom used in primary care settings. The Surgeon General of California has addressed this care gap by introducing ACEs Aware, an ACEs screening fee-for-service healthcare policy signed into law by Gov. Gavin Newsom. Since January 2020, Medi-Cal, California's Medicaid health care program, has reimbursed primary care providers for using the Pediatric ACEs and Related Life-events Screener (PEARLS) tool to screen children and adults for ACEs during wellness visits. To achieve the goals set by the ACEs Aware state policy, it is essential to develop and test implementation strategies that are informed by the values, priorities, and resources of clinical settings, healthcare professionals, and end-users. To address this need, we partnered with a system of federally qualified health centers in Southern California on a pilot study to facilitate the implementation of ACEs screenings in five community-based clinics. The health centers had broad ideas for an implementation strategy, as well as best practices to improve adoption of screenings, such as focusing on staff training to improve clinic workflow. This knowledge was incorporated into the development of an implementation strategy template, used at the outset of this study. We used the Exploration, Preparation, Implementation and Sustainment (EPIS) framework to guide the study and inform a participatory planning process called Implementation Mapping. In this paper, we describe how Implementation Mapping was used to engage diverse stakeholders and guide them through a systematic process that resulted in the development of the implementation strategy. We also detail how the EPIS framework informed each Implementation Mapping Task and provide recommendations for developing implementation strategies using EPIS and Implementation Mapping in health-care settings.

Moral Injury and Recovery in Uniformed Professionals: Lessons From Conversations Among International Students and Experts

Introduction

In the course of service, military members, leaders, and uniformed professionals are at risk of exposure to potentially morally injurious events (PMIEs). Serious mental health consequences including Moral Injury (MI) and Post-traumatic stress disorder (PTSD) can result. Guilt, shame, spiritual/existential conflict, and loss of trust are described as core symptoms of MI. These can overlap with anxiety, anger, re-experiencing, self-harm, and social problems commonly seen in PTSD. The experiences of General (retired) Romeo Dallaire and other international experts who have led in times of crisis can help us better understand MI and recovery.

Objectives

In honor of Dallaire, online opportunities were created for international students and leaders/experts to discuss topics of MI, stigma, and moral codes in times of adversity as well as the moral impact of war. We aimed to (1) better understand MI and moral dilemmas, and (2) identify key insights that could inform prevention of and recovery from MI.

Materials and Methods

Webinars and conversations of 75-90 min duration on MI and recovery were facilitated by Leiden University, the University of Alberta and the Dallaire Institute for Children, Peace and Security between General Dallaire, world experts, and graduate students. Sessions were recorded, transcribed and thematically analyzed with NVivo using standard qualitative methodology.

Results

Ninety four participants engaged in conversations. Student engagements were attended by participants [N = 51; female (29), male (22)] from the Netherlands and Canada. Conversations were held with international experts [N = 43; female (19) and male (24)] from North America, Europe, Australia and the global south. Themes included: (1) recognizing the impact of exposure to PMIEs, (2) reducing stigma around MI, and (3) embracing the spiritual depth of humanity.

Conclusion

Exposure to PMIEs can have devastating impacts on military members, leaders and other uniformed professionals. This may lead to development of MI and PTSD. Recognizing MI as honorable may reduce stigma and psychological harm, and facilitate help-seeking among uniformed personnel and other trauma-affected populations. Salient efforts to address MI must include use of accurate measurements of MI and integrated holistic therapeutic approaches, inclusive of spiritual and social components. Urgency remains regarding the prediction, identification and treatment of MI.

Feasibility and Impact of Trauma-Informed Care Training in Internal Medicine Residency: A Pilot Study

Introduction: Mounting evidence indicates that early life trauma is highly prevalent and associated with adverse health outcomes later in life. However, primary care providers report lacking the training to effectively address trauma encountered in daily practice. There is a paucity of research describing the implementation and evaluation of trauma-informed care (TIC) curricula within Graduate Medical Education.

Methods: We piloted a three-hour TIC workshop facilitated by a community-based psychologist expert to assess the feasibility and impact of TIC training on Internal Medicine (IM) residents’ knowledge, attitudes and skills related to TIC. Participants were a subset of IM residents in a health-equity-focused curricular pathway in the University of Colorado IM Residency. Residents completed anonymous surveys one week before and after the workshop, and a final survey 10 weeks later. Residents who did not participate in the workshop completed a similar baseline survey (control group). Data were analyzed using matched pair T-tests.

Results: Fourteen of 20 residents (70%) who participated in the pilot workshop completed the initial survey. Of these, 10 (71%) completed the first post-workshop survey, and seven (50%) completed the final survey. We observed significant improvements in residents’ self-reported knowledge, attitudes and skills related to TIC. The majority of residents in the control group reported a desire for TIC training.

Conclusions: TIC is an important curricular gap in IM training. A single, brief TIC workshop was feasible and was associated with improved self-reported knowledge, attitudes and skills among IM residents.

Hypertension and Its Associated Mental Health Challenges Among Female African Refugees in Durban, South Africa

ABSTRACT

Hypertension is a serious medical condition that leads to various adverse health complications when left untreated. In addition to psychological challenge that female migrant refugees are exposed to premigration, they encounter barriers to care postmigration from xenophobia that affects their hypertension. We investigated the extent and mental health drivers of hypertension in refugees in Durban, South Africa. We interviewed 178 adult female African help-seeking refugees/migrants for hypertension (blood pressure ≥130/90 mm Hg) and mental health challenges (e.g., adverse childhood experience [ACE] and depression using the Center for Epidemiologic Studies-Depression scale). Eighty-six percent (n = 153) of participants were hypertensive, and based on the adjusted regression models, exposure to at least one ACE (adjusted odds ratio [aOR], 2.83; 95% confidence interval [CI], 1.11-7.26) and depression (aOR, 3.54; 95% CI, 1.10-11.37) were associated with hypertension, independent of smoking, alcohol, obesity, and physical exercise status. Hypertension and its associated mental health challenges are overlooked conditions in this population, with further efforts for screening being needed.

The Relevance of the Adverse Childhood Experience International Questionnaire to Working Children: Knowledge Gaps and Implications for Policy Makers

(1) Adverse childhood experiences (ACE) are a global challenge, prioritized in the United Nations’ Sustainable Development Goals. The ACE questionnaire is widely adopted in the USA as a tool for measuring population-level trends, such as negative health, behavioral, and economic outcomes. Intuitively, children in resource-scarce settings are exposed to higher levels of trauma. To understand the global picture, the World Health Organization (WHO) adapted the ACE international questionnaire (ACE-IQ), to inform policy and target interventions. However, evaluation of whether the ACE-IQ captures the experiences of around 160 million working children remains limited. (2) I applied the ACE-IQ scoring tools to detailed case studies of working children, comparing issues highlighted by holistic assessment to those captured by the ACE-IQ. (3) The ACE-IQ struggles to capture nuance across cultural contexts. As a consequence, application of the ACE-IQ as a policy tool risks “policy failure”. The tool reflects prevalent Western concerns, such as school attendance and parental supervision, but global concerns affecting working children such as forced economic migration and famine are neglected. This limitation produces “policy myopia”, sidelining certain global challenges. (4) The ACE-IQ is a useful public health tool, increasingly used to define policy goals. However, given the limitations of the ACE-IQ, the consequences of prioritizing these particular policy goals need to be actively acknowledged and mitigated.

Traumatic life-events and suicidality among Mexican adolescents as they grow up: A longitudinal community survey

OBJECTIVE

Limited research exists on the impact of type and number of traumatic events on the incidence of suicide ideation and attempts (suicidality) among adolescents in low/middle income countries where violence is common.

METHOD

We estimated prospective associations of 7 types of events on the new occurrence of suicidality from a follow-up conducted in 2013 (n = 1071; ages 19-26) of the original Mexican Adolescent Mental Health Survey conducted in 2005 (ages 12-17), by using Hazard Ratios (HR) estimates.

RESULTS

For new onset of suicide ideation, those reporting "Ever raped or sexually assaulted" had the highest adjusted HR (3.8), followed by "Ever other traumatic event" (HR = 1.9), "Ever committed or witnessed violence" (HR = 1.7) and "Beaten as a child or witnessed physical fights at home" (HR = 1.5). For suicide attempt, those reporting "Ever beaten up by spouse, partner, someone else, mugged with a weapon, or stalked" (HR = 3.8) and "Ever other traumatic event" (HR = 2.0) had the higher hazards. Compared to those without a traumatic event, increased hazards of ideation and attempt were found for those reporting a greater number of types of events.

CONCLUSIONS

Our sample is representative of the largest metropolitan area in Mexico but does not include other cities or age groups that may differ in risk factors. Traumatic events that happened in the eight years between waves are not considered. Traumatic events increased the risk of suicidality, independent of common mental disorders. Identifying and addressing these events in clinical settings may therefore be important for preventing suicide in this population.

Adverse Childhood Experiences Among Low-Income, Latinx Children in Immigrant Families: Comparison of Children in Rural Farmworker and Urban Non-Farmworker Communities

Adverse childhood experiences (ACEs) are stressors that can have lifelong detrimental health effects. ACEs are a concern for children of immigrant parents. The low-income mothers of 75 rural farmworker and 63 urban non-farmworker 8-year old Latinx children in immigrant families completed a standardized ACEs inventory. 47.1% of mothers reported no ACEs, 33.3% reported 1, 8.7% reported 2, and 10.9% reported 3 or more. A logistic regression model indicated that urban versus rural children had a higher odds (OR = 2.35, 95% CI = 1.01, 5.48) of at least one ACE. Children living in families with 2 versus 1 adults (OR = 0.10, 95% CI = 0.02, 0.49) and 3 versus 1 adults (OR = 0.12, 95% CI = 0.02, 0.78) had a lower odds of at least one ACE. ACEs prevalence was similar to other children in immigrant families, with children living in urban communities having twice the likelihood of experiencing an ACE. Detailed research is needed on locality-based ACEs prevalence.

Prevalence of Adverse Childhood Experiences (ACEs) and associated health risks and risk behaviors among young women and men in Honduras

BACKGROUND

Adverse Childhood Experiences (ACEs) are potentially traumatic childhood events associated with negative health outcomes. Limited data on ACEs exists from low- and middle-income countries (LMICs). No ACEs studies have been done in Honduras.

OBJECTIVE

This study assessed the prevalence of ACEs in Honduras and associated health risks and risk behaviors among young adults.

PARTICIPANTS AND SETTING

Data from the 2017 Honduras Violence Against Children and Youth Survey (VACS) were used. Analyses were restricted to participants ages 18-24 years (n = 2701).

METHODS

This study uses nationally representative VACS data to estimate the weighted prevalence of ACEs (physical, emotional, and sexual violence; witnessing violence; parental migration). Logistic regression analyses assessed the relationship between individual ACEs, cumulative ACEs, and health risks and risk behaviors (psychological distress; suicide ideation or self-harm; binge drinking; smoking; drug use; STIs; early pregnancy). Chi-square tests examined differences by sex.

RESULTS

An estimated 77 % of 18-24 year olds in Honduras experienced at least 1 ACE and 39 % experienced 3+ ACEs. Women experienced significantly more sexual, emotional, and physical violence compared to men. Compared to youth with no ACEs, those with 1-2 ACEs and 3+ ACEs had 1.8 and 2.8 increased odds for psychological distress, 2.3 and 6.4 increased odds for suicidal ideation and self-harm, and 1.7 and 1.9 increased odds for smoking, respectively, adjusting for age, education, and food insecurity. Physical violence victimization and witnessing violence in the community were associated with increased odds of all health risks and risk behaviors.

CONCLUSIONS

The high prevalence of ACEs and associated negative health risks and risk behaviors in this population support the need for prevention and early intervention for ACEs.

Special Issues in Immigrant Medicine

Immigrants enrich the United States through economic contributions and unique perspectives. Immigrants find themselves navigating a new culture, a complicated health care system, unfamiliar social programs, and an ever-changing policy environment. They may be discouraged by unmet expectations of life in the United States, changing family dynamics, and discrimination. Screening for the social determinants of health is crucial, as not all patients will proactively seek the advice of their health care provider for these issues. Health care providers can assist and empower immigrants to navigate these challenges, as well as serve as advocates on a broader scale.