Factors Associated With Whether Pediatricians Inquire About Parents' Adverse Childhood Experiences

Parents' perceptions of the safe environment for every kid (SEEK) model in the Swedish child health services

BACKGROUND

The Safe Environment for Every Kid (SEEK) model was developed to address psychosocial risk factors (financial worries, depressive symptoms, major parental stress, alcohol misuse and intimate partner violence) in the pediatric primary care setting but has not been evaluated from the parents' perspective. To further investigate the usefulness of SEEK, it is important to explore how parents perceive the model.

OBJECTIVE

The aim of the present study was to explore parents' perceptions of the SEEK model as a part of regular health visits in the Child Health Services in Sweden.

PARTICIPANTS AND SETTING

Eighteen parents (13 women and five men) in two Swedish counties participated in the study.

METHODS

Semi-structured telephone interviews were conducted, and the resulting data were analyzed using reflective thematic analysis.

RESULTS

Three themes were identified: Acceptance and understanding of the SEEK model in the child health services, The questionnaire as a bridge to a dialogue, and Feeling trust in the system and the child health nurse's professional competence. Further, an overarching theme was created that encompassed a core meaning of all three themes; SEEK provides a process-oriented framework to receive support in parenting with a focus on child health.

CONCLUSIONS

The study showed that parents express both acceptance and understanding of the SEEK model and they perceive that the model provides an avenue for repeated dialogues about the family's situation during the child's upbringing and an opportunity to access support if needed.

A Short Adverse Experiences Measure Among Mothers of Young Children

OBJECTIVES

Screening for parental adverse childhood experiences (ACEs) in pediatric settings can be burdensome because of the questionnaire's length and sensitive nature. Rapid screening tools may help address these challenges. We evaluated a 2-item short ACE measure developed for adults in a cross-sectional sample of mothers of young children in an urban pediatric emergency department.

METHODS

From January 2011 to March 2020, we administered the ACE questionnaire in English or Spanish to 3999 biological mothers of children aged <4 years in a pediatric emergency department in Philadelphia, Pennsylvania. We assessed sensitivity and specificity of a shortened 2-item ACE measure defined as report of childhood emotional abuse and/or household substance use, using 4+ ACEs on the full questionnaire as the standard. We assessed convergent validity by comparing associations of the 2-item and standard measures with maternal, household, and child outcomes using adjusted log-binomial regression.

RESULTS

Mothers were racially and ethnically diverse (54% Latina, 35% Black non-Latina); 94% of children were publicly insured. Thirteen percent of mothers reported childhood emotional abuse and 16% childhood household substance use; 23% reported at least 1 of these and 6% both. Compared with 4+ ACEs on the full questionnaire, the 2-item measure had sensitivity 88% and specificity 90%. In adjusted models, high adversity was associated with poor maternal, household, and child outcomes.

CONCLUSIONS

A 2-item ACE measure assessing childhood emotional abuse and household substance use may be useful in pediatric settings to identify mothers who may have experienced significant child adversity and inform development, testing, or provision of comprehensive family supports.

The effect of adverse childhood experience training, screening, and response in primary care: a systematic review

Background

Adverse childhood experiences (ACEs) can have harmful, long-term health effects. Although primary care providers (PCPs) could help mitigate these effects, no studies have reviewed the impacts of ACE training, screening, and response in primary care.

Methods

This systematic review searched four electronic databases (PubMed, Web of Science, APA PsycInfo, CINAHL) for peer-reviewed articles on ACE training, screening, and/or response in primary care published between Jan 1, 1998, and May 31, 2023. Searches were limited to primary research articles in the primary care setting that reported provider-related outcomes (knowledge, confidence, screening behavior, clinical care) and/or patient-related outcomes (satisfaction, referral engagement, health outcomes). Summary data were extracted from published reports.

Findings

Of 6532 records, 58 met inclusion criteria. Fifty-two reported provider-related outcomes; 21 reported patient-related outcomes. 50 included pediatric populations, 12 included adults. A majority discussed screening interventions (n = 40). Equal numbers (n = 25) discussed training and clinical response interventions. Strength of evidence (SOE) was generally low, especially for adult studies. This was due to reliance on observational evidence, small samples, and self-report measures for heterogeneous outcomes. Exceptions with moderate SOE included the effect of training interventions on provider confidence/self-efficacy and the effect of screening interventions on screening uptake and patient satisfaction.

Interpretation

Primary care represents a potentially strategic setting for addressing ACEs, but evidence on patient- and provider-related outcomes remains scarce.

Funding

The California Department of Health Care Services and the Office of the California Surgeon General.

Is Academic Medicine Prepared to Teach About the Intersection of Childhood Experiences and Health? An Exploratory Survey of Faculty

INTRODUCTION

Childhood experiences affect health across the lifespan. Evidence-based strategies targeting early-life stress are emerging. Nevertheless, faculty physicians' preparation to incorporate this science into practice has not been well studied. This study explores medical faculty knowledge and beliefs, timing and route of knowledge acquisition, perceived relevance and application of study topics, and characteristics associated with concept mastery.

METHODS

The authors developed and administered an exploratory survey to faculty from six departments at two medical schools. The team analyzed responses using quantitative and qualitative methods.

RESULTS

Eighty-one (8.8%) eligible faculty completed the survey. Of respondents, 53 (65.4%) achieved high knowledge, 34 (42.0%) high beliefs, and 42 (59.1%) high concept exposure question scores, but only 6 (7.4%) through a formal route. Although 78 (96.8%) respondents indicated that survey concepts are relevant, only 18 (22.2%) reported fully incorporating them in their work, and 48 (59.2%) identified the need for additional coaching. Respondents reporting full incorporation were significantly more likely to attain high concept exposure scores (17 respondents, 94.4%, versus 25 respondents, 39.7%, P < .001). Quantitative and qualitative analysis highlighted limited respondent awareness of trauma prevalence among health care workers, lack of familiarity with interventions, and time and resource challenges addressing childhood adversity.

DISCUSSION

Although survey respondents had some familiarity with study concepts and perceived their relevance, most are not fully applying them. Results suggest that exposure to study concepts is associated with full incorporation. Therefore, intentional faculty development is essential to prepare faculty to include this science in practice.

Des expériences négatives de l'enfance à la santé relationnelle précoce : les conséquences pour la pratique clinique

Les enfants grandissent et se développent dans un environnement de relations. Des relations sécuritaires, stables et bienveillantes contribuent à consolider la résilience et à atténuer les répercussions des expériences négatives. La promotion de la santé relationnelle en pratique clinique recentre l'attention accordée aux expériences négatives de l'enfance sur les expériences positives de l'enfance. Cette approche, qui évalue les forces et les atouts d'une famille, peut être intégrée à la fois aux rendez-vous réguliers de l'enfant en santé et aux soins surspécialisés. Il est optimal de réaliser de telles interventions pendant la période prénatale ou le plus rapidement possible avant l'âge de trois ans, mais il n'est jamais trop tard pour les entreprendre. Le présent document de principes décrit comment les cliniciens peuvent adopter une approche de santé relationnelle lors de chacune de leurs rencontres médicales s'ils comprennent ce qu'est le stress toxique et ses effets sur le cerveau en développement, les relations familiales et le développement de l'enfant; à quel point les relations, expériences et comportements positifs peuvent en atténuer les effets et renforcer la résilience; quels sont les signes observables de la santé relationnelle et des risques relationnels dans les interactions entre les parents et l'enfant; quelles sont les caractéristiques de relations thérapeutiques de confiance avec les familles et comment en optimiser les avantages par les échanges et la pratique clinique.

From ACEs to early relational health: Implications for clinical practice

Children grow and develop in an environment of relationships. Safe, stable, nurturing relationships help build resilience and buffer the negative impact of adverse experiences. Promoting relational health in clinical practice shifts the focus from adverse childhood experiences (ACEs) to positive childhood experiences (PCEs). This approach evaluates a family's strengths and assets, and can be incorporated into both well-child and subspecialty care. While the optimal window for such interventions is in the prenatal period or as early as possible within the first 3 years of life, it is never too late to start. This statement describes how clinicians can bring a relational health approach to any medical encounter by understanding: what toxic stress is and how it can affect the developing brain, family relationships, and child development; how positive relationships, experiences, and behaviours can help buffer such effects and build resilience; observable signs of relational health and risk in parent-child interactions; the attributes of trustful, therapeutic relationships with families; and how to optimize these benefits through conversation and clinical practice.

When Attitudes Become Obstacles: An Exploratory Study of Future Physicians' Concerns about Reporting Child Maltreatment

BACKGROUND

Child maltreatment (CM) makes up a significant portion of events under the larger umbrella term of adverse childhood experiences (ACEs). Therefore, we need to develop a competent healthcare workforce that is prepared to assess and report CM in order to create a comprehensive framework for assessing and addressing ACEs. The objective of the present study was to examine the obstacles to reporting CM among a sample of future physicians.

METHODS

Two samples of medical students and residents (N = 196) completed the Healthcare Provider Attitudes Toward Child Maltreatment Reporting Scale and rated how likely they would be to report suspected CM.

RESULTS

Medical students were found to have more negative feelings about and perceive more obstacles to reporting CM compared to residents in our sample. Scores on the Reporting Responsibilities subscale were not significantly associated with increased likelihood of reporting CM. However, lower scores on the Concerns about Reporting subscale were related to an increased likelihood of reporting CM.

CONCLUSIONS

Future physicians who perceived fewer obstacles to reporting CM reported being more likely to report suspected CM. Misinformed fears about outcomes such as retaliation, removal of the child from the home, and being sued may interfere with future physicians' adherence to mandated reporting responsibilities. Efforts should be made early in physician education to identify and address common myths and misconceptions around mandated reporting and its outcomes.

Creation and validation of an instrument to quantify attitudes, knowledge and difficulties in the approach to social problems

OBJECTIVES

The aim of the study was to develop and validate a questionnaire to assess attitudes, knowledge and difficulties in the management of social problems by paediatric care providers.

METHODS

The development of the tool started with a conceptualization phase, followed by the design, pilot testing and psychometric evaluation of the questionnaire based on the responses obtained from 407 professionals. We performed exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) to assess the construct validity of the questionnaire. We used the normed fit index (NFI), the root mean square error of approximation (RMSEA), the χ² test and the comparative fit index (CFI) to test the goodness of fit. We assessed reliability through the Cronbach's α coefficient of internal consistency. All quantitative analyses were performed with the Stata/SE software, version16.1.

RESULTS

The EFA identified twelve factors. All factors exhibited a good internal consistency (Cronbach's α, 0.8434). The CFA showed the model was a good fit (RMSEA=0.037). The NAI and CAI values were 0.742 and 0.797, respectively.

CONCLUSIONS

This questionnaire comprising 138 items distributed in twelve factors is a reliable and valid instrument to analyse the attitudes, knowledge and difficulties in the approach to social problems in children by paediatricians, which will allow the design of interventions according to the needs and deficiencies identified through it.

Identification of families in need of support: Correlates of adverse childhood experiences in the right@home sustained nurse home visiting program

Background

Little is known about the efficacy of pregnancy screening tools using non-sensitive sociodemographic questions to identify the possible presence of as yet undiagnosed disease in individuals and later adverse childhood events disclosure.

Objectives

The study aims were to: 1) record the prevalence of risk disclosed by families during receipt of a sustained nurse home visiting program; and 2) explore patterns of relationships between the disclosed risks for their child having adverse experiences and the antenatal screening tool, which used non-sensitive demographic questions.

Design

Retrospective, observational study.

Participants and methods

Data about the participants in the intervention arm of the Australian right@home trial, which is scaffolded on the Maternal Early Childhood Sustained Home-visiting model, collected between 2013 and 2017 were used. Screening data from the 10-item antenatal survey of non-sensitive demographic risk factors and disclosed risks recorded by the nurse in audited case files during the subsequent 2 year intervention were examined (n = 348). Prevalence of disclosed risks for their child having adverse experiences were analysed in 2019 using multiple response frequencies. Phi correlations were conducted to test associations between screening factors and disclosed risks.

Results

Among the 348 intervention participants whose files were audited, 300 were noted by nurses to have disclosed risks during the intervention, with an average of four disclosures. The most prevalent maternal disclosures were depression or anxiety (57.8%). Mental health issues were the most prevalent partner and family disclosures. Screening tool questions on maternal smoking in pregnancy, not living with another adult, poverty and self-reporting anxious mood were significantly associated with a number of disclosed risks for their child having adverse experiences.

Conclusions

These findings suggest that a non-sensitive sociodemographic screening tool may help to identify families at higher risk for adverse childhood experiences for whom support from a sustained nurse home visiting program may be beneficial.

Child health nurses' experiences of using the Safe Environment for Every Kid (SEEK) model or current standard practice in the Swedish child health services to address psychosocial risk factors in families with young children - A mixed-methods study

BACKGROUND

Child maltreatment (CM) is often hidden, and the youngest children are often those most exposed. CM can be prevented through programs that address risk factors, but few primary prevention strategies have been evaluated.

OBJECTIVE

To examine the experiences of nurses using the Safe Environment for Every Kid (SEEK) model compared to nurses using current standard practice in the Swedish child health services (CHS) to address psychosocial risk factors in the family environment.

PARTICIPANTS AND SETTING

Nurses at 27 child health centers in the CHS in the county of Dalarna, Sweden participated in the study. A survey was answered by 55 nurses and 18 nurses participated in focus-group interviews.

METHODS

A convergent mixed methods research design with focus-group interviews and survey data was used. Qualitative Content Analysis was used to analyze the interview data and Mann Whitney U test was used to analyze the survey data.

RESULTS

The qualitative analysis identified four categories - "Framing the prerequisites for successful practice"; "Managing the mission of the CHS"; "Meeting the family as a professional"; and "Working with psychosocial risk factors can be emotional" - under the overarching theme "Universal application of a structured method adds value to experience-based knowledge when addressing psychosocial risk factors". Survey data showed that SEEK nurses rated to a greater degree that they possessed adequate knowledge, competence and sense of security to address psychosocial risk factors in their work.

CONCLUSIONS

This study indicates that using SEEK can strengthen the nurses in identifying and responding to families in need of psychosocial support.

The Associations between Adverse Childhood Experiences and Social Services Use among Head Start-Eligible Low-Income Families

This study examined the effects of adverse childhood experiences (ACEs) on parental social services use among Head Start-eligible low-income families. Based on the Head Start Impact Study data (N = 3,562), three questions were addressed: (1) Does the number of ACEs impact parental social services use? (2) Do family characteristics have any association with parental social services use? and (3) Does parental social services use differ between Head Start and non-Head Start parents? Regression indicated that parents with more ACEs tended to use more social services. Compared with parents with one ACE, parents with two ACEs and parents with three or more ACEs used more social services with income assistance, food and nutrition assistance, and housing and utility assistance programs. Parents with three or more ACEs tended to use more social services related to alcohol and drug use, mental health, and foster care payments than parents with one ACE. Barriers to social services use were identified and include racial disparities, native language, immigration status, and geographical location. Head Start was not found to have a significant impact on whether parents used more social services. Recommendations include increasing effective collaboration between social workers and services, assessing barriers to receiving services, and implementing ACE screenings.

Co-producing a social determinants of health questionnaire for an urban population in community child health

We used quality improvement (QI) and co-production methodologies to explore how child health professionals can be helped to open up conversations about poverty and other social issues in a London community child health clinic between July and October 2019.

Inter-Clinician Variability in Primary Care Providers' Adverse Childhood Experience Knowledge, Training, Screening Practices, and Perceived Intervention Barriers: an Exploratory Cross-Sectional Study

Adverse childhood experiences (ACEs) are traumatic events that occur before the age of 18 that can have immediate and long-term negative health, behavioral, and social outcomes. Primary care providers (PCPs) can help mitigate the negative effects of ACEs by identifying at-risk children and families in need of support. This cross-sectional study, that incorporates inter-clinician variability into the sample, explored PCPs ACE knowledge, training, screening practices, and perceived intervention barriers to addressing ACEs. Results found that PCPs had limited familiarity with the ACE study and the effects of ACEs, few PCPs received training on ACEs, only some PCPs formally screened their patients for ACEs, and lack of time and training were PCPs most cited perceived barriers to addressing ACEs. A statistically significant difference in PCPs ACE knowledge and perceived barriers to addressing ACEs by inter-clinician variability was found. To more effectively address ACEs in the primary care setting, the following is recommended - effective ACEs educational tools and resources for both resident and attending PCPs, training on addressing sensitive topics including ACEs beginning in resident physician education, efficient models for ACEs office-based screening, increased access to mental health care for patients, strengthened care coordination with community organizations, and collaborative practice networks.

Screening for Adverse Childhood Experiences in Children: A Systematic Review

CONTEXT

Adverse childhood experiences (ACEs) are associated with increased risk of poor mental health outcomes. Although there is interest in screening for ACEs for early identification and intervention, it is not known whether screening improves outcomes for children.

OBJECTIVE

To systematically review whether screening for ACEs in children leads to an increase in (1) identification of ACEs, (2) referrals to services, (3) increased uptake of services, and (4) improved mental health outcomes for children and parents.

DATA SOURCES

Ovid Medline, PsycINFO, CINAHL, and Center for Clinical and Translational Research electronic databases were searched between 2009 and 2021.

STUDY SELECTION

Studies were included if researchers screened for current ACEs in children aged 0 to 12 years and they had a control comparison.

DATA EXTRACTION

Information was extracted, including study characteristics, sample demographics, screening tool characteristics, referral rates to services, uptake rates, and mental health outcomes.

RESULTS

A total of 5816 articles were screened, with 4 articles meeting inclusion criteria. Screening for ACEs increases identification of adversity and may increase referrals to services. There are limited data about whether this leads to an increase in referral uptake by families. There are no reported data addressing mental health outcomes.

LIMITATIONS

There are few published control trials of moderate quality.

CONCLUSIONS

There is limited evidence that screening for ACEs improves identification of childhood adversity and may improve referrals. If we are to realize the hypothesized benefits of ACEs screening on child and parent mental health, it is essential to understand the barriers for families taking up referrals.

Impact of Parental Adverse Childhood Experiences on Offspring Development in Early Head Start: Parental Adversity and Offspring Development

Adverse childhood experiences (ACEs) are potentially traumatic events that can cause lifelong suffering, with 1 out of 2 children in the United States experiencing at least 1 ACEs. The intergenerational effect of ACEs has been described, but there's still paucity of knowledge of its impact on child development and behavior in children enrolled in Early Head Start (EHS) home visiting programs. A retrospective observational study was performed with 71 parents and 92 children participating in the EHS Home Visiting Program in Olmsted County from 2014 to 2019. Parents reported their own ACEs using a 10-item questionnaire. Children's social-emotional status was evaluated with Devereux Early Childhood Assessment Second Edition (DECA) and development was evaluated using the Brigance Early Childhood Screens III. Referrals of children by EHS staff to community agencies were recorded. The association between parental ACEs score, developmental outcomes and referrals was analyzed. Parental ACEs score of 4 or more was associated with failing at least 1 domain on the Brigance screen (P = .02) especially adaptive/cognitive domain (P = .05), and increased risk of referral to community resources (P < .001). However, there was no association between ACEs scores and failing DECA screens. We identified an intergenerational association between parental exposure to ACEs and risk for childhood developmental delay and referrals to community services. Parental adverse childhood experiences (ACEs) have intergenerational effects on offspring. In our study, parental ACEs are associated with offspring developmental delays and referral to community resources. Screening for parental adverse childhood experiences, a key social determinant of health, is imperative and should be incorporated into primary care and early childhood settings to identify children at risk for developmental delay.

Lessons Learned from a Quality Improvement Initiative: Adverse Childhood Experiences Screening in a Pediatric Clinic

Universal screening for adverse childhood experiences (ACEs) is recommended by the American Academy of Pediatrics due to downstream health risks. However, widespread screening practices have not been adopted.

Methods

We used quality improvement methods to establish ACEs screening in a busy pediatric clinic that serves primarily Medicaid-insured and Spanish-speaking patients. The final Plan-Do-Study-Act cycle included the screening of both the patient and his/her caregiver(s). ACEs scores were a process measure; balancing measures were the average time to screen, the number of referrals generated, and qualitative caregiver reception.

Results

We screened 232 families, and the process maintained a ≥ 80% completion rate of ACEs screening for 1-month-old children and their caregivers during the final 10 weeks. 23% of caregivers had an ACEs score ≥ 4; overall, 6% were referred for further resources. The average time to discuss the screen was 86.78 seconds. The general caregiver reception was gratitude; 2% refused screening.

Conclusion

This study demonstrates the feasibility of initiating ACEs screening of 1 age group and their caregivers using quality improvement methods.

Public health for paediatricians: Fifteen-minute consultation on addressing child poverty in clinical practice

Paediatricians and other child health professionals have a key role in identifying, preventing or mitigating the impacts of poverty on child health. Approaching a problem as vast and intractable as poverty can seem daunting. This article will outline how social determinants impact child health, and provide practical guidance on how to address this problem through a public health lens. The aim is to give frontline practitioners a straightforward, evidence-based framework and practical solutions for tackling child poverty, across three levels: (1) the clinical consultation; (2) the clinical service for the population of children and young people we serve and (3) with a broader policy and social view.

The assessment of adverse childhood experiences in clinical settings: Practitioner competencies and perceptions

Issues concerning the screening and assessment of adverse childhood experiences (ACEs) in healthcare settings have been subject to growing scrutiny in recent years, yet relatively little is known about practitioner perceptions and competencies related to such practices. This study examined practitioner knowledge, ability and concerns about the assessment of ACEs among parents and children in clinical settings and the acceptability of a newly validated measure (The Adverse Life Experiences Scale, ALES) for this purpose. Participants were (N = 144) healthcare practitioners (predominantly psychologists, nurses, social workers and psychiatrists). Measures were completed online, and the effects of family characteristics on practitioner perceptions were tested experimentally using case vignettes. Participants indicated moderate-to-high levels of knowledge and ability regarding the assessment of ACEs, and the ALES demonstrated high levels of acceptability across hypothetical cases involving various levels of risk. Practitioner concerns about such assessment were also found to be influenced by the level of risk indicated by case referral information. Specifically, concerns that assessment would be too upsetting or time-consuming were greater in response to a case with a high level of ACEs, compared to one with low-to-moderate ACEs (p < .05; large effect size). Practitioners demonstrated relatively high competencies regarding the assessment of ACEs and supported the use of the ALES for this purpose. Those families with the highest levels of ACEs may nonetheless be the least likely to receive such assessment in clinical settings.

Intergenerational Associations between Parents' and Children's Adverse Childhood Experience Scores

BACKGROUND

Adverse childhood experiences (ACEs) are stressful childhood events associated with behavioral, mental, and physical illness. Parent experiences of adversity may indicate a child's adversity risk, but little evidence exists on intergenerational links between parents' and children's ACEs. This study examines these intergenerational ACE associations, as well as parent factors that mediate them.

METHODS

The Panel Study of Income Dynamics (PSID) 2013 Main Interview and the linked PSID Childhood Retrospective Circumstances Study collected parent and child ACE information. Parent scores on the Aggravation in Parenting Scale, Parent Disagreement Scale, and the Kessler-6 Scale of Emotional Distress were linked through the PSID 1997, 2002, and 2014 PSID Childhood Development Supplements. Multivariate linear and multinomial logistic regression models estimated adjusted associations between parent and child ACE scores.

RESULTS

Among 2205 parent-child dyads, children of parents with four or more ACEs had 3.25-fold (23.1% [95% CI 15.9-30.4] versus 7.1% [4.4-9.8], p-value 0.001) higher risk of experiencing four or more ACEs themselves, compared to children of parents without ACEs. Parent aggravation, disagreement, and emotional distress were partial mediators.

CONCLUSIONS

Parents with higher ACE scores are far more likely to have children with higher ACEs. Addressing parenting stress, aggravation, and discord may interrupt intergenerational adversity cycles.

Parent Traumatic Events and Adolescent Internalizing Symptoms: The Mediating Role of Parental Depression Among Youth with Persistent Post-concussive Symptoms

OBJECTIVE

Research has demonstrated associations between parental depression (PD) and negative psychological outcomes among their children. However, little is known about the pathways through which lifetime parent traumatic events (PTEs) influence their adolescents' internalizing symptoms. Our study examined whether PD mediates the association between PTE and adolescent depressive and anxious symptoms among youth with persistent postconcussive symptoms (PPCS).

METHODS

We used baseline data from a randomized effectiveness trial of collaborative care for treatment of persistent postconcussive symptoms among sports-injured adolescents aged 11-18 years. Parent-adolescent dyads were recruited from pediatric clinics throughout western Washington. Eligible adolescents had three or more PPCS that lasted for at least 1 month but <9 months and spoke English. Of 1,870 potentially eligible adolescents, 1,480 (79%) were excluded for not meeting the inclusion criteria. Of the eligible 390 adolescents, 189 (49%) declined to participate/consent. Participants included 200 parent-adolescent dyads (adolescent Mage = 14.7 years, SD = 1.7). Parent respondents were mostly female (83%) and mothers (81%). Adolescents reported on their depressive (Patient Health Questionnaire-9; PHQ-9) and anxious symptoms (Revised Child Anxiety and Depression Scale-Short Version [anxiety subscale]) and parents reported on their depressive symptoms (M = 3.7, SD = 3.7; PHQ-9).

RESULTS

Mediation analyses revealed two (out of four) significant indirect effects of PTE on both adolescent and parent report of depressive symptoms, but not anxiety.

CONCLUSIONS

This study elucidates one pathway (PD) through which PTE history influences adolescent depressive symptoms, supporting a two-generation approach to pediatric patient care for youth experiencing PPCS.

Parenting and Child Development: A Relational Health Perspective

A child's development is embedded within a complex system of relationships. Among the many relationships that influence children's growth and development, perhaps the most influential is the one that exists between parent and child. Recognition of the critical importance of early parent-child relationship quality for children's socioemotional, cognitive, neurobiological, and health outcomes has contributed to a shift in efforts to identify relational determinants of child outcomes. Recent efforts to extend models of relational health to the field of child development highlight the role that parent, child, and contextual factors play in supporting the development and maintenance of healthy parent-child relationships. This review presents a parent-child relational health perspective on development, with an emphasis on socioemotional outcomes in early childhood, along with brief attention to obesity and eating behavior as a relationally informed health outcome. Also emphasized here is the parent-health care provider relationship as a context for supporting healthy outcomes within families as well as screening and intervention efforts to support optimal relational health within families, with the goal of improving mental and physical health within our communities.

Co-located Parent Coaching Services Within Pediatric Primary Care: Feasibility and Acceptability

INTRODUCTION

This project assessed the feasibility and acceptability of Parent Connext, a positive parenting program that integrates screening and co-located parent coaching within pediatric primary care.

METHOD

Eleven practices implemented Parent Connext in phases between November 1, 2016, and July 31, 2019. Screening and surveillance for parenting and family psychosocial concerns were performed during patient visits. Providers responded with brief motivational interviewing and referral. Parenting Specialists provided individualized parent coaching to referred caregivers.

RESULTS

Screens were completed at 13,346 (65%) targeted visits, with 26% positive for concerns. Parent coaching was provided to 1,301 of 2,711 (48%) referred families (average 2.2 sessions per family). Providers and staff felt significantly more supported, confident, and knowledgeable about addressing parenting and family psychosocial concerns after implementing Parent Connext and felt the program improved their relationships with families and quality of care.

DISCUSSION

Co-located parent coaching was found to be a feasible and worthwhile addition to pediatric primary care.

Exploring the health and service utilisation of general practice patients with a history of adverse childhood experiences (ACEs): an observational study using electronic health records

OBJECTIVES

To examine the relationships between adverse childhood experiences (ACEs), chronic health and health service utilisation among a sample of general practice patients.

DESIGN

Cross-sectional observational study using anonymised data from electronic health records for 763 patients.

SETTING

Four general practices in northwest England and North Wales.

OUTCOME MEASURES

Patient demographic data (age, gender); body mass index; self-reported smoking status; self-reported ACEs; diagnosis of chronic health conditions; current mental health problems; total number of service contacts and repeat medication use in the previous 6 months.

RESULTS

A history of ACEs (experiencing abuse or neglect as a child, and/or growing up in a household characterised by violence, substance use, mental health problems or criminal behaviour) was strongly independently associated with current mental health problems, smoking and chronic obstructive pulmonary disease, showing a dose-response relationship with level of ACE exposure. Medication use and contact were significantly greater among patients with high ACE exposure (≥4 ACEs), compared with those with no ACEs. However, contrary to findings from population studies, health service utilisation was not significantly different for patients with increased ACE exposure (1-3 ACEs) and their ACE-free counterparts.

CONCLUSIONS

Findings highlight the contribution ACEs make to unequal distributions of risk to health and well-being and patterns of health service use in the UK.

Specific adverse childhood experiences and their association with other adverse childhood experiences, asthma and emotional, developmental and behavioral problems in childhood

BACKGROUND

Adverse childhood experiences (ACEs) have lifelong health consequences, yet screening remains challenging. Particularly in clinical settings, brief screeners that could lead to comprehensive assessments may be more feasible. We explore how two ACEs (economic hardship, parental/caregiver divorce/separation) are associated with other ACEs, asthma, and emotional, developmental, or behavioral (EDB) problems.

METHODS

Using the 2016 National Survey of Children's Health, we assessed the associations between ACEs and asthma and EDB problems and calculated sensitivities, specificities and predictive values.

RESULTS

Parents frequently reported 1+ ACEs for their child (50.3%). Individual ACE frequency ranged from 4.2 to 29.6%; all were significantly associated with EDB problems (adjusted odds ratios (aORs): 2.2-5.1) and more ACEs confirmed higher odds. Two ACES (economic hardship, parental/caregiver divorce/separation) co-occurred frequently with other ACEs, having either predicted EDB problems similarly to other ACEs (aORs 1.8; 95% CI 1.4, 2.3) and having both greatly increased odds (aOR 3.8; 95% CI 2.8, 5.2). The negative predictive value of EDB problems associated with citing neither ACE was high (95.7%). Similar trends with asthma were observed.

CONCLUSIONS

Economic hardship and caregiver separation are strongly associated with other ACEs, EDB problems and asthma. A brief screener including these ACEs may reduce clinical barriers to broader ACEs screening.

Antecedents of fathers' perception of child behavior at child age 12 months

This study investigates whether fathers' adverse childhood experiences (ACE) and attachment style reported during pregnancy predict fathers' perception of child behavior assessed 12 months postpartum, expressed by the Parenting Stress Index (PSI), Child Domain. Prospective fathers (N = 835) were recruited to "The Little in Norway (LiN) study" (Moe & Smith) at nine well-baby clinics in Norway, with data collection composed of five time points during pregnancy and two time points postpartum (6 and 12 months). The main analyses included linear regression, path-analysis modeling, and intraclass correlation based on mixed effects modeling. First, linear regression analyses showed that neither fathers' ACE nor attachment style significantly predicted perceived child behavior postpartum directly. Furthermore, path analyses showed that ACE and less secure attachment style (especially avoidant attachment) measured early in pregnancy strongly predicted negatively perceived child behavior, mediated by fathers' mental health symptoms during pregnancy and partner disharmony postpartum. Second, intraclass correlation analyses showed that fathers' perceived child behavior showed substantial stability between 6 and 12 months postpartum. Family interventions beginning in pregnancy may be most beneficial given that fathers' early experiences and perceptions of attachment in pregnancy were associated with later partner disharmony and stress.

Screening for Adverse Childhood Experiences in Primary Care: A Quality Improvement Project

INTRODUCTION

The American Academy of Pediatrics (AAP) advocates for the screening of Adverse Childhood Experiences (ACEs) during well-child care visits by pediatric health care providers. The evidence shows a strong correlation between children with high ACE scores and the likelihood of physical and mental health problems as adults. The purpose of this Quality Improvement (QI) project was to increase pediatric providers' awareness on ACEs through education and increase the utilization of an ACE screening tool.

METHOD

This QI project used a pre-post test to evaluate the effectiveness of the educational model and the utilization of the screening tool within an urban pediatric primary care clinic.

RESULTS

This project demonstrated an increase in provider awareness as well as a marked increase in the utilization of the screening tool.

DISCUSSION

Four hundred eighty ACE screening tools were collected over a 12-week period. By introducing the ACE screening tool as the standard of care in the primary care office, providers can provide early interventions to mitigate the potential untoward outcomes. This QI project also demonstrated that there was a statistical and clinical significance (p value < 0.001) in the provider's knowledge pre-post the educational intervention.

Pediatric Practitioners' Screening for Adverse Childhood Experiences: Current Practices and Future Directions

This pilot study surveyed pediatric medical practitioners on their screening of Adverse Childhood Experiences (ACEs). The study focused on perspectives related to engagement in screening and barriers to screening. Practitioners were pediatric and family physicians and physician assistants (N = 48). Results suggest that although practitioners believed it was their role to screen, less than half did so. They were more likely to screen if they were familiar with the research on ACEs, or had received training on ACEs screening. Perceived barriers included lack of professional education on the topic, not enough time to screen, and lack of appropriate screening tools. Other issues such as which ACEs were most likely to be screened for and follow-up practices after positive screening also were explored. Further work is needed to understand screening and treatment practices, and policy changes should be explored in an attempt to increase practitioner involvement in ACEs screening.

Identifying adverse childhood experiences in pediatrics to prevent chronic health conditions

Despite evidence that over 40% of youth in the United States have one or more adverse childhood experiences (ACEs), and that ACEs have cumulative, pernicious effects on lifelong health, few primary care clinicians routinely ask about ACEs. Lack of standardized and accurate clinical assessments for ACEs, combined with no point-of-care biomarkers of the "toxic stress" caused by ACEs, hampers prevention of the health consequences of ACEs. Thus, there is no consensus regarding how to identify, screen, and track ACEs, and whether early identification of toxic stress can prevent disease. In this review, we aim to clarify why, for whom, when, and how to identify ACEs in pediatric clinical care. To do so, we examine the evidence for such identification; describe the efficacy and accuracy of potential screening instruments; discuss current trends in, and potential barriers to, the identification of ACEs and the prevention of downstream effects; and recommend next steps for research, practice, and policy.

Early life stress: update on neurophysiologic effects and treatment

PURPOSE OF REVIEW

Recent research on childhood trauma has focused on the effects of in-utero and early life stress (ELS) as well as improving access to care. This review includes the previous year's clinically relevant research with attention to gaps that require further research that should improve patient care.

RECENT FINDINGS

The current article focuses on the latest understanding of ELS effects on the neuroendocrine, inflammatory, immune, and neurologic systems, as well as epigenetic effects with a focus on research examining sex-specific differences. Resilience and innovative treatment delivery models are reviewed with emphasis on integrated care models and technology-based treatments.

SUMMARY

The findings reviewed point toward clinically relevant research avenues. The call for more and better treatment options can only be realized with a better understanding of ELS effects. There is a specific need for more in depth exploration and application of sex-specific differences as well as an examination of the effects of age of onset and chronicity of stressors. New developments in the delivery of interventions and treatment allow the potential to provide broader early access to care.

Screening for Adverse Childhood Experiences in Pediatric Primary Care: Pitfalls and Possibilities

Addressing adverse childhood experiences (ACEs) in primary care pediatric practice is riddled with potential pitfalls that prevent most providers from implementing ACE or toxic stress screening in their practices. However, the growing body of literature and clinician experience about ACE screening shows how this practice is also ripe with possibilities beyond just the treatment of trauma-related diagnoses and for the prevention of intergenerational transmission of toxic stress. This article reviews the current state of screening for ACEs and toxic stress in practice, describes how pediatricians and clinics have overcome pitfalls during implementation of practice-based screening initiatives, and discusses possibilities for the future of primary care-based screening. [Pediatr Ann. 2019;48(7):e257-e261.].

Screening and treatment of trauma-related symptoms in youth with autism spectrum disorder among community providers in the United States

Using a cross-sectional survey of 673 multidisciplinary autism spectrum disorder providers recruited from five different sites in the United States, we examined the frequency with which community-based providers inquire about, screen, and treat trauma-related symptoms in their patients/students and assessed their perceptions regarding the need for and barriers to providing these services. Univariate and bivariate frequencies of self-reported trauma service provision, training needs, and barriers were estimated. Multivariable logistic regressions identified provider and patient-related factors associated with trauma-related symptoms screening and treatment. Over 50% of providers reported some screening and treatment of trauma-related symptoms in youth with autism spectrum disorder. Over 70% informally inquired about trauma-related symptoms; only 10% universally screened. Screening and treatment varied by provider discipline, setting, amount of interaction, and years of experience with autism spectrum disorder, as well as by patient/student sex, ethnicity, and socioeconomic status. Most providers agreed that trauma screening is a needed service impeded by inadequate provider training in trauma identification and treatment. The findings indicate that community providers in the United States of varied disciplines are assessing and treating trauma-related symptoms in youth with autism spectrum disorder, and that evidence-based approaches are needed to inform and maximize these efforts.

The evidence base for routine enquiry into adverse childhood experiences: A scoping review

BACKGROUND

Exposure to adverse childhood experiences (ACEs; e.g., maltreatment, household dysfunction) is associated with a multiplicity of negative outcomes throughout the life course. Consequently, increasing interest is being paid to the application of routine enquiry for ACEs to enable identification and direct interventions to mitigate their harms.

OBJECTIVE

To explore the evidence base for retrospective routine enquiry in adults for ACEs, including feasibility and acceptability amongst practitioners, service user acceptability and outcomes from implementation.

METHODS

A scoping review of the literature was conducted, drawing upon three databases (CINAHL, MEDLINE, PsycINFO) and manual searching and citation tracking. Searches included studies published from 1997 until end of April 2018 examining enquiry into ACEs, or the feasibility/acceptability of such enquiry across any setting. All included studies presented empirical findings, with studies focusing on screening for current adversities excluded.

RESULTS

Searches retrieved 380 articles, of which 15 met the eligibility criteria. A narrative approach to synthesize the data was utilized. Four studies examined practitioner feasibility and/or acceptability of enquiry, three reported service user acceptability and six studies implemented routine ACE enquiry (not mutually exclusive categories). Further, eight studies explored current practice and practitioner attitudes towards ACE enquiry.

CONCLUSIONS

Limited literature was found providing evidence for outcomes from enquiry. No studies examined impacts on service user health or service utilization. Few studies explored feasibility or acceptability to inform the application of routine ACE enquiry. The implementation of routine ACE enquiry therefore needs careful consideration. Focus should remain on evaluating developing models of ACE enquiry to advance understanding of its impact.

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

Introduction

Exposure to adversity in childhood has been shown to impact the development of children and increase their risk of poor early childhood mental health and chronic medical conditions in young children, and developing chronic diseases, mental health disorders, and substance abuse disorders as adults. The recognition of adverse childhood experiences (ACEs) and provision of behavioral-based interventions can help children build resilience. We implemented a screening method to help providers better assess patients' exposure to adversity. Our goal was to increase the screening for ACEs utilizing a standardized ACEs screening tool from 0% to 80% of children presenting for annual well-child visits within 1 year.

Methods

We implemented a screening tool to determine a child's exposure to ACEs within our general pediatrics clinic. A variety of interventions, including resident, faculty, and staff-focused educational lectures, simulation, and process changes were performed to increase screening. Also, we surveyed resident physicians and faculty about their experiences with ACEs screening.

Results

Over 1 year, we screened 1,206 patients for exposure to ACEs and increased screening from 0% to 60%. Provider comfort with discussing abuse with patients and familiarity with resources for children exposed to ACEs did not change significantly.

Conclusions

Patients can successfully be screened in a resident-led, general pediatric clinic using a standardized ACEs screening tool. Such an approach can successfully identify patients with high-risk ACE scores. Additionally, education on and implementation of the tool may improve provider comfort with screening for ACEs.

Integration of the Safe Environment for Every Kid (SEEK) Model Across Primary Care Settings

This project sought to assess the generalizability, barriers, and facilitators of implementing the Safe Environment for Every Kid (SEEK) model for addressing psychosocial risk factors for maltreatment across multiple primary care settings, including a pediatric practice, federally qualified health center, and family medicine practice. The SEEK model includes screening caregivers for psychosocial risk factors at well-child visits age 0 to 5 years, brief intervention incorporating principles of motivational interviewing to engage caregivers, and referral to treatment. All practices successfully implemented SEEK, with screening completion rates from 75% to 93% and brief intervention rates from 61% to 81%. Major parental stress (14%) and food insecurity (11%) were the most common risk factors. Providers found SEEK worthwhile for improving their knowledge, skills, and ability to address psychosocial concerns and provide whole person care. Barriers included limited time and resources, incomplete resource knowledge, and lack of follow-up. Facilitators included on-site support staff to assist with communication and referrals.

Medical Students' Perspectives on Trauma-Informed Care Training

INTRODUCTION

Adults exposed to traumatic events during childhood commonly seek medical services, but health care practitioners hesitate to address and assess early trauma despite its known negative health effects. This study examines medical students' perspectives on a brief course that addressed the health care needs of patients exposed to adverse childhood experiences.

METHODS

A convenience sample of 20 University of California, Davis medical students from the Summer Institute on Race and Health received 6 hours of trauma-informed care training. The course was delivered in 2-hour modules during the course of 3 days, and included lectures, discussions, and practice. A questionnaire assessing students' perspectives on training benefits, current practice challenges, and necessary resources to provide trauma-informed medical care was distributed posttraining.

RESULTS

From the students' perspectives, this course increased their ability to recognize various clinical manifestations of adverse childhood experience exposure in adult patients. Students said they learned how to ask about and respond to adverse childhood experience disclosures and identify necessary resources to responsibly implement trauma-informed care in medical settings. Students identified provision of adequate resources and links to appropriate treatment identified as common challenges in providing health care to trauma-affected patients.

CONCLUSION

Study findings illustrate that trauma training can fill a knowledge gap and provide associated benefits for medical students. Initial training may pique students' interest by demonstrating the relevance of trauma knowledge in clinical practice; additional training likely is needed to support skills and confidence.

Intergenerational Associations of Parent Adverse Childhood Experiences and Child Health Outcomes

BACKGROUND

Adverse childhood experiences (ACEs) robustly predict future morbidity and mortality. Researchers are just beginning to investigate intergenerational effects. We hypothesize there are intergenerational associations between parent ACE exposure and worse child health, health behaviors, and health care access and use.

METHODS

We linked data from 2 population-based cross-sectional telephone surveys in Philadelphia, Pennsylvania, that were used to ask parents about their past exposure to ACEs and their child's health, respectively. Participants were 350 parent-child dyads. Logistic regression models adjusted for parent and child characteristics. Parent ACE score was used to summarize indicators of parents' childhood adversity. Child health outcomes were poor overall health status, asthma diagnosis, obesity, low fruit and vegetable consumption, any soda consumption, inadequate physical activity, excessive television watching, no health insurance, no usual source of health care, and no dental examination in past 12 months.

RESULTS

Of adult participants, 80% were female participants and 45% were non-Latino African American. Eighty-five percent of parents had experienced ≥1 ACE and 18% had experienced ≥6 ACEs. In adjusted models, each additional parent ACE was associated with higher odds of poor child overall health status (odds ratio [OR] = 1.19; 95% confidence interval [CI]: 1.07-1.32), asthma (OR = 1.17; 95% CI: 1.05-1.30), and excessive television watching (OR = 1.16; 95% CI: 1.05-1.28).

CONCLUSIONS

The full scope of the health effects of ACEs may not be limited to the exposed individual, highlighting the need for a 2-generation approach to addressing the social determinants of child health.

[Screening of adverse childhood experiences in preschoolers: scoping review]

The aim of the present article was to describe available scientific publications detailing strategies and screening tools for Adverse Childhood Experiences in preschoolers (2 to 5 years of age). A scoping review of the topic was carried out through investigative articles published in peer review journals from January 1998 to June 2017 and indexed in seven international databases (Cochrane Library, EBSCO, PubMed, Science Direct, Springer, Web of Science and Scielo). The articles were selected based on predefined criteria, using limiters and manual screening. Twenty articles published between 1999 and 2017 were selected. The screening of adverse childhood experiences is performed through opportunistic recruitment in a professional context aimed at caregivers and children, which integrates training actions, application of screening tools and reception of identified cases. Screening tools differ between interviews and questionnaires. Furthermore, we report the periodicity of the screening, the behaviors and beliefs of the professionals against it and the barriers to its implementation. This review confirms that the screening of Adverse Childhood Experiences is an emerging topic in the research field. We emphasize the need to systematize and evaluate the strategies and tools for screening Adverse Childhood Experiences, as well as to develop local approaches to respond to the needs of children exposed to adversity.

Child Maltreatment Screening and Anticipatory Guidance: A Description of Pediatric Nurse Practitioner Practice Behaviors

INTRODUCTION

Given the number of children affected by child maltreatment and the dire consequences that can develop, prompt identification of child maltreatment is crucial. The purpose of this study was to describe pediatric nurse practitioner (PNP) practice behaviors related to screening and providing anticipatory guidance for child maltreatment and its psychosocial risk factors.

METHOD

The Risk Assessment Survey was developed for this study by 12 PNPs, all of whom were members of NAPNAP's Child Maltreatment Special Interest Group to ensure face validity; all 12 PNPs were content experts in child maltreatment. The content of the survey was derived from key characteristics from the evidence on child maltreatment. The survey was emailed to the more than 8500 NAPNAP members.

RESULTS

Two hundred forty-three PNPs responded to the survey, which represents a response rate of 3%. Approximately half of the participants (n = 121; 51%) stated that they never/rarely ask parents questions about domestic violence, more than one-fourth (n = 71; 30%) reported that they never/rarely ask parents questions about discipline, and half of the responding PNPs (n = 120; 50%) reported that they perform an ano-genital exam at well visits.

DISCUSSION

This study demonstrates that a significant number of PNPs do not routinely screen for child maltreatment and psychosocial risk factors. This is especially true in regards to sexual abuse screening and anticipatory guidance.

The Central Role of Relationships With Trauma-Informed Integrated Care for Children and Youth

OBJECTIVE

Primary care plays an essential role in the primary and secondary prevention of children's mental health problems. A growing series of trials have shown the capacity of primary care providers to deliver care that specifically addresses risks to healthy social and emotional development by incorporating mental health services into their routines and integrating their work with the mental health care system. In this article elements common to various integration schemes that seem essential to their success are described.

METHODS

Narrative review, combining conclusions from 3 previous systematic reviews.

RESULTS

Trusting, personal relationships between patients and providers, and among collaborating providers, are a critical element of successful trauma-informed integrated care. Patient-provider relationships are essential to disclosure of sensitive concerns, to engaging patients in care, and to designing care that is responsive to individual patient needs. Studies of patient-centered care and psychotherapy suggest ways that these relationships can be built and maintained. Provider-provider relationships are, in turn, essential to coordinating the work of the range of providers and services needed to address trauma prevention and treatment. These relationships can form within a variety of organizational structures but building them might require staff training, redesign of work flows, and support from organizational structures and goals.

CONCLUSIONS

A variety of interventions at the patient-provider, clinical site, system, and policy levels can foster relationships and provide the foundation for care capable of addressing promotion of social and emotional well-being in general and trauma prevention and treatment in particular.