Evolving a More Nurturing Society to Prevent Adverse Childhood Experiences

Facilitators and barriers for implementing the PALS school-wide positive behavior support model in a Swedish municipality: A focus group study

A research-supported model to support schools' prevention of behavior problems and promotion of a positive school climate is school-wide positive behavior support (SW-PBS), in Scandinavia adapted into "positive behavior, interactions and learning environment in school" (PALS). Facilitators and barriers for achieving and sustaining a full implementation of PALS in a Swedish primary school context have not previously been studied. The purpose of this study was to explore school staff and administrators' experiences of implementing PALS in a municipal school district in the western region of Sweden. Using a qualitative focus group design, staff with roles in the implementation and school administrators (N = 22) representing 12 schools were asked about their experiences regarding facilitators and barriers for implementing PALS. Data were analyzed using qualitative content analyses involving a combination of inductive (data-driven) and deductive (theory-driven) approaches. In the deductive, final step, the inductively derived categories were associated with the Normalization process theory core constructs coherence, cognitive participation, collective action and reflexive monitoring. The analysis resulted in nine categories in which both facilitators and barriers were identified: alignment with school mission and values; building and strengthening relationships; shared staff engagement; administrators' commitment and leadership; support and resources for adopting PALS; changed experiences of PALS work over time; positive feedback sustains motivation; learning for quality improvement; and staff continuity throughout implementation. Findings indicate that staff and administrators experienced the implementation as predominantly positive, that PALS provides a structure for relationship-based work, and fits particularly well in primary school contexts. The facilitators and barriers identified provide valuable knowledge that can inform sustainable implementations of PALS in similar contexts.

Child and Adolescent Health in the United States: The Role of Adverse and Positive Childhood Experiences

Background

Adverse childhood experiences (ACEs) have been associated with poorer health from childhood into adulthood. There has been limited prior research examining the associations between positive childhood experiences (PCEs) and health among children.

Objective

The present study examines the association between PCES and child health, controlling for ACE counts, using a nationally representative sample.

Participants and Setting

: The data for this study came from the 2019-2020 National Survey of Children's Health and were limited to children six years of age or older with complete demographic information and information on ACEs, PCEs, and child health (n = 46,913).

Methods

Bivariate analyses between PCEs, ACEs, child/adolescent characteristics, or caregiver's characteristics and child/adolescent health were examined using Pearson's Chi-square tests, weighted to produce nationally representative distributions. Multivariable regression models were used to examine the association between selected PCEs and good health, controlling for whether a child had two or more ACEs.

Results

In adjusted analyses, children who experienced any of the following PCEs had a higher odds of good health, compared to children who did not experience each type of these PCEs: after school activities (aOR 1.85; 95% CI 1.11-3.09), resilient family (aOR 2.22; 95% CI 1.45-3.41), supportive neighborhood (aOR 1.56; 95% CI 1.01-2.41), and connected caregiver (aOR 1.84; 95% CI 1.22-2.77).

Conclusions

Examining and understanding PCEs and how they are associated with child health is a unique opportunity to guide more targeted policies and intervention efforts. Efforts to provide PCEs in schools, homes, and communities may help to reduce health inequities early in childhood.

Universal and Trauma-Specific Care Suggestions for Pediatric Primary Care Settings

Trauma exposure and other adverse life events are common experiences among youth and present long-standing mental and physical health consequences. Given the ongoing lack of sufficient mental health services, pediatricians play a critical role in supporting trauma-exposed youth. We propose both universal precaution and trauma-specific strategies for pediatric primary care settings. Universal interventions include recommendations to make health care systems more trauma-informed, reduce trauma or re-traumatization in the medical setting, eliminate potential bias, and focus on a strengths-based approach to support diverse youth and families. Trauma-specific strategies include screening for trauma-related symptomatology and risk stratification to link youth to appropriate levels of care. Specific assessment tools, resources, and materials are provided. [Pediatr Ann. 2023;52(11):e418-e421.].

Normalization of Prevention Principles and Practices to Reduce Substance Use Disorders Through an Integrated Dissemination and Implementation Framework

Major research breakthroughs over the past 30 years in the field of substance use prevention have served to: (1) enhance understanding of pharmacological effects on the central and peripheral nervous systems and the health and social consequences of use of psychoactive substances, particularly for children and adolescents; (2) delineate the processes that increase vulnerability to or protect from initiation of substance use and progression to substance use disorders (SUDs) and, based on this understanding, (3) develop effective strategies and practices to prevent the initiation and escalation of substance use. The challenge we now face as a field is to "normalize" what we have learned from this research so that it is incorporated into the work of those involved in supporting, planning, and delivering prevention programming to populations around the world, is integrated into health and social service systems, and helps to shape public policies. But we wish to go further, to incorporate these effective prevention practices into everyday life and the mind-sets of the public, particularly parents and educators. This paper reviews the advances that have been made in the field of prevention and presents a framework and recommendations to achieve these objectives generated during several meetings of prevention and implementation science researchers sponsored by the International Consortium of Universities for Drug Demand Reduction (ICUDDR) that guides a roadmap to achieve "normalization."

Childhood adversities and mental disorders in first-year college students: results from the World Mental Health International College Student Initiative

BACKGROUND

This study investigates associations of several dimensions of childhood adversities (CAs) with lifetime mental disorders, 12-month disorder persistence, and impairment among incoming college students.

METHODS

Data come from the World Mental Health International College Student Initiative (WMH-ICS). Web-based surveys conducted in nine countries (n = 20 427) assessed lifetime and 12-month mental disorders, 12-month role impairment, and seven types of CAs occurring before the age of 18: parental psychopathology, emotional, physical, and sexual abuse, neglect, bullying victimization, and dating violence. Poisson regressions estimated associations using three dimensions of CA exposure: type, number, and frequency.

RESULTS

Overall, 75.8% of students reported exposure to at least one CA. In multivariate regression models, lifetime onset and 12-month mood, anxiety, and substance use disorders were all associated with either the type, number, or frequency of CAs. In contrast, none of these associations was significant when predicting disorder persistence. Of the three CA dimensions examined, only frequency was associated with severe role impairment among students with 12-month disorders. Population-attributable risk simulations suggest that 18.7-57.5% of 12-month disorders and 16.3% of severe role impairment among those with disorders were associated with these CAs.

CONCLUSION

CAs are associated with an elevated risk of onset and impairment among 12-month cases of diverse mental disorders but are not involved in disorder persistence. Future research on the associations of CAs with psychopathology should include fine-grained assessments of CA exposure and attempt to trace out modifiable intervention targets linked to mechanisms of associations with lifetime psychopathology and burden of 12-month mental disorders.

When Adverse Childhood Experiences Present to a Statewide Child Psychiatry Access Program

Many children experience adversity, yet few receive needed psychiatric services. Pediatric primary care providers (PCPs) are uniquely positioned to intervene but often lack training and resources to provide patients with adverse childhood experiences (ACEs) the psychiatric support they need. The current study examines characteristics of youth with and without ACEs who were the focus of PCP contacts with a statewide child psychiatry access program (CPAP). Compared to those without ACEs, patients with ACEs were more often receiving medication treatment at time of CPAP contact, prescribed two or more psychotropic medications, and diagnosed with two or more mental health disorders. Study findings indicate that patients with ACEs for whom PCPs sought CPAP support were experiencing more clinically severe and complex mental health concerns. These findings underscore the important role of CPAPs in supporting PCPs with pediatric patients who have ACEs and will inform training provided by CPAPs to PCPs.

The contribution of childhood adversities to the persistence of severe role impairment among college students: a follow-up study

PURPOSE

While the association between childhood adversities (CAs) and negative mental health outcomes is robustly supported throughout the epidemiological literature, little is known about their contribution to the persistence of role impairment. The present study aims to investigate the association of three facets of CAs with the persistence of severe role impairment among college students using a follow-up design.

METHODS

Data were drawn from the French portion of the World Mental Health International College Student Initiative. Students who completed both the baseline and 1-year follow-up surveys were included (n = 1,188). Exposure to 12 types of CAs before the age of 18 was assessed at baseline, and 12-month role impairment and 12-month mental disorders were assessed at baseline and follow-up. Logistic regressions estimated associations by jointly using types, number of types, and cumulative frequency of exposure to CAs as predictors.

RESULTS

At baseline, 27.6% of students reported any severe role impairment. Among them, 47.5% reported the persistence of any impairment at one year. In models adjusted for 12-month mental disorders, only the frequency of CAs was associated with the persistence of impairment, namely college-related and other work impairment (aOR = 1.17, 95% CI [1.01, 1.35]).

CONCLUSION

Role impairment is prevalent among college students, and studies are needed to better understand its persistence. Beyond the primary prevention of early stressors, screening for and treating mental health problems during college may help reduce the impact of CAs on the persistence of role impairment.

Examining the association between rurality and positive childhood experiences among a national sample

PURPOSE

The present study examines the association between rurality and positive childhood experiences (PCEs) among children and adolescents across all 50 states and the District of Columbia. Recent work has quantified the prevalence of PCEs at the national level, but these studies have been based on public use data files, which lack rurality information for 19 states.

METHODS

Data for this cross-sectional analysis were drawn from 2016 to 2018 National Survey of Children's Health (NSCH), using the full data set with restricted geographic data (n = 63,000). Descriptive statistics and bivariate analyses were used to calculate proportions and unadjusted associations. Multivariable regression models were used to examine the association between residence and the PCEs that were significant in the bivariate analyses.

FINDINGS

Rural children were more likely than urban children to be reported as having PCEs: volunteering in their community (aOR 1.29; 95% CI 1.18-1.42), having a guiding mentor (aOR 1.75; 95% CI 1.45-2.10), residing in a safe neighborhood (aOR 1.97; 95% CI 1.54-2.53), and residing in a supportive neighborhood (aOR 1.10; 95% CI 1.01-1.20) than urban children.

CONCLUSIONS

The assessment of rural-urban differences in PCEs using the full NSCH is a unique opportunity to quantify exposure to PCEs. Given the higher baseline rate of PCEs in rural than urban children, programs to increase opportunities for PCEs in urban communities are warranted. Future research should delve further into whether these PCEs translate to better mental health outcomes in rural children.

Sustaining Personal Activism: Behavior Analysts as Antiracist Accomplices

One pervasive social issue that has received little attention within the behavior-analytic community is racism and the systemic oppression of Black, Indigenous, and non-Black people of color. The present article offers guidance and examples of how each of us as behavior analysts might build individualized self-management behavior change plans that support initiating and sustaining socially significant antiracism work as we move from allies to accomplices within our own sphere of influence. This article introduces the concept of self-managed antiracism behavior change plans that (a) operationally define antiracist action using measurable outcomes and strategies for data collection on specific antiracist and support actions, (b) provide choices to improve engagement and reduce barriers to adherence, and (c) use effective behavioral interventions to alter the availability of discriminative stimuli or reduce their influence, and increase the availability of reinforcers that are compatible with the goal of the behavior change plan for increasing antiracism behavior and dismantling structures perpetuating racial inequities.

Examining Racial/Ethnic Differences in Positive Childhood Experiences Among Respondents in a Southern State

Adverse childhood experiences (ACEs) and positive childhood experiences (PCEs) may impact brain development in children and adolescents into adulthood. While prior research demonstrated racial-ethnic disparities in ACEs, less is known about racial and ethnic differences in PCEs, particularly among adults. To better understand racial and ethnic differences in positive childhood experiences, this study (1) examined the prevalence of PCEs in an adult population in South Carolina (SC), a representative southern US state and (2) examined whether PCE exposure differed across racial and ethnic groups. Data were drawn from the 2019 SC Behavioral Risk Factor Surveillance System survey (BRFSS). Descriptive statistics and bivariate analyses were used to calculate frequencies, proportions and unadjusted associations for each variable. Multivariable regression models were used to examine the association between race/ethnicity and PCEs. Our analyses revealed that people of color were less likely to be supported by friends, have an adult who took interest in them, and have a family who stood by them during difficult times. Education and poverty were significantly associated with feeling safe and protected, supported by friends, and having a family that stood by them during difficult times. Conclusions: Findings from this study may be used to promote health equity in early childhood through programs, policies, and practices that seek to address historic, systemic, and intergenerational trauma.

Using intergenerational photovoice to understand family strengths among Native American children and their caregivers

The purpose of the current study was to examine Native American children and caregivers' perspectives of family and cultural strengths using photovoice and to identify lessons learned from the first-ever implementation of intergenerational photovoice with Native Americans. Participants were Native American, low-income caregivers (n = 6) and their children (n = 12) between the ages of 10 and 15 who participated in six photovoice sessions. The themes that emerged from photos and group discussion included myriad challenges faced by Native American families including exposure to community violence, substance abuse, and criminal offending and incarceration. Themes also emerged that highlighted the strengths of Native families that were used to overcome identified challenges, including religion/spirituality, engagement in traditional cultural practices (e.g., prayer, song, dance), healthy activities (e.g., running, meditation). These data provided foundational information that is currently being used, along with other data, to develop a culturally grounded, strengths-focused, family-based program (Tiwahe Wicagwicayapi [Strengthening/Growing Families in Lakota]) to prevent adverse childhood experiences. We also discuss the challenges of intergenerational photovoice and lessons learned to inform future intergenerational photovoice projects.

Patterns of adversity and post-traumatic stress among children adopted from care

BACKGROUND

Children adopted from care are more likely to have experienced early adversity, but little is known about the impact of early adversity on later post-traumatic stress (PTS) symptoms.

OBJECTIVE

To investigate sub-groups of adversity in a sample of adopted children and examine the association with later PTS symptoms.

PARTICIPANTS AND SETTING

A study of British children adopted from care using social worker records (N = 374) and questionnaire-based longitudinal study of n = 58 children over 4-years post adoptive placement.

METHODS

We used latent class analysis to identify subgroups of children based on commonalities in perinatal and postnatal adversity experienced prior to adoption and examined differences in PTS symptoms at 4-years post-placement between subgroups.

RESULTS

Nearly one in five (19 %) children were in the clinical or borderline ranges for symptoms of PTS arousal, 14 % for PTS avoidance and 8 % for PTS intrusion. The 5-class solution fitted the data best, with one class characterized by children with a low probability of experiencing any adversity, one perinatal adversity class and three classes capturing different patterns of adversity. The multiple complex adversity class involving both perinatal and postnatal adversity had significantly higher symptoms of PTS avoidance and arousal than other sub-groups.

CONCLUSIONS

The prevalence and complexity of PTS symptoms among adoptive children highlights the need for effective interventions considering different profiles of early adversity.

Adverse Childhood Experiences Across Birth Generation and LGBTQ Identity, Behavioral Risk Factor Surveillance System, 2019

Objectives. To identify and describe differences in exposure to adverse childhood events (ACEs) by birth generation and lesbian, gay, bisexual, transgender, and queer plus (LGBTQ+) identity. Methods. Using data from the 2019 Behavioral Risk Factor Surveillance System, we examined the odds of experiencing 4 or more ACEs for Generation X, millennials, and Generation Z relative to baby boomers (n = 56 262). We also explored differences between generations based on LGBTQ+ identity. Results. The odds of experiencing 4 or more ACEs were higher for Generation X (odds ratio [OR] = 1.67; 95% confidence interval [CI] = 1.52, 1.83), millennials (OR = 2.12; 95% CI = 1.92, 2.35), and Generation Z (OR = 2.12; 95% CI = 1.79, 2.52) than for baby boomers. This disparity was amplified by LGBTQ+ identity (P = .016). The frequency of individual ACEs also varied by generation. Conclusions. Exposure to 4 or more ACEs has increased for each generation since the baby boomers, and more so for the LGBTQ+ population. The ACEs experienced differ by generation. Public Health Implications. Increasing ACE scores suggest that younger generations may have an increased risk of ACE-related health problems. Policies are needed to prevent ACE exposure and address the potential fallout from the ACEs that have seen the largest increases. (Am J Public Health. 2022;112(4):662-670. https://doi.org/10.2105/AJPH.2021.306642).

Progress Toward a Multisectoral Community Intervention Approach to Prevention of the Word Gap

Children learn language through the interactions they have with their parents/caregivers beginning at birth. Hart and Risley (1995) discovered an inequity in the home language input children received from parents/caregivers. Children reared in low-income families received less input (conversations, turns) from parents than did children reared in more advantaged families. Less language input was linked to a disparity in children's vocabulary learning by age 3. The long-term result of this social determinant of early language/literacy learning is a life trajectory of poor educational, economic, and health attainment for many children in families with limited resources, at vast cost to individuals, communities, and the nation. What is needed is an approach to word-gap prevention that is capable of achieving positive individual, community, and population outcomes. Translating research into practice, we developed the Bridging the Word Gap Community Action Planning Guide (BWG-CAPG) using a combined behavior-analytic, community psychology, and public health framework for this purpose (Greenwood et al., 2017). We also developed a progress-monitoring measure, the online BWG Community Check Box Evaluation System, to provide feedback on a community's actions and progress in implementing their plan. Results from an initial pilot investigation within and across three community sectors in a large urban city were promising. BWG Community Check Box results indicated a number of desired outcomes: (a) capacity development and mobilization, (b) community implementation actions, and (c) community changes in practices, programs, and policies. Implications are discussed.

The effect of violence in childhood on school success factors in US children

BACKGROUND

A robust literature-base on adverse childhood experiences (ACEs) provides strong evidence on the relationships between social adversity in childhood and the health and well-being of individuals across the lifespan. One form of social adversity, exposure to violence in childhood, is not only harmful to a child's health and well-being, but detrimental to their performance in school. Poor performance in school may affect educational attainment later in life and hinder a child's upward social mobility. We focus on the impact of violence-related ACEs on school success factors to add new evidence on how violence in childhood affects a child's educational progress.

OBJECTIVE

To examine the impact of violence-related ACEs on school success factors, including grade repetition, school absence, and school-home contact.

PARTICIPANTS AND SETTINGS

This study uses secondary data analysis of a nationally representative survey, the National Survey of Children's Health (NSCH), to study a sample of non-institutionalized children aged 6-17 in the US (n = 35,122).

METHODS

We employed binary logistic regression and multinomial logistic regression using 95% confidence intervals to analyze the effect of violence in childhood on three school success factors, controlling for socio-demographic and health status characteristics.

RESULTS

We found that violence in childhood increases the likelihood of grade repetition (OR = 1.47, 95% CI, 1.12-1.92), school-home contact (OR = 2.20, 95% CI, 1.86-2.60), and school absence greater than one week (OR=1.4, 95%CI,1.08-2.00; OR=1.86, 95%CI, 1.36-2.60), controlling for socio-demographic and health status characteristics.

CONCLUSIONS

Violence in childhood has a statistically significant negative impact on each of the school success factors included in this study.

Positive Childhood Experiences Promote School Success

OBJECTIVES

Educational attainment has been demonstrated as a protective factor for the physical and mental health of children into adulthood, yet there has been limited research on the association between positive childhood experiences (PCEs) and school success. The purpose of this study is to examine the associations between PCEs and challenges to school success.

METHODS

This cross-sectional study used data of 33,450 children from the 2017-2018 National Survey of Children's Health to examine PCEs and two challenges to school success (school absenteeism and repeated grades), using multivariable logistic regression analysis.

RESULTS

The most prevalent types of PCEs were mentor for advice or guidance (89.8%), family resilience (81.1%), and after-school activity participation (79.8%). Children who participated in after-school activities had lower odds of reported school absenteeism (aOR 0.59; 95% CI 0.46-0.76) and repeating a grade (aOR 0.75; 95% CI 0.59-0.97) than their counterparts. Children who shared ideas with their caregiver had lower odds of repeating a grade (aOR 0.78; 95% CI 0.63-0.97) than children who did not share ideas with their caregiver. Children who lived in a supportive neighborhood were less likely to have reported school absenteeism than children who did not live in a supportive neighborhood (aOR 0.77; 95% CI 0.60-0.98).

CONCLUSIONS FOR PRACTICE

Participation in after-school activities had optimal associations with both school absenteeism and repeated grade, suggesting its potential protective effect for school success. Promoting PCEs at the school, family, and community levels may help address school absenteeism and grade retention.

Racial/ethnic differences in positive childhood experiences across a national sample

BACKGROUND

Examination of racial/ethnic differences in positive childhood experiences (PCEs) is needed, as the absence of supportive factors may hinder children from healthy processing and mitigation of adversity.

OBJECTIVE

The purpose of this study was to examine the prevalence of PCEs in a nationally representative sample of children and determine whether PCE exposure differed across race and ethnic groups.

PARTICIPANTS AND SETTING

Data were drawn from the nationally representative 2017-2018 National Survey of Children's Health (NSCH) (n = 33,747).

METHODS

Descriptive statistics and bivariate analyses were used in order to calculate frequencies, proportions, and unadjusted associations for each variable. Multivariable regression models were used to examine the association between race/ethnicity and PCEs.

RESULTS

All racial-ethnic minority groups of children had a lower likelihood of mentorship, living in a safe neighborhood, or living in a supportive neighborhood, than their Non-Hispanic White counterparts. Non-Hispanic Black children had a lower likelihood of having a mentor for advice or guidance (aOR 0.50; 95 % CI 0.38-0.62), living in a safe neighborhood (aOR 0.62; 95 % CI 0.52-0.73), and living in a supportive neighborhood (aOR 0.75; 95 % CI 0.64-0.87) than Non-Hispanic white children.

CONCLUSIONS

The information from this study highlights the negative disparities borne by racial/ethnic minority populations. Findings can be used to inform policymakers, program developers, and stakeholders on where to target interventions and how to bring together families and communities to not only confront adversity in childhood, but also to leverage community and family-level assets to create PCEs for all children.

Scaling up and scaling out: Consilience and the evolution of more nurturing societies

This paper argues that diverse disciplines within the human sciences have converged in identifying the conditions that human beings need to thrive and the programs, policies, and practices that are needed to foster well-being. In the interest of promoting this view, we suggest that this convergence might usefully be labeled "The Nurture Consilience." We review evidence from evolutionary biology, developmental, clinical, and social psychology, as well as public health and prevention science indicating that, for evolutionary reasons, coercive environments promote a "fast" life strategy that favors limited self-regulation, immediate gratification, and early childbearing. However, this trajectory can be prevented through programs, practices, and policies that (a) minimize toxic social and biological conditions, (b) limit opportunities and influences for problem behavior, (c) richly reinforce prosocial behavior, and (d) promote psychological flexibility. The recognition of these facts has prompted research on the adoption, implementation, and maintenance of evidence-based interventions. To fully realize the fruits of this consilience, it is necessary to reform every sector of society. We review evidence that free-market advocacy has promoted the view that if individuals simply pursue their own economic well-being it will benefit everyone, and trace how that view led business, health care, education, criminal justice, and government to adopt practices that have benefited a small segment of the population but harmed the majority. We argue that the first step in reforming each sector of society would be to promote the value of ensuring everyone's well-being. The second step will be to create contingencies that select beneficial practices and minimizes harmful ones.

Rural-Urban Differences in Positive Childhood Experiences Across a National Sample

PURPOSE

The purpose of this study was to examine the prevalence of positive childhood experience (PCE) and adverse childhood experience (ACE) exposures in 31 states plus the District of Columbia and to estimate exposure differences between rural and urban children.

METHODS

A cross-sectional study was conducted with a sample of 19,251 respondents from the 2017-2018 National Survey of Children's Health (NSCH), a nationally representative sample of US children. Sociodemographic information, residence, and PCE and ACE responses were utilized. To calculate frequencies, proportions, and unadjusted associations for each variable, descriptive statistics and bivariate analyses were used. Multivariable regression models were used to examine the association between residence and PCEs that showed significance in bivariate analyses.

FINDINGS

In adjusted analyses of PCEs, there was no significant difference between rural and urban children for after-school activities. However, rural children were more likely to volunteer in the community, school, or church than were urban children (aOR 1.32; 95% CI: 1.14-1.54). Rural children also had greater odds of having a mentor for advice or guidance, compared to urban children (aOR 1.8; 95% CI: 1.40-2.52).

CONCLUSIONS

An examination of both PCEs and ACEs provides policy makers, program developers, and other stakeholders the opportunity to determine needs of rural children and where to target interventions. Furthering the understanding of PCEs and ACEs is important to bring individuals, families, and communities together to both address childhood adversity and utilize existing family and community-level assets.

Navigating the Intersection Between Persistent Pain and the Opioid Crisis: Population Health Perspectives for Physical Therapy

The physical therapy profession has recently begun to address its role in preventing and managing opioid use disorder (OUD). This topic calls for discussion of the scope of physical therapist practice, and the profession's role, in the prevention and treatment of complex chronic illnesses, such as OUD. OUD is not just an individual-level problem. Abundant scientific literature indicates OUD is a problem that warrants interventions at the societal level. This upstream orientation is supported in the American Physical Therapy Association's vision statement compelling societal transformation and its mission of building communities. Applying a population health framework to these efforts could provide physical therapists with a useful viewpoint that can inform clinical practice and research, as well as develop new cross-disciplinary partnerships. This Perspective discusses the intersection of OUD and persistent pain using the disease prevention model. Primordial, primary, secondary, and tertiary preventive strategies are defined and discussed. This Perspective then explains the potential contributions of this model to current practices in physical therapy, as well as providing actionable suggestions for physical therapists to help develop and implement upstream interventions that could reduce the impact of OUD in their communities.

Promoting Equity and Resilience: Wellness Navigators' Role in Addressing Adverse Childhood Experiences

Objective

Adverse childhood experiences (ACEs) have demonstrable negative effects on long-term physical and mental health. Racial and ethnic minority children disproportionally experience ACEs due to the impacts of structural inequality and discrimination, which could drive health disparities. Pediatric settings offer an opportune context to address ACEs and improve health equity, and to link families to the necessary resources to promote resilience. Wellness navigators (WNs), who can reflect patients' cultural, linguistic, and other shared characteristics, have the potential to improve patient care and integrated behavioral health services to mitigate the public health impact of ACEs. In the current study, bilingual and bicultural WNs helped to deliver an ACEs screening and response to predominately Latinx patients in a pediatric service setting.

Methods

Quantitative data on referrals made by WNs and qualitative interviews were analyzed to understand the role of WNs in ACEs screening.

Results

Among families (infants and caregivers) that screened positive for ACEs, WNs addressed social determinants of health and, based on individual needs assessments, made referrals to community resources in over half of the cases. Insurance, childcare, and housing were the most frequent referral sources. WNs supported caregivers in initiating services with 94% of the referrals that were made. Qualitative interviews with medical providers and caregivers underscored WNs' role in the ACEs screening process. Implications for ACEs screening, trauma-responsive pediatric care, and integrating WNs into an integrated behavioral health team are discussed.

Prevalence, socio-demographic correlates and associations of adverse childhood experiences with mental illnesses: Results from the Singapore Mental Health Study

BACKGROUND

Adverse childhood experiences (ACEs) are associated with deleterious consequences throughout the lifespan of the individual, including an increased risk of mental disorders. However, an in-depth understanding of ACEs in diverse populations is still lacking especially in Asian populations, with few studies done at a population level.

OBJECTIVE

The current study aimed to establish the (i) prevalence of ACEs and its socio-demographic correlates, and, (ii) association of ACEs with mental disorders and suicidality in a multiethnic Asian country.

PARTICIPANTS AND SETTING

Singapore residents aged 18 years and older were recruited from the community as part of a nation-wide cross-sectional epidemiological study.

METHODS

Trained interviewers conducted face-to-face interviews with participants, and administered the Adverse Childhood Experiences - International Questionnaire and the Composite International Diagnostic Interview.

RESULTS

A total of 6126 participants completed the survey. The lifetime prevalence of ACEs in the sample was 63.9 %. Multiple logistic regression analyses revealed that odds of any ACE were higher among those above 65 years (OR = 1.7) and those without university education (OR = 2.2, 1.9, and 1.5 among those with primary and below, secondary and vocational education respectively). The presence of any ACE was significantly associated with increased odds of mood (OR = 3.7, 95 % CI: 2.3-6.0), anxiety (OR = 3.9, 95 % CI: 2.3-6.8) and alcohol use (OR = 1.7, 95 % CI: 1.1-3.0) disorders.

CONCLUSIONS

ACEs are not uncommon in Asian populations. There is a need to build trauma-informed communities that can incorporate the knowledge of the impact of early trauma into policies and programs.

Ethnic disparity and exposure to supplements rather than adverse childhood experiences linked to preterm birth in Pakistani women

BACKGROUND

Adverse childhood experiences (ACEs) are associated with prenatal mental health and negative pregnancy outcomes in high income countries, but whether the same association exists in Pakistan, a low- to middle-income (LMI) country, remains unclear.

METHODS

Secondary data analyses of a prospective longitudinal cohort study examining biopsychosocial measures of 300 pregnant women at four sites in Karachi, Pakistan. A predictive multiple logistic regression model for preterm birth (PTB; i.e., <37 weeks' gestation) was developed from variables significantly (P < 0.05) or marginally (P < 0.10) associated with PTB in the bivariate analyses.

RESULTS

Of the 300 women, 263 (88%) returned for delivery and were included in the current analyses. The PTB rate was 11.1%. We found no association between ACE and PTB. Mother's education (P = 0.011), mother's ethnicity (P = 0.010), medications during pregnancy (P = 0.006), age at birth of first child or current age if primiparous (P = 0.049) and age at marriage (P = 0.091) emerged as significant in bivariate analyses. Mother's ethnicity and taking medications remained predictive of PTB in the multivariate model.

LIMITATIONS

Findings are limited by the relatively small sample size which precludes direct testing for possible interactive effects.

CONCLUSIONS

In sum, pathways to PTB for women in LMI countries may differ from those observed in high-income countries and may need to be modelled differently to include behavioural response to emotional distress and socio-cultural contexts.

Trauma-Responsive Care in a Pediatric Setting: Feasibility and Acceptability of Screening for Adverse Childhood Experiences

Adverse childhood experiences (ACEs) have demonstrable negative effects on long-term physical and mental health. Low-income and ethnic minority communities face significant disparities in exposure to ACEs. Pediatric settings offer an opportune context to identify and address ACEs, with the potential to reduce barriers in access to resources and services. The current study examined the feasibility and acceptability of screening infants and their parents for ACEs at a community medical clinic. Feasibility data indicated that 151 (92%) of the 164 unique patients that presented for well-child visits for infants (4- to 12-months) across a 13-month period were screened for infant and parent ACEs. Of these 151 patients, 47% met eligibility (infants with 1 + ACEs, parents with 2 + ACEs) deemed intermediate risk and indicated referral to prevention services. The majority of referred families (77%) accepted prevention services, including appointments with bilingual and bicultural wellness navigators who provided a cultural bridge and access to resources that could address patients' social determinants of health. Qualitative interviews with providers expand upon screening acceptability. Implications for integrated behavioral health, ACEs screening, and trauma-responsive prevention in a pediatric setting are discussed.

Maternal Adverse Childhood Experiences, Family Strengths, and Chronic Stress in Children

BACKGROUND

Researchers have demonstrated that maternal adverse childhood experiences (ACEs), such as abuse and neglect, are associated with prenatal risk factors and poor infant development. However, associations with child physiologic and health outcomes, including biomarkers of chronic or "toxic" stress, have not yet been explored.

OBJECTIVES

The purpose of this study was to examine the associations among past maternal experiences, current maternal posttraumatic stress disorder (PTSD) symptoms, and children's indicators of exposure to chronic stress in a multiethnic sample of mothers and children at early school age (4 to 9 years).

METHODS

This cross-sectional study included maternal-child dyads (N = 54) recruited from urban community health centers in New Haven, Connecticut. Mothers reported history of ACEs, family strengths, and current PTSD symptoms. Child measures included biomarkers and health and developmental outcomes associated with chronic stress. Correlational and regression analyses were conducted.

RESULTS

Childhood trauma in mothers was associated with higher systolic blood pressure percentile (ρ = .29, p = .03) and behavioral problems (ρ = .47, p = .001) in children, while maternal history of family strengths was associated with lower salivary interleukin (IL)-1β (ρ = -.27, p = .055), salivary IL-6 (ρ = -.27, p = .054), and body mass index z-scores (ρ = -.29, p = .03) in children. Maternal PTSD symptoms were associated with more child behavioral problems (ρ = .57, p < .001) and higher odds of asthma history (ρ = .30, p = .03).

DISCUSSION

Results indicate that past maternal experiences may have important influences on a child's health and affect his or her risk for experiencing toxic stress.

Emotional wellbeing in youth: A concept analysis

AIM

The aim of this concept analysis is to report a synthesis of the extant literature and define emotional wellbeing in youth as a concept of emerging importance.

BACKGROUND

Emotional wellbeing is a national research priority in the United States. It is not well defined nor understood in the context of its ontology, mechanisms, biomarkers, or promotion. As a result, interventional research cannot be adequately informed.

DESIGN

A comprehensive review of the literature was conducted to inform the sample.

DATA SOURCE

The scientific databases PubMed, Cochrane Library, Ovid Medline, PsycINFO, NCBI, Allied and Complementary Medicine, EMBASE, EBSCO, JAMAevidence, CINAHL, Joanna Briggs Institute, and Reporter were queried.

REVIEW METHODS

The Walker and Avant method was utilized to analyze the resultant sample for common themes of antecedents, attributes, and consequences of emotional wellbeing.

RESULTS

Seventeen scientific research studies were included in the final sample.

CONCLUSION

Attributes of emotional wellbeing in youth include overall positive emotions, positive self-esteem, and resilience. Antecedents are safe and stable nurturing relationships; family and social connectedness, hope, and positive body-image. The consequences of emotional wellbeing in youth include self-efficacy, self-actualization, the presence of positive health behaviors, and the absence of high-risk behaviors.

Positive Childhood Experiences and Adult Mental and Relational Health in a Statewide Sample: Associations Across Adverse Childhood Experiences Levels

IMPORTANCE

Associations between adverse childhood experiences (ACEs) and risks for adult depression, poor mental health, and insufficient social and emotional support have been documented. Less is known about how positive childhood experiences (PCEs) co-occur with and may modulate the effect of ACEs on adult mental and relational health.

OBJECTIVE

To evaluate associations between adult-reported PCEs and (1) adult depression and/or poor mental health (D/PMH) and (2) adult-reported social and emotional support (ARSES) across ACEs exposure levels.

DESIGN, SETTING, AND PARTICIPANTS

Data were from the cross-sectional 2015 Wisconsin Behavioral Risk Factor Survey, a random digit-dial telephone survey of noninstitutionalized Wisconsin adults 18 years and older (n = 6188). Data were weighted to be representative of the entire population of Wisconsin adults in 2015. Data were analyzed between September 2016 and January 2019.

MAIN OUTCOMES AND MEASURES

The definition of D/PMH includes adults with a depression diagnosis (ever) and/or 14 or more poor mental health days in the past month. The definition of PCEs includes 7 positive interpersonal experiences with family, friends, and in school/the community. Standard Behavioral Risk Factor Survey ACEs and ARSES variables were used.

RESULTS

In the 2015 Wisconsin Behavioral Risk Factor Survey sample of adults (50.7% women; 84.9% white), the adjusted odds of D/PMH were 72% lower (OR, 0.28; 95% CI, 0.21-0.39) for adults reporting 6 to 7 vs 0 to 2 PCEs (12.6% vs 48.2%). Odds were 50% lower (OR, 0.50; 95% CI, 0.36-0.69) for those reporting 3 to 5 vs 0 to 2 PCEs (25.1% vs 48.2%). Associations were similar in magnitude for adults reporting 1, 2 to 3, or 4 to 8 ACEs. The adjusted odds that adults reported "always" on the ARSES variable were 3.53 times (95% CI, 2.60-4.80) greater for adults with 6 to 7 vs 0 to 2 PCEs. Associations for 3 to 5 PCEs were not significant. The PCE associations with D/PMH remained stable across each ACEs exposure level when controlling for ARSES.

CONCLUSIONS AND RELEVANCE

Positive childhood experiences show dose-response associations with D/PMH and ARSES after accounting for exposure to ACEs. The proactive promotion of PCEs for children may reduce risk for adult D/PMH and promote adult relational health. Joint assessment of PCEs and ACEs may better target needs and interventions and enable a focus on building strengths to promote well-being. Findings support prioritizing possibilities to foster safe, stable nurturing relationships for children that consider the health outcomes of positive experiences.

Adverse Childhood Experiences of Children Adopted from Care: The Importance of Adoptive Parental Warmth for Future Child Adjustment

We investigated the relationship between adverse childhood experiences (ACEs) and children's internalising symptoms and externalising problems in the Wales Adoption Cohort Study, a prospective longitudinal study that used case file records (n = 374) for a sample of British children adopted from care (M = 2 years, 55% male). Parents (n = 96) completed questionnaires at 3-5 months, 15-17 months, and 31-33 months post-placement. We hypothesised that: (1) children adopted from care would have experienced more ACEs than children in the general population; (2) the number of ACEs would be associated with higher internalising symptom and externalising problem scores; and (3) adoptive parental warmth would moderate the relationship between ACEs and post-placement internalising symptoms and externalising problems. Nearly half (42%) of the children experienced four or more ACEs. Internalising symptoms and externalising problems were significantly higher than the UK general population. The number of ACEs was associated with internalising symptoms 3 years post-adoptive placement but this relationship was moderated by adoptive parental warmth. This study profiles the experiences and characteristics of a national sample of adopted children and highlights the potential importance of parent warmth as a factor that ameliorates the impact of ACEs on poor child outcomes.

Developmental and mental health characteristics of children exposed to psychosocial adversity and stressors at the age of 18-months: Findings from a population-based cohort study

BACKGROUND

Prior research on adverse experiences in early childhood has mainly focused on at-risk populations while studies of unselected populations are scarce. This topic therefore remains to be elucidated in broader child populations. Accordingly, the aim of this study was to examine if and to what extent children from a general population sample are exposed to psychosocial adversity and stressors in early childhood and whether the development and mental health of children with and without such exposure differ at the age of 18-months.

METHODS

A random sample of the Copenhagen Child Cohort (CCC2000) comprising 210 children and their parents participated in the study when the children were approximately 18-months. Information on exposures was obtained from a semi-structured interview including the Mannheim Parent Interview (MPI) and classified in agreement with the Multiaxial Classification of Child and Adolescent Psychiatric Disorders (ICD-10), and the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC: 0-3). Child development was assessed with the Bayley Scales of Infant and Toddler Development - Second Edition (BSID-II), while mental health was measured using the Child Behavior Check List (CBCL 1½-5).

RESULTS

Among the 210 children, 91 (43%) had been exposed to psychosocial adversity and persistent stressors. The exposed children differed from the non-exposed children by poorer cognitive development and behavioral regulation, as well as more attention problems and anxious/depressed symptoms. The children exposed to adverse caregiving environments were specifically more likely to have delayed cognitive development than the rest of the sample.

CONCLUSIONS

In a general population sample of children aged 18-months, exposure to psychosocial adversity and stressors was associated with poorer development and mental health in cognitive and affective domains. These findings highlight an avenue for further research with potential implications for early preventative practices.

Adverse Childhood Experiences in Infancy and Toddlerhood Predict Obesity and Health Outcomes in Middle Childhood

BACKGROUND

The Adverse Childhood Experiences (ACEs) study articulated the negative effects of childhood trauma on adult weight and health. The purpose of the current study is to examine the associations between ACEs in infancy and toddlerhood and obesity and related health indicators in middle childhood.

METHODS

We used data collected from a sample of low-income families enrolled in the national evaluation of Early Head Start (EHS). Data come from 1335 demographically diverse families collected at or near children's ages 1, 2, 3, and 11. An EHS-ACE index was created based on interview and observation items from data collected at ages 1, 2, and 3, which were averaged to represent exposure across infancy and toddlerhood. At age 11, children's height and weight were measured and parents were asked about their child's health.

RESULTS

Children were exposed at rates of 30%, 28%, 15%, and 8% to one, two, three, and four or more EHS-ACEs, respectively. Logistic regressions revealed significant associations between EHS-ACEs in infancy/toddlerhood and obesity, respiratory problems, taking regular nonattention-related prescriptions, and the parent's global rating of children's health at age 11. Across all outcomes examined, children with four or more ACEs had the poorest health. Compared with children with no ACE exposure, the odds of each of the examined health outcomes were over twice as high for children who experienced four or more ACEs.

CONCLUSIONS

Findings highlight that ACEs experienced very early in development are associated with children whose health is at risk later in childhood.

Circumstances of Substance Use by Street Youth in Egypt Support the Case for Intervening to Prevent Adverse Childhood Experiences

BACKGROUND

Egyptian street youth use substances including tobacco, illicit drugs, and pharmaceutical drugs. To understand the circumstances, including adverse childhood experiences, that place adolescents at risk for engaging in substance use, we conducted in-depth interviews among a sample of Egyptian street children.

METHODS

From youth residing at or attending Caritas, a non-profit organization, which provides shelter and education to street youth, seven girls and twelve boys, aged 12 to 18 years, participated in open-ended, in-depth interviews.

RESULTS

Eight out of the 19 participants reported family history (early exposure) to substance use; and seven of them were initiated by either a family member (sibling), friend or coworker. Most of the participants reported a history of conflict with or abuse (verbal or physical) by their parents or siblings, or stressful situations at home; they used substance(s) to alleviate their stress. Few attended school, and some were forced to work and help their family.

CONCLUSIONS

Among Egyptian youth, adverse childhood experiences, such as poverty, child abuse, and family substance use, challenge somewhat susceptible youths and lead them to the path of substance use and addiction. Prevention intervention should be multifaceted, culturally adaptable, and primarily targeting the social environment during childhood.

Adverse Childhood Experiences in Children with Intellectual Disabilities: An Exploratory Case-File Study in Dutch Residential Care

Adverse Childhood Experiences (ACEs) are negative childhood events occurring in a child’s family or social environment, that may cause harm or distress. Children with intellectual disabilities (ID) and their families are underrepresented in international ACEs research, while current insights can also contribute to the improvement of their health and well-being. Deficiencies in intellectual and adaptive functioning and living circumstances can increase their vulnerability to adversities. In the present exploratory study 69 case-files of children referred to a Dutch national center for residential youth care for children with ID were analyzed to assess the prevalence and associations of ACEs. It was found that almost half (49.3%) of the children experienced 2 ACEs from the original ACEs framework or more (M (mean) = 2.1; SD (standard deviation) = 1.8) and that the number of ACEs in children was related to the presence of ACEs in parents. Both child and parental ACEs were also related to attachment- and trauma- and stressor-related disorders. Finally, living circumstances and multiple ACEs from the expanded ACEs framework, especially related to parental characteristics, were found to be related to ACEs in children with ID. This implicates the importance of a transgenerational approach when further investigating the impact of ACEs on mental and physical health in children with ID (intellectual disabilities).

Prioritizing Possibilities for Child and Family Health: An Agenda to Address Adverse Childhood Experiences and Foster the Social and Emotional Roots of Well-being in Pediatrics

OBJECTIVE

A convergence of theoretical and empirical evidence across many scientific disciplines reveals unprecedented possibilities to advance much needed improvements in child and family well-being by addressing adverse childhood experiences (ACEs), promoting resilience, and fostering nurturance and the social and emotional roots of healthy child development and lifelong health. In this article we synthesize recommendations from a structured, multiyear field-building and research, policy, and practice agenda setting process to address these issues in children's health services.

METHODS

Between Spring of 2013 and Winter of 2017, the field-building and agenda-setting process directly engaged more than 500 individuals and comprised 79 distinct agenda-setting and field-building activities and processes, including: 4 in-person meetings; 4 online crowdsourcing rounds across 10 stakeholder groups; literature and environmental scans, publications documenting ACEs, resilience, and protective factors among US children, and commissioning of this special issue of Academic Pediatrics; 8 in-person listening forums and 31 educational sessions with stakeholders; and a range of action research efforts with emerging community efforts. Modified Delphi processes and grounded theory methods were used and iterative and structured synthesis of input was conducted to discern themes, priorities, and recommendations.

RESULTS

Participants discerned that sufficient scientific findings support the formation of an applied child health services research and policy agenda. Four overarching priorities for the agenda emerged: 1) translate the science of ACEs, resilience, and nurturing relationships into children's health services; 2) cultivate the conditions for cross-sector collaboration to incentivize action and address structural inequalities; 3) restore and reward for promoting safe and nurturing relationships and full engagement of individuals, families, and communities to heal trauma, promote resilience, and prevent ACEs; and 4) fuel "launch and learn" research, innovation, and implementation efforts. Four research areas arose as central to advancing these priorities in the short term. These are related to: 1) family-centered clinical protocols, 2) assessing effects on outcomes and costs, 3) capacity-building and accountability, and 4) role of provider self-care to quality of care. Finally, we identified 16 short-term actions to leverage existing policies, practices, and structures to advance agenda priorities and research priorities.

CONCLUSIONS

Efforts to address the high prevalence and negative effects of ACEs on child health are needed, including widespread and concrete understanding and strategies to promote awareness, resilience, and safe, stable, nurturing relationships as foundational to healthy child development and sustainable well-being throughout life. A paradigm-shifting evolution in individual, organizational, and collective mindsets, policies, and practices is required. Shifts will emphasize the centrality of relationships and regulation of emotion and stress to brain development as well as overall health. They will elevate relationship-centered methods to engage individuals, families, and communities in self-care related to ACEs, stress, trauma, and building the resilience and nurturing relationships science has revealed to be at the root of well-being. Findings reflect a palpable hope for prevention, mitigation, and healing of individual, intergenerational, and community trauma associated with ACEs and provide a road map for doing so.

ACE, Place, Race, and Poverty: Building Hope for Children

Adverse childhood experiences research has focused attention on the importance of family safety, stability, and nurturing in ensuring healthy development. This safety, stability, and nurturing can be compromised by family poverty, discrimination and marginalization, and geographic location. Drawing upon census data, this report shows that place, race, and poverty are intertwined concepts with particular implications for young children. Examining census tracts according to their levels of poverty shows that the poorest census tracts also: 1) are the "richest" in the proportion of young children, 2) have the least realized social, physical, and educational, as well as economic capital, and 3) are highly racially segregated and separated from many sources of economic opportunity. The implications are that the country's poorest neighborhoods require substantially more supports for young children but currently have many fewer. This includes individual services to young children and their families but also publicly available services and voluntary supports, such as parks, playgrounds, and libraries. These data suggest that improving child health trajectories and reducing health disparities according to race and socioeconomic status therefore will require concerted individual service as well as community-building efforts directed to poor and usually racially segregated neighborhoods and communities.