Adverse childhood experiences and prescribed psychotropic medications in adults

Adverse Childhood Experiences Moderate the Relationship Between Pain and Later Suicidality Severity Among Youth: A Longitudinal High-Risk Cohort Study

Pain in adolescence can lead to the development of serious mental health issues, including suicidality. This risk may be strengthened among youth exposed to more adverse childhood experiences (ACEs; abuse, neglect, household challenges). This longitudinal study examined the role of ACEs in the relationship between pain and later suicidality onset and severity among a cohort of adolescents at risk for developing mental health problems. Participants were 139 healthy youth (Mage = 13.74 years, standard deviation = 1.56, 64% female) between the ages of 11 to 17 years, recruited based on parental history of depression or anxiety. Youth completed validated measures of internalizing symptoms, ACEs, and pain characteristics at baseline and follow-up diagnostic interviews 9 and/or 18 months later to assess for onset and severity of suicidality. After controlling for demographics, baseline internalizing symptoms, and ACEs, worse pain interference and increased ACEs at baseline predicted increased suicidality severity at follow-up. Moderation analyses revealed that there was a significant interaction between ACEs and pain interference and pain intensity. Increased pain interference (b = 7.65, P < .0001) or intensity (b = 6.96, P = .0003) was only associated with increased suicidality severity at follow-up in youth with high levels of ACEs. This study demonstrates that ACEs strengthen the relationship between pain and later suicidality severity among youth at risk of developing mental health problems. Findings underscore the critical need to adopt a trauma-informed lens to pediatric pain prevention and treatment (eg, screening for ACEs) and for the pain to be on the child's mental health agenda. PERSPECTIVE: This article provides evidence that, while pain is a risk factor for future increased suicidality severity, it is a particularly strong risk factor in youth who experienced increased childhood adversity. These results may help identify youth at greatest risk for suicidality.

Adverse childhood experiences and intimate partner violence: A meta-analysis

Intimate partner violence (IPV) represents a significant public health concern. Adverse childhood experiences (ACEs) represent one risk factor for IPV, however, the results of existing research on the association between ACEs and IPV demonstrate mixed findings. The present research sought to meta-analytically examine the association between ACEs and (a) IPV perpetration and (b) IPV victimization. Moderator analyses were conducted to determine factors that may impact the association between ACEs and IPV involvement. Electronic searches were conducted in MEDLINE, Embase, and PsycINFO in August of 2021. One-hundred and twenty-three records were screened for inclusion. All studies included a measure of ACEs and IPV victimization or perpetration. Among the 27 studies and 41 samples included in the meta-analysis, 65,330 participants were included. The results of the meta-analyses demonstrated that ACEs were positively associated with IPV perpetration and victimization. Significant methodological and measurement moderators further inform our understanding of ACEs and IPV involvement. The present meta-analyses demonstrates that trauma-informed approaches to IPV screening, prevention, and intervention may be useful, given that individuals who are involved with IPV may be more likely to possess a history of ACEs exposure.

Early life adversity in primates: Behavioral, endocrine, and neural effects

BACKGROUND

Evidence suggests that early life adversity is associated with maladaptive behaviors and is commonly an antecedent of stress-related psychopathology. This is particularly relevant to rearing in primate species as infant primates depend on prolonged, nurturant rearing by caregivers for normal development. To further understand the consequences of early life rearing adversity, and the relation among alterations in behavior, physiology and brain function, we assessed young monkeys that had experienced maternal separation followed by peer rearing with behavioral, endocrine and multimodal neuroimaging measures.

METHODS

50 young rhesus monkeys were studied, half of which were rejected by their mothers and peer reared, and the other half were reared by their mothers. Assessments were performed at approximately 1.8 years of age and included: threat related behavioral and cortisol responses, cerebrospinal fluid (CSF) measurements of oxytocin and corticotropin releasing hormone (CRH), and multimodal neuroimaging measures (anatomical scans, resting functional connectivity, diffusion tensor imaging, and threat-related regional glucose metabolism).

RESULTS

The results demonstrated alterations across behavioral, endocrine, and neuroimaging measures in young monkeys that were reared without their mothers. At a behavioral level in response to a potential threat, peer reared animals engaged in significantly less freezing behavior (p = 0.022) along with increased self-directed behaviors (p < 0.012). Levels of oxytocin in the CSF, but not plasma, were significantly reduced in the peer reared animals (p = 0.019). No differences in plasma cortisol or CSF CRH were observed. Diffusion tensor imaging revealed significantly decreased white matter density across the brain. Exploratory correlational and permutation analyses suggest that the impact of peer rearing on behavior, endocrine and brain structural alterations are mediated by separate parallel mechanisms.

CONCLUSIONS

Taken together, these results demonstrate in NHPs the importance of maternal rearing on the development of brain, behavior and hormonal systems that are linked to social functioning and adaptive responses. The findings suggest that the effects of maternal deprivation are mediated via multiple independent pathways which may account for the heterogeneity in behavioral and biological alterations observed in individuals that have experienced this early life adversity.

Adverse childhood experiences and psychotropic medication prescription among cancer patients

BACKGROUND

This study aimed at identifying and characterizing adverse childhood experiences (ACEs) in a sample of cancer patients and subsequently evaluating the relationship between ACEs and prescription of psychotropic medication among them. Individuals with ACEs have a higher risk of mental health conditions and are more likely to be prescribed psychotropic medications.

METHODS

A sample of 178 adult patients receiving Supportive Oncology & Survivorship (SOS) services at Huntsman Cancer Hospital in Utah was obtained. ACEs and Brief Resilient Coping Scale (BRCS) questionnaires were administered confidentially. A multivariable mixed effect model, adjusting for sex, age, and insurance type while controlling for zip-codes clustering were employed.

RESULTS

Compared to the prevalence of ACEs in the general population, from the CDC-Kaiser Permanente ACEs Study, we found no significant difference in the prevalence of people who had experienced an adverse childhood event (ACEs score > = 1) between our study of cancer patients and the CDC-Kaiser study (67.4% vs. 63.6%, p = 0.29372), but found a significant difference in the prevalence of people who had experienced severe adverse childhood experiences (ACES score > =4) (25.3% vs. 12.1%, p < 0.00001). Furthermore, this study reveals a significant association between an increase of one unit in the total ACEs score and the odds of psychotropic medication prescription in the past 12 months (OR: 1.233; 95% CI: 1.025, 1.483). Those with a total ACEs score of three or more were found to have 280% higher odds of being prescribed psychotropic medication compared to those with ACEs ≤ 2 (OR: 3.822; 95% CI: 1.404,10.407).

CONCLUSION

A significant proportion of cancer patients have a history of ACEs, and thus trauma-informed care approach is essential during their treatment.

Adverse childhood experiences, risk of opioid misuse and its pathway among students at a public university

OBJECTIVE

We examine role of ACEs and pathways to risk of opioid misuse among young adults. Participants and Methods: A cross-sectional survey of validated measures of ACEs, risk of opioid misuse, and health conditions with a sample of 1,402 students from a large public university followed by multivariate logistic regression and pathway analysis. Results: Majority (61%) of participants reported at least one ACE. A dose-response relationship between numbers of ACEs with risk for opioid misuse was present. Compared to participants with no ACEs, participants with ≥4 ACEs and 0-3 ACEs were 2.93 (95% CI: 1.95, 4.39; p < 0.001) and 1.96 (95% CI: 1.46, 2.65; p < 0.001) times more likely to be at risk for opioid misuse, respectively. Having at least one existing or past health condition significantly mediated the association. Conclusions: Our findings suggest need to include assessment of ACEs as a screening criterion for opioid prescription and administration among college-aged individuals.

From childhood adversity to latent stress vulnerability in adulthood: the mediating roles of sleep disturbances and HPA axis dysfunction

Childhood adversity is a prominent predisposing risk factor for latent stress vulnerability, expressed as an elevated likelihood of developing stress-related psychopathology upon subsequent exposure to trauma in adulthood. Sleep disturbances have emerged as one of the most pronounced maladaptive behavioral outcomes of childhood adversity and are also a highly prevalent core feature of stress-related psychopathology, including post-traumatic stress disorder (PTSD). After reviewing the extensive literature supporting these claims, the current review addresses the notion that childhood adversity-induced sleep disturbances may play a causal role in elevating individuals' stress vulnerability in adulthood. Corroborating this, sleep disturbances that predate adult trauma exposure have been associated with an increased likelihood of developing stress-related psychopathology post-exposure. Furthermore, novel empirical evidence suggests that sleep disturbances, including irregularity of the sleep-wake cycle, mediate the link between childhood adversity and stress vulnerability in adulthood. We also discuss cognitive and behavioral mechanisms through which such a cascade may evolve, highlighting the putative role of impaired memory consolidation and fear extinction. Next, we present evidence to support the contribution of the hypothalamic-pituitary-adrenal (HPA) axis to these associations, stemming from its critical role in stress and sleep regulatory pathways. Childhood adversity may yield bi-directional effects within the HPA stress and sleep axes in which sleep disturbances and HPA axis dysfunction reinforce each other, leading to elevated stress vulnerability. To conclude, we postulate a conceptual path model from childhood adversity to latent stress vulnerability in adulthood and discuss the potential clinical implications of these notions, while highlighting directions for future research.

A pilot study of the adverse childhood experiences-dimensions questionnaire (ACE-DQ): Associations with depression

BACKGROUND

Recent ACE research proposed items to assess ACE dimensions, such as the frequency or timing of adverse events, that can be added to the original ACE-Study Questionnaire.

OBJECTIVE

The goal of our study was to pilot-test the refined ACE-Dimensions Questionnaire (ACE-DQ) to determine its predictive validity and compare scoring approaches.

PARTICIPANTS AND SETTING

Cross-sectional online survey via MTurk with U.S. adults to collect data on the ACE-Study Questionnaire and the newly developed ACE dimension items, and mental health outcomes.

METHODS

We compared ACE exposure by assessment approach and their associations with depression outcomes. We used logistic regression to compare the predictive validity of different ACE scoring approaches for depression outcomes.

RESULTS

Participants (n = 450) were on average 36 years old, half were female, and the majority was White. Almost half reported depressive symptoms; approximately two-thirds had experienced ACEs. Participants reporting depression had significantly higher ACE scores. Using the ACE index, participants with ACEs were 45 % more likely to report depression symptoms than participants without ACEs (OR 1.45, 95%CI 1.33-1.58). When using perception-weighted scores, participants had smaller, yet significant odds of reporting depression outcomes.

CONCLUSIONS

Our results suggest that the ACE index may overestimate the impact of ACEs and the effects of ACEs on depression. Adding the comprehensive set of conceptual dimensions to more fully weigh participants' experience of adverse events can increase the accuracy of ACE measurement but will also increase participant burden considerably. We recommend including items to assess a person's perception of each adverse event for improved screening efforts and in research focused on cumulative adversity.

Health of Young Adults Experiencing Social Marginalization and Vulnerability: A Cross-National Longitudinal Study

People who experience social marginalization and vulnerability have uniquely complex health needs and are at risk of poor health outcomes. Regression analyses using longitudinal data from a cross-national, population-based sample of young adults participating in the International Youth Development Study, tested associations between social marginalization and vulnerabilities and physical health, mental health, and substance use outcomes. Participants from Victoria, Australia, and Washington State in the US were surveyed at ages 25 (2014) and 29 years (2018; N = 1944; 46.7% male). A history of adverse childhood experiences (ACEs), LGBT identity, financial insecurity, and justice system involvement at age 25 predicted poor health outcomes at age 28, including lower perceived health status, risk for chronic illness, depression and anxiety symptoms, and diagnosed mental health/substance use disorders. Tests of model equivalence across states showed that a history of ACEs was more strongly related to health status and serious injury at age 28 and justice system involvement at age 25 was more strongly related to age 28 serious injury in Victoria than in Washington State. Findings strengthen the case for future population-based research identifying life-course interventions and state policies for reducing poor health and improving health equity among members of socially marginalized groups.

Enhancing supports to children of incarcerated parents: Introducing trauma informed training to church mentors

A child who has a parent incarcerated is likely to experience a number of life challenges including school failure, poverty, substance abuse, and justice system involvement. The negative outcomes associated with having a parent incarcerated disproportionately expose children to adverse childhood events (ACE's) which have been associated with higher morbidity and mortality. However, engagement with caring adults who can provide both practical and spiritual mentorship can increase a child's resilience and buffer the impact of these negative outcomes. Church-based mentors have the capacity to provide support to this population when adequately trained in trauma-informed responses. This study describes Camp Agape California (CAC), a church-based mentoring program for children with an incarcerated parent. Specifically, this study describes the development and implementation of a trauma focused mentorship training purposed to equip church members to better meet the needs of this vulnerable population. Seventy-six volunteer mentors from various churches participated in the training and completed the post-training survey. Results suggest that the trauma informed training was effective at increasing knowledge and self-efficacy and was identified as being relevant to the mentor role. Implications for the utility of church-based mentorship for vulnerable populations are explored.

Combined effects of nitric oxide synthase 3 genetic variant and childhood emotional abuse on earlier onset of suicidal behaviours

Marked heterogeneity in suicide attempters has been observed, with earlier onset being linked to stronger heritability, more childhood maltreatment. Nitric oxide signalling system might be implicated in this relationship through its role in the stress response/adaptation. This study examined how NOS genetic variants and childhood maltreatment were associated with age at first suicide attempt (SA). Adult patients with SA history (N = 414) filled in the Childhood Trauma Questionnaire, and six functionally relevant NOS2 and NOS3 polymorphisms were genotyped. Analyses included χ², Mann-Whitney U tests, Kendall's regression, multivariate linear and Cox survival regressions, and a moderation analysis. The NOS3 promotor 27-bp variable number tandem repeat (VNTR) bb homozygous state and childhood emotional abuse were independently associated with earlier age at first SA, which was robust after controlling for confounders [regression coefficient - 3.975, 95% CI -6.980 - (-0.970), p = 0.010, and - 1.088, 95% CI -2.172 - (-0.004), p = 0.049]. No interaction was observed. In the Cox proportional hazards model for age at first SA, the hazard ratio for patients with childhood emotional abuse and NOS3 27-bp VNTR bb was 0.533 (95% CI 0.394-0.720, p < 0.001) compared to patients without. Intermediate scores were observed with either only the risk genotype or only childhood emotional abuse. A graded relationship was also observed for repeated SA, family history of SA, and severe SA history. These results are preliminary due to a low statistical power and call for replication and further characterization of the role of nitric oxide system in the susceptibility to early-onset SB.

"Psychologically and emotionally, it affects me 'til this day": exploration of childhood sexual abuse perspectives among older adults living with HIV in South Carolina

OBJECTIVES

The influence of childhood sexual abuse (CSA) may be seen immediately or across the life course. CSA is also associated with increased HIV-risk behavior, and greater likelihood of an HIV/STI diagnosis. The aim of this study was to explore the perspectives of CSA among older adults living with HIV.

METHODS

Twenty-four adults living with HIV aged 50 to 67 years (mean age = 58.5 years), with a history of CSA, receiving care from an HIV clinic in South Carolina, participated in the study. In-depth semi-structured interviews were conducted, audio recorded and analyzed using a thematic analytic approach. The iterative analytic process included a three-step approach: discussion of initial thoughts and key concepts, identification and reconciliation of codes, and naming of emergent themes.

RESULTS

Four themes emerged: Psychological issues due to CSA, relationship challenges due to CSA, self-blame, and reliving childhood trauma (subtheme: lack of influence of CSA today). Some participants reported feeling the influence of CSA several years after the event while others noted that that there was a lack of influence of CSA at present.

CONCLUSIONS

Trauma-informed intervention programs are needed for older adults living with HIV who still experience the influence of their CSA experience. Future research should delve into the design and feasibility of implementing these programs.

Child maltreatment, anxiety and depression, and asthma among British adults in the UK Biobank

BACKGROUND

Child maltreatment is associated with asthma in adults. We examined whether lifetime major depressive disorder (MDD) or lifetime generalised anxiety disorder (GAD) mediate an association between child maltreatment and current asthma among 81 105 British adults in the UK Biobank who completed a mental health survey and had complete data on child maltreatment, GAD, MDD, asthma and relevant covariates but no diagnosis of chronic obstructive pulmonary disease.

METHODS

Child maltreatment was ascertained based on answers to the five questions in the Childhood Trauma Screener. Two mediators, lifetime MDD and GAD, were assessed based on the Composite International Diagnostic Interview Short Form. Current asthma was defined as physician-diagnosed asthma and wheeze or whistling in the chest in the previous year. Logistic regression was used for the multivariable analysis of child maltreatment and current asthma, and a mediation analysis was conducted to estimate the contributions of lifetime MDD and lifetime GAD to the child maltreatment-current asthma association.

RESULTS

In a multivariable analysis, any child maltreatment was associated with asthma (adjusted OR 1.22, 95% CI 1.15-1.28; p<0.01). In a mediation analysis adjusted for household income, educational attainment, smoking status, pack-years of smoking and other covariates, lifetime GAD and lifetime MDD explained 21.8% and 32.5%, respectively, of the child maltreatment-current asthma association. Similar results were obtained after excluding current smokers and former smokers with ≥10 pack-years of smoking from the mediation analysis.

CONCLUSION

Our findings suggest that GAD and MDD mediate an association between child maltreatment and asthma in adults, independently of smoking.

Inequities in Community Exposure to Deadly Gun Violence by Race/Ethnicity, Poverty, and Neighborhood Disadvantage among Youth in Large US Cities

Understanding the burden of gun violence among youth is a public health imperative. While most estimates are based on direct and witnessed victimization, living nearby gun violence incidents may be consequential too. Yet detailed information about these broader experiences of violence is lacking. We use data on a population-based cohort of youth merged with incident-level data on deadly gun violence to assess the prevalence and intensity of community exposure to gun homicides across cross-classified categories of exposure distance and recency, overall and by race/ethnicity, household poverty, and neighborhood disadvantage. In total, 2-18% of youth resided within 600 m of a gun homicide occurring in the past 14-365 days. These percentages were 3-25% for incidents within 800 m and 5-37% for those within a 1300-m radius. Black and Latinx youth were 3-7 times more likely, depending on the exposure radius, to experience a past-year gun homicide than white youth and on average experienced incidents more recently and closer to home. Household poverty contributed to exposure inequities, but disproportionate residence in disadvantaged neighborhoods was especially consequential: for all racial/ethnic groups, the difference in the probability of exposure between youth in low vs high poverty households was approximately 5-10 percentage points, while the difference between youth residing in low vs high disadvantage neighborhoods was approximately 50 percentage points. Given well-documented consequences of gun violence exposure on health, these more comprehensive estimates underscore the importance of supportive strategies not only for individual victims but entire communities in the aftermath of gun violence.

Adequacy of Inquiry About, Documentation of, and Treatment of Trauma and Adversities: A Study of Mental Health Professionals in England

This study aimed to ascertain how often staff in community mental health services (CMHSs) in England ask about adverse experiences in childhood and adulthood, including abuse and neglect, how often those experiences are known about and documented by staff, and how staff respond when such experiences are known about and documented. The files of 400 people using four CMHSs in England were reviewed. Only 13% of clinical records contained documentation of any adverse experiences. One percent showed clear evidence that clients had been asked about adversities. People with psychosis diagnoses were less likely to have adverse experiences documented in their file. Rates of responses to adversities of which staff were aware were high, with 90% of records indicating some appropriate support following disclosure. Future research endeavours are recommended, including on reasons for not routinely asking and on type of training needed. Recommendations are made in relation to policy change, staff training and guidelines to improve routine enquiry about adversities. Ultimately, a move to 'trauma-informed' services, already underway in some areas, is required for all mental health services.

How Do Fathers Help? A Moderation Analysis of the Association between Adverse Childhood Experiences and Child Behavioral Health in Fragile Families

Existing research has built concrete links between trauma exposure and lifelong behavioral health outcomes. However, the ways by which father engagement buffers the detrimental effects of trauma on early childhood behavioral health remains unexplored. Using the data of 3001 mothers from the Fragile Families and Child Well-being Study, we conducted a moderation analysis to examine the associations between adverse childhood experiences (ACEs), child behavioral health, father engagement, and maternal education. We found that ACEs at child age three were positively associated with child externalizing and internalizing behaviors at child age five. Father engagement at child age one buffered the harmful effects of ACEs on child externalizing behaviors, but this effect was only significant for children living with mothers with an education level lower than high school. Child psychiatrists should view father engagement as a critical factor in fostering child resilience, particularly for children living in families with limited resources.

Prevalence of and Relationship Between Caregiver Adversity Scores and Child Client Eco-systemic Structural Family Therapy (ESFT) Outcome: Implications for Family Based Mental Health Services (FBMHS)

Adverse childhood experiences, especially with primary caregivers, impacts the mental, physical, and relational health of individuals (Felitti et al. in Am J Prev Med, 14(4):245-258. https://doi.org/10.1016/s0749-3797(98)00017-8 , 1998). Therefore, caregiver adversity is important to consider when delivering therapeutic interventions to children (Gardner et al. in Clin Soc Work J 42(1):81-89. https://doi.org/10.1007/s10615-012-0428-8 , 2014; Eslinger et al. in J Child Fam Stud 24(9):2757. https://doi.org/10.1007/s10826-014-0079-1 , 2015; Hagan et al. in J Trauma Stress 30(6):690-697, 2017). This study analyzed archival data to understand the role of caregiver adversity in Eco-Systemic Structural Family Therapy (ESFT) outcomes, within Family Based Mental Health Services. Results indicate caregiver lifetime adversity score did not predict treatment outcome. However, caregiver current adversity and family length of stay were negatively correlated as were length of stay and client discharge level of care. These findings suggest that ESFT benefits families regardless of caregiver childhood adversity level and that clinician attention to caregiver current adversity is important to ensure families receive the full benefits of ESFT. Implications for optimizing ESFT and future directions for ESFT clinical research are discussed.

Mothers and Their Children: An Exploration of the Relationship Between Maternal Mental Health and Child Well-Being

INTRODUCTION

Psychosocial factors and life stressors have an impact on long-term health effects on mothers and their children. Recent studies examining maternal mental health have predominantly focused on identifying maternal experiences with depression; however, there has been minimal research investigating maternal experiences with psychosocial risk factors and its relationship with child well-being.

METHODS

Secondary analysis was conducted using data from the Fragile Families and Child Well-Being Study. The study sample includes 2396 adolescents and their biological mothers. Adolescents were between the ages of 14 and 19. We examined primary outcomes regarding mental health (depression and anxiety), life-satisfaction, and substance usage (alcohol and drugs).

RESULTS

The association between maternal psychosocial factors an adolescent depression was significant, F(26) = 5.29, p < .01. Mothers educational attainment and poverty level significantly predicted adolescent depression; with completion of some college (B = -0.411, p 0.025), a college degree (B = -0.540, p = 0.018), and living at the 300% poverty level (B = -0.725, p = 0.002) predicting lower levels of adolescent depression.

CONCLUSION

Our study demonstrates that there was a positive relationship between maternal mental health and adolescent mental health. Further, this study demonstrated that maternal mental health and social determinants of health are predictors of adolescent mental health and social functioning, thus indicating an inextricable connection to child well-being.

Prescribing of antipsychotics among people with recorded personality disorder in primary care: a retrospective nationwide cohort study using The Health Improvement Network primary care database

OBJECTIVES

To investigate the extent of antipsychotic prescribing to people with recorded personality disorder (PD) in UK primary care and factors associated with such prescribing.

DESIGN

Retrospective cohort study.

SETTING

General practices contributing to The Health Improvement Network UK-wide primary care database, 1 January 2000-31 December 2016.

PARTICIPANTS

46 210 people registered with participating general practices who had a record of PD in their general practice notes. 1358 (2.9%) people with missing deprivation information were excluded from regression analyses; no other missing data.

MAIN OUTCOME MEASURES

Prescriptions for antipsychotics in general practice records and length of time in receipt of antipsychotic prescriptions.

RESULTS

Of 46 210 people with recorded PD, 15 562 (34%) were ever prescribed antipsychotics. Among the subgroup of 36 875 people with recorded PD, but no recorded severe mental illness (SMI), 9208 (25%) were prescribed antipsychotics; prescribing was lower in less deprived areas (adjusted rate ratio (aRR) comparing least to most deprived quintile: 0.56, 95% CI 0.48 to 0.66, p<0.001), was higher in females (aRR:1.25, 95% CI 1.16 to 1.34, p<0.001) and with a history of adverse childhood experiences (aRR:1.44, 95% CI 1.28 to 1.56, p<0.001). Median time prescribed antipsychotics was 605 days (IQR 197-1639 days). Prescribing frequency has increased over time.

CONCLUSIONS

Contrary to current UK guidelines, antipsychotics are frequently and increasingly prescribed for extended periods to people with recorded PD, but with no history of SMI. An urgent review of clinical practice is warranted, including the effectiveness of such prescribing and the need to monitor for adverse effects, including metabolic complications.

Recognizing the importance of childhood maltreatment as a critical factor in psychiatric diagnoses, treatment, research, prevention, and education

Childhood maltreatment is the most important preventable risk factor for psychiatric disorders. Maltreated individuals typically develop psychiatric disorders at an earlier age, have a more pernicious course, more comorbidities, greater symptom severity, and respond less favorably to treatments than non-maltreated individuals with the same primary DSM-5 diagnosis. Furthermore, maltreated individuals have alterations in stress-susceptible brain regions, hypothalamic-pituitary-adrenal response, and inflammatory marker levels not discernible in their non-maltreated counterparts. Hence, maltreated and non-maltreated individuals with the same primary DSM-5 diagnoses appear to be clinically and neurobiologically distinct. The failure to embody this distinction in DSM-5 has interfered with our ability to discover novel treatments, to recommend currently available treatments most likely to be efficacious, and has been a largely unrecognized confound that has thwarted our ability to identify the biological basis for major psychiatric disorders. Incorporating this distinction into DSM will help transform this sign and symptom-based classification system to a more etiologically informed nosology. We discuss several diagnostic alternatives and recommend the inclusion of a Developmental Trauma Disorder diagnosis for severely dysregulated individuals, of all ages, with numerous comorbidities, who experienced interpersonal victimization and disruptions in attachment, such as emotional maltreatment or neglect. For less severely affected maltreated individuals, we suggest using conventional diagnostic categories, such as major depression, but with an essential modifier indicating a history of childhood maltreatment, or early life stress, to delineate the ecophenotypic variant. Implementing this strategy should improve our ability to effectively diagnose and treat individuals with psychiatric disorders and to accelerate discovery.

Altered regional brain activity and functional connectivity patterns in major depressive disorder: A function of childhood trauma or diagnosis?

Childhood trauma (CT) is a non-specific risk factor for major depressive disorder (MDD). However, the neurobiological mechanisms of MDD with CT remain unclear. In the present study, we sought to determine the specific brain regions associated with CT and MDD etiology. Fractional amplitude of low-frequency fluctuation (fALFF) and functional connectivity (FC) analyses were performed to assess alterations of intrinsic brain activity in MDD with CT, MDD without CT, healthy controls with CT, and healthy controls without CT. Two-by-two factorial analyses were performed to examine the effects of the factors "MDD" and "CT" on fALFF and FC. Moderator analysis was used to explore whether the severity of depression moderated the relationship between CT and aberrant fALFF. We found that the etiological effects of MDD and CT exhibited negative impacts on brain dysfunction including altered fALFF in the left postcentral gyrus, left lingual gyrus, left paracentral lobule (PCL), and left cuneus. Decreased FC was observed in the following regions: (i) the left lingual gyrus seed and the left fusiform gyrus as well as the right calcarine cortex; (ii) the left PCL seed and the left supplementary motor area, left calcarine cortex, left precentral gyrus, and right cuneus; (iii) the left postcentral gyrus seed and left superior parietal lobule, right postcentral gyrus, and left precentral gyrus. Furthermore, the severity of depression acted as a moderator in the relationship between CT and aberrant fALFF in the left PCL. These data indicate that MDD patients with and without trauma exposure are clinically and neurobiologically distinct.

The relationship between adverse childhood experiences, the frequency and acuity of emergency department utilization and primary care engagement

INTRODUCTION

A history of adverse child experiences (ACEs) is associated with increased high-risk adult behaviors, morbidity, mortality, and use of the emergency department. This study was designed to understand the relationship between ACEs and the characteristics of emergency department use and primary care engagement.

METHODS

An in-person survey was conducted at an academic emergency department (ED) assessing ACE score, emergency department utilization and acuity, and primary care engagement.

RESULTS

The prevalence of ACEs was 71.1% with 1+ ACE and 32.5% with 4+ ACE. ACE scores of four or more were associated with three or more ED visits in the past year compared those with an ACE score of zero (OR 3.22; p < 0.05) and when adjusted for sociodemographic factors (OR 3.22; p < 0.10). Higher ACE scores were associated with lower acuity presentations as indicated by the Emergency Severity Index before (ACE score 1 OR 3.91 p < 0.05; ACE score 2-3 OR 2.35 p < 0.05; ACE score 4+ OR 3.95 p < 0.05) and after adjustment (ACE score 1 OR 3.80 p < 0.10; ACE 2-3 OR 3.50 p < 0.10; ACE 4+ OR 4.36 p < 0.05). There was no association between ACE score and having a primary care provider (PCP), frequency of PCP visits, or PCP rating.

CONCLUSION

Higher ACE scores were associated with higher emergency department utilization and lower acuity presentations but not associated with levels of primary care engagement. Additional investigations are needed to adequately characterize the discrete causal mechanisms behind these current findings.

School age effects of Minding the Baby-An attachment-based home-visiting intervention-On parenting and child behaviors

Multiple interventions have been developed to improve the caregiver-child relationship as a buffer to the effects of early life adversity and toxic stress. However, relatively few studies have evaluated the long-term effects of these early childhood interventions, particularly on parenting and childhood behaviors. Here we describe the early school-age follow-up results of a randomized controlled trial of Minding the Baby ® (MTB), a reflective, attachment-based, trauma-informed, preventive home-visiting intervention for first-time mothers and their infants. Results indicate that mothers who participated in MTB are less likely to show impaired mentalizing compared to control mothers two to eight years after the intervention ended. Additionally, MTB mothers have lower levels of hostile and coercive parenting, and their children have lower total and externalizing problem behavior scores when compared to controls at follow-up. We discuss our findings in terms of their contribution to understanding the long-term parenting and childhood socio-emotional developmental effects of early preventive interventions for stressed populations.

Childhood adversities among students at an English University: A latent class analysis

University students routinely participate in research, including research on trauma and adversity, but the unique implications of trauma and adversity for educational and developmental outcomes for this group have received less attention. This study surveyed first year undergraduate students at an urban university located in the most ethnically diverse district in England, with the second highest poverty rate. Of 7,110 students, 858 responded; a response rate of 12%. The survey included thirteen questions about adverse events and circumstances before age 18. Four in five students (79%) reported at least one adversity, 51% reported three or more, and 20% reported at least six. Female students reported a higher mean number of adversities than men, but men were significantly more likely to report having been "attacked, stabbed, shot or robbed by threat." Where comparisons were possible, rates were higher than for the general population or for the only other UK university survey. A Latent Class Analysis produced four groupings. Besides the 'No adversity' (36%) and "Intermediate" (46%) classes, there were two "High adversity" groups, differentiated by high (12%) or moderate (6%) adversities related to cohabitation (parental separation, lived with depressed person, lived with alcohol/drug user, and lived with incarcerated person). Higher rates of adversities, and latent class membership, were related to predictions that one would not complete one's degree. Implications and next steps are discussed.

An Association of Adverse Childhood Experiences with Binge Drinking in Adulthood: Findings from a Population-Based Study

Background: Adverse childhood experiences (ACEs) are a major public health issue linked to negative health outcomes. Yet, few recent studies drawing on national data have examined the association between ACEs and binge drinking. Objective: The objective of this study was to examine the association between ACEs and binge drinking among adults in the United States and whether this association is dependent on sex. Methods: Data for this study were obtained from the 2019 Behavioral Risk Factor Surveillance System survey. An analytic sample of 41,322 adults aged 18-64 years (50.7% male) from 17 states was analyzed using binary logistic regression. The outcome variable was binge drinking, and the main explanatory variable was ACEs. Results: Of the 41,322 respondents, 21.3% engaged in binge drinking. About 30% of the respondents had no ACEs and 23.9% had four or more ACEs. In the multivariable logistic regression, we observed that sex moderated the association between ACEs and binge drinking. Odds were 1.36 times higher for females who experienced two ACEs (aOR = 1.36 p < .05, 95% CI = 1.04-1.77) and 1.58 times higher for females who experienced three ACEs (aOR = 1.58 p < .01, 95% CI = 1.17-2.12) to engage in binge drinking. Other factors associated with binge drinking include younger age, non-Hispanic White, higher income level, higher education, not being married, being overweight, and history of cigarette smoking. Conclusion: The findings of this study underscore the importance of developing sex-appropriate screening and intervention strategies to support individuals exposed to ACEs and potentially mitigate negative health outcomes later in life.

Adverse childhood experiences predict reaction to multiple sclerosis diagnosis

Objective

At the time of multiple sclerosis (MS) diagnosis, identifying those at risk for poorer health-related quality of life and emotional well-being can be a critical consideration for treatment planning. This study aimed to test whether adverse childhood experiences predict MS patients’ health-related quality of life and emotional functioning at time of diagnosis and initial course of disease.

Methods

We recruited patients at the time of new MS diagnosis to complete self-report surveys at baseline and a one-year follow-up. Questionnaires included the Adverse Childhood Experiences (ACEs), as well as the MS Knowledge Questionnaire (MSKQ), the 36-Item Short Form Health Survey (SF-36), and Self-Management Screening (SeMaS).

Results

A total of n = 31 participants recently diagnosed with relapsing remitting MS (median EDSS = 1.0, age M = 33.84 ± 8.4 years) completed the study measures. The ACEs significantly predicted health-related quality of life (SF-36) at baseline (Adjusted R² = 0.18, p = 0.011) and follow-up (Adjusted R² = 0.12, p = 0.03), baseline scores on the SeMaS Depression scale (Adjusted R² = 0.19, p = 0.008), as well as follow-up scores on the SeMaS Anxiety (Adjusted R² = 0.19, p = 0.014) and SeMaS Depression (Adjusted R² = 0.14, p = 0.036) scales. Importantly, increased ACEs scores were predictive of increased anxiety at the one-year follow-up assessment, compared to baseline.

Conclusions

Childhood adversity predicts health-related quality of life and emotional well-being at time of MS diagnosis and over the initial course of the disease. Measured using a brief screening inventory (ACEs), routine administration may be useful for identifying patients in need of increased supportive services.

A retrospective study examining the adverse effect of childhood abuse among adult psychiatric service users in Britain

The long-term effects of childhood abuse have been well studied though the effects of abuse of specific types in adult psychiatric service users are less known. This study aimed to assess the association between childhood abuse and the development of harmful social and behavioural outcomes among adult psychiatric service users. Adult psychiatric service users were accessed from secondary mental health services in South London. A retrospective analysis was conducted of a randomly selected sample of 342 mental health records. Chi-square tests and logistic regression models were used to examine associations between childhood abuse - sexual abuse, physical abuse and psychological/emotional abuse - and health and behavioural outcomes. This study identified that 109 (31.8%) psychiatric service users had some history of childhood abuse and more often presented with high-risk or severe behaviours. Sexual abuse in childhood was linked with social isolation related to loss of friends (odds ratio (OR) = 2.68, P < 0.01), risky behaviours such as binge drinking (OR = 2.15, P < 0.05) and self-harming (OR = 2.86, P < 0.01), while childhood physical abuse was associated with drug abuse in adulthood (OR = 1.88, P < 0.05). Revictimization (adult domestic violence) also impacted on service users' quality of life in terms of loss of housing (OR = 2.21, P < 0.05) and loss of friends/family contact (OR = 2.73, P < 0.01). These findings suggest childhood abuse may play an important role in shaping risk and vulnerability for mental health problems across a lifespan. In acute mental health services, the incorporation of a trauma-informed nursing care model is necessary to generate a shift in culture in the delivery of care.

Preventing Childhood Toxic Stress: Partnering With Families and Communities to Promote Relational Health

By focusing on the safe, stable, and nurturing relationships (SSNRs) that buffer adversity and build resilience, pediatric care is on the cusp of a paradigm shift that could reprioritize clinical activities, rewrite research agendas, and realign our collective advocacy. Driving this transformation are advances in developmental sciences as they inform a deeper understanding of how early life experiences, both nurturing and adverse, are biologically embedded and influence outcomes in health, education, and economic stability across the life span. This revised policy statement on childhood toxic stress acknowledges a spectrum of potential adversities and reaffirms the benefits of an ecobiodevelopmental model for understanding the childhood origins of adult-manifested disease and wellness. It also endorses a paradigm shift toward relational health because SSNRs not only buffer childhood adversity when it occurs but also promote the capacities needed to be resilient in the future. To translate this relational health framework into clinical practice, generative research, and public policy, the entire pediatric community needs to adopt a public health approach that builds relational health by partnering with families and communities. This public health approach to relational health needs to be integrated both vertically (by including primary, secondary, and tertiary preventions) and horizontally (by including public service sectors beyond health care). The American Academy of Pediatrics asserts that SSNRs are biological necessities for all children because they mitigate childhood toxic stress responses and proactively build resilience by fostering the adaptive skills needed to cope with future adversity in a healthy manner.

Developmental Antecedents of Adult Macaque Neurogenesis: Early-Life Adversity, 5-HTTLPR Polymorphisms, and Adolescent Hippocampal Volume

INTRODUCTION

Attenuated adult hippocampal neurogenesis may manifest in affective symptomatology and/or resistance to antidepressant treatment. While early-life adversity and the short variant ('s') of the serotonin transporter gene's long polymorphic region (5-HTTLPR) are suggested as interacting risk factors for affective disorders, no studies have examined whether their superposed risk effectuates neurogenic changes into adulthood. Similarly, it is not established whether reduced hippocampal volume in adolescence, variously identified as a marker and antecedent of affective disorders, anticipates diminished adult neurogenesis. We investigate these potential developmental precursors of neurogenic alterations using a bonnet macaque model.

METHODS

Twenty-five male infant bonnet macaques were randomized to stressed [variable foraging demand (VFD)] or normative [low foraging demand (LFD)] rearing protocols and genotyped for 5-HTTLPR polymorphisms. Adolescent MRI brain scans (mean age 4.2y) were available for 14 subjects. Adult-born neurons were detected post-mortem (mean age 8.6y) via immunohistochemistry targeting the microtubule protein doublecortin (DCX). Models were adjusted for age and weight.

RESULTS

A putative vulnerability group (VG) of VFD-reared 's'-carriers (all 's/l') exhibited reduced neurogenesis compared to non-VG subjects. Neurogenesis levels were positively predicted by ipsilateral hippocampal volume normalized for total brain volume, but not by contralateral or raw hippocampal volume.

LIMITATIONS

No 's'-carriers were identified in LFD-reared subjects, precluding a 2×2 factorial analysis.

CONCLUSION

The 's' allele (with adverse rearing) and low adolescent hippocampal volume portend a neurogenic deficit in adult macaques, suggesting persistent alterations in hippocampal plasticity may contribute to these developmental factors' affective risk in humans.

The impact of adverse childhood experiences on adolescent health risk indicators in a community sample

OBJECTIVE

Despite growing awareness of the high prevalence of adverse childhood experiences (ACEs) in community samples of adolescents, little work has examined the impact of ACEs on adolescence and well-being during this critical period of development. Much research has focused on retrospective reports of ACEs by adults and adult physical and mental health, finding that ACEs contribute to a range of diseases and mental health disorders in adulthood. This study examined differences in self-reported mental health, nonsuicidal self-injury, suicidality, violence, and substance use between adolescents without self-reported history of ACEs, youth with one self-reported ACE, and youth with self-reported multiple (2 or more) ACEs.

METHOD

The sample included 1,532 adolescents who completed the Youth Risk Behavior Surveillance Survey in their local high schools. By local consensus, this national survey was augmented with questions exploring prevalence of 11 commonly identified ACEs.

RESULTS

After controlling for age, gender, and race, youth with multiple ACEs reported 3 to 15 times the odds of a range of negative health experiences.

CONCLUSIONS

Findings indicate a serious burden of ACEs on adolescent social emotional well-being. This study did not include youth in out of school placements or who were not present the day the survey was given, and thus represent youth who may benefit from universal prevention and intervention programs. Universal screening of ACEs and health-related outcomes suggests that reporting multiple ACEs is strongly related to a wide range of mental health, violence, and substance use histories. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Adverse childhood experiences (ACEs) research: A bibliometric analysis of publication trends over the first 20 years

BACKGROUND

The relative health and robustness of a field of research can be approximated by assessing peer reviewed journal publication trends for articles pertinent to the field. To date, there have been no such assessments of the burgeoning research on adverse childhood experiences (ACEs).

OBJECTIVE

The overall goal of this study was to examine ACEs research trends using bibliometric methods. More specifically, we sought to describe observed publication trends of the ACEs literature from its inception in the late 1990s. We also analyzed the nature of ACEs publications with regard to key characteristics of main outcomes, levels of analysis, and populations of primary focus.

METHODS

A search was conducted using Scopus to identify English language papers on ACEs published in peer-reviewed journals between 1998 and 2018. The primary field of research was determined by having independent raters code the title of the publishing journal into distinct categories. Main research outcomes were similarly coded.

RESULTS

A total of 789 articles on ACEs appearing in 351 different academic journals were published between 1998 and 2018. There was considerable growth in the number of ACEs papers published over the past several years. General medicine and multidisciplinary research were the most frequent of 12 primary fields of research characterizing ACEs research. Of 16 primary outcomes on which ACEs research focused, the most common were mental health and physical health.

CONCLUSION

Significant growth in ACEs research over the past several years suggest the field is thriving. Observed publication trends and publication characteristics are discussed briefly.

Early childhood adversity and HPA axis activity in adulthood:The importance of considering minimal age at exposure

Early adversity (EA) modulates stress hormone secretion in mixed directions. The Accumulation Model suggests that the number of EA predicts patterns of cortisol dysregulations, while the Life Cycle Model of Stress highlights the importance of considering the timing at which EA began, given that brain regions sensitive to stress hormones follow distinct developmental trajectories. We aimed to test these two models in 85 healthy men and women, aged 21-40 years old who reported having been exposed to EA during childhood. Participants were grouped based on the number of EA events to which they were exposed during their lifespan (Accumulation Model) and the age of first exposure to EA (Life Cycle Model). Diurnal and stress-induced reactive cortisol secretion were measured in all participants. Results showed that although the number of EA was not associated with patterns of basal or reactive cortisol secretion, adults first exposed to EA between the ages of 3 and 7 - an important time window for amygdala development - showed greater cortisol awakening response and lower cortisol reactivity relative to those first exposed to EA before 3 or after 7. These results provide support for the Life Cycle Model of Stress and highlight the importance of considering minimal age at exposure to EA when assessing the effects of early adversity on patterns of cortisol secretion.

The impact of adverse childhood experiences on healthcare utilization in children

BACKGROUND

Adverse childhood experiences (ACEs) are related to long-term negative outcomes. The impact of these experiences on healthcare utilization in children has been understudied.

OBJECTIVE

To examine the impact of ACEs on children's healthcare utilization, medical diagnoses, and pharmacological treatment.

PARTICIPANTS AND SETTING

Children aged 6 months to 17 years who were screened for ACEs in the Behavioral Health Department or in primary care locations as part of an initial consultation visit and who had at least one subsequent healthcare visit during the study period were included in the study.

METHODS

Adverse childhood experiences were measured using the ACE screening questionnaire designed by Felitti et al. (1998). Data from the year following administration of the ACE screening tool were retrospectively extracted from the electronic health record.

RESULTS

Overall, 1,183 children met study inclusion criteria. Children with any reported ACEs were more likely to no show appointments (1-3 ACEs incidence rate ratio (IRR) [95 % confidence interval (CI)]: 1.40 [1.11-1.77]; 4+ ACEs IRR [95 % CI]: 1.41 [1.08-1.84]) and to use emergency services (1-3 ACEs IRR [95 % CI]: 1.24 [1.00-1.53]; 4+ ACEs: IRR [95 % CI]: 1.42 [1.11-1.81) than children with no ACEs. Those with 4+ ACEs used the telephone nurse advisor less frequently (1-3 ACEs IRR [95 % CI]: 0.67 [0.53-0.84]; 4+ ACEs IRR [95 % CI]: 0.69 [0.53-0.90]). Although ACE scores were associated with healthcare utilization, insurance status was more robustly associated with healthcare utilization than ACE score.

CONCLUSIONS

Healthcare systems may employ results from this study to adopt trauma-informed care initiatives. Ensuring that all patients have insurance may be a first step toward improving healthcare utilization.

The impact of COVID-19 on the mental health of Canadian children and youth

Children and youth flourish in environments that are predictable, safe, and structured. The COVID-19 pandemic has disrupted these protective factors making it difficult for children and youth to adapt and thrive. Pandemic-related school closures, family stress, and trauma have led to increases in mental health problems in some children and youth, an area of health that was already in crisis well before COVID-19 was declared a global pandemic. Because mental health problems early in life are associated with significant impairment across family, social, and academic domains, immediate measures are needed to mitigate the potential for long-term sequalae. Now more than ever, Canada needs a national mental health strategy that is delivered in the context in which children and youth are most easily accessible—schools. This strategy should provide coordinated care across sectors in a stepped care framework and across a full continuum of mental health supports spanning promotion, prevention, early intervention, and treatment. In parallel, we must invest in a comprehensive population-based follow-up of Statistics Canada’s Canadian Health Survey on Children and Youth so that accurate information about how the pandemic is affecting all Canadian children and youth can be obtained. It is time the Canadian government prioritizes the mental health of children and youth in its management of the pandemic and beyond.

Health care consumption and psychiatric diagnoses among adolescent girls 1 and 2 years after a first-time registered child sexual abuse experience: a cohort study in the Stockholm Region

Child sexual abuse (CSA) is a crime against human rights with severe health consequences, and suicidal actions, stress, eating disorders, and borderline disorder are common among survivors of CSA. The objective of this study was to analyze how health care consumption patterns developed among adolescent girls in the Stockholm Region, Sweden, 1 and 2 years after the first registration of CSA experience appeared in their medical record, as compared to age-matched controls without such registration. In this cohort study, number of healthcare visits, comorbidities, and prescribed drugs were collected through the Stockholm Region administrative database (VAL), for girls age 12-17 with registration of CSA experience in their medical record (n = 519) and age-matched controls (n = 4920) between 2011 and 2018. Healthcare consumption patterns remained higher among the girls with a registered CSA experience compared to the controls, both 1 and 2 years after the first CSA experience registration. Highest odds ratios (ORs) were found for suicide attempts [OR 26.38 (12.65-55.02) and 6.93 (3.48-13.49)]; stress disorders [25.97 (17.42-38.69) and 15.63 (9.82-24.88)]; psychosis [OR 19.39 (1.75-214.13) and 9.70 (1.36-68.95)], and alcohol abuse [OR 10.32 (6.48-16.44) and 6.09 (1.98-18.67)], 1 and 2 years, respectively, after the first CSA experience registration. The drug prescriptions were also significantly higher among the girls with a CSA experience registration than for the controls. The results highlight the need to systematically evaluate and develop assessment, treatment planning, and interventions offered to adolescent girls after their first CSA experience registration.

Resilience is inversely associated with self-harm behaviors among Chinese adolescents with childhood maltreatment

Background

Abundant studies have identified the association between childhood maltreatment and self-harm (SH), but little has been discussed with regard to the role of resilience in SH behaviors of adolescents who had experienced childhood maltreatment. In this study, we investigated if resilience, as well as its five dimensions, could present negative associations with presence, repetition, and severity of SH among maltreated and neglected adolescents in China.

Methods

A cross-sectional survey including 2,084 maltreated teenagers aged from 10 to 17 years was conducted in southwest China Yunnan province. The Childhood Trauma Questionnaire (CTQ), The Resilience Scale for Chinese Adolescents (RSCA), and the Modified version of Adolescents Self-Harm Scale (MASHS) were adopted to measure childhood maltreatment experiences, psychological resilience, and SH behaviors of the respondents, respectively. Binary univariate and multivariate logistic regression models were employed to discuss the associations between resilience and occurrence, repetition, severity of SH.

Results

Among the participants who met the criteria of CTQ, the prevalence rates of SH were 63.83%, 73.94%, 71.50%, 55.53%, and 58.21% for physical abuse (PA), emotional abuse (EA), sexual abuse (SA), physical neglect (PN), and emotional neglect (EN). Final regression model demonstrated that resilience was in general inversely associated with SH, repeated SH, and severe SH for all types of childhood maltreatment, with adjusted odds ratios (aORs) ranging from 0.29 (95% CI: 0.19-0.44) to 0.46 (95% CI: 0.26-0.81). Of the five dimensions of resilience, emotion regulation served as the strongest associated factor of SH among abused youths, regardless of maltreatment types. Besides, compared with those who had lower level of goal concentration and interpersonal assistance, subjects with higher resilience level reported significantly decreased risks of SH occurrence, SH repetition, and more severe SH, in adolescents who had experienced EA and PN.

Conclusions

Resilience showed inverse association with childhood maltreatment related SH in Chinese adolescents. These findings preliminarily indicated that interventions targeting on building up resilience, especially enhancing emotion regulation ability, improving goal concentration, and consolidating interpersonal assistance, could be effective in reducing SH risk, repetition, and severity in maltreated Chinese teenagers.

Introducing ACEs (Adverse Childhood Experiences) and Resilience to First-Year Medical Students

INTRODUCTION

Adverse childhood experiences (ACEs) are associated with negative mental and physical health outcomes and predictive of higher sociodemographic risk. Introducing ACEs into undergraduate medical education is key to prevention, early recognition, and intervention.

METHODS

In a 1-hour lecture, held live and viewed online, we delivered a condensed introduction to ACEs to first-year medical students. Live-classroom participants completed pre-/postsession questionnaires self-assessing their knowledge of 10 content areas on a 5-point Likert scale. We analyzed quantitative data to determine mean scores and differences. We synthesized qualitative data obtained from feedback.

RESULTS

One hundred twenty-four students, including 32 live-classroom attendees and 92 online viewers, participated in this activity. Self-assessment scores increased in all content areas measured, with a mean increase of 1.5 (p < .0001). The most significant increases occurred in identifying household dysfunction as ACEs (increase of 2.3), calculating an ACE score (increase of 2.2), differentiating between child abuse acts of commission and omission (increase of 1.9), describing resilience (increase of 1.7), and recognizing the link between ACEs and chronic medical conditions (increase of 1.4). Participants found the lecture informative, appreciating the use of the case illustrating how ACEs impact health and an interactive slide on the risks conferred by cumulative ACEs. Learners welcomed the positive message of resilience.

DISCUSSION

Introducing ACEs in medical student education is feasible. Educating the next generation of health providers on ACEs while highlighting prevention and resilience and teaching trauma-informed care is crucial. This lecture can be readily incorporated into medical student curricula.

Psychiatric Disorders in Facial Plastic Surgery

Body dysmorphic disorder and borderline personality disorder are common in esthetic practices and occur in up to 15% of patients. Operating on these patients may not only lead to dissatisfaction but may also worsen their premorbid condition and can induce negative behavior toward the practice. Preventing surgery and referring patients for cognitive therapy is essential. An adequate understanding of these conditions and the available screening tools is indispensable for all esthetic practitioners. Unrealistic emotional attribution to a facial shape, multiple procedures, a near-normal nose at the outset, childhood trauma, multiple comorbid mental conditions, and social dysfunction are red-flags to consider.

Patterns and evidence of human rights violations among US asylum seekers

BACKGROUND

Asylum seekers report exposure to human rights violations associated with a range of psychological and medical sequelae. Clinical evaluators can provide forensic evaluations that document evidence associated with their reports of persecution. The aim of this study was to characterize the forms of abuse experienced by asylum seekers, the psychological consequences of abuse, and the frequency with which clinician-evaluators found evidence that corroborated asylum seekers' reports.

METHOD

We completed a retrospective chart review of 121 asylum seekers who received pro bono medical-legal evaluations through a human rights program and analyzed data using the constant comparative method.

RESULTS

Eighty-eight percent of the clients reported experiencing multiple human rights abuses. Ninety-one percent of the clients who received psychological evaluations presented with symptoms associated with depression, anxiety, or trauma and stressor-related disorders. Clinician-evaluators found physical or psychological evidence consistent with the clients' reports in 97% of cases. Forms, perpetrators, and psychological consequences of abuse varied significantly by gender and geographic region.

DISCUSSION

Asylum seekers report diverse forms of persecution in their countries of origin that differ by gender and geographic region. Clinician-evaluators overwhelmingly found physical and psychological evidence consistent with the asylum seekers' accounts of persecution.

Repeated maternal separation causes transient reduction in BDNF expression in the medial prefrontal cortex during early brain development, affecting inhibitory neuron development

It is widely accepted that maternal separation (MS) induces stress in children and disrupts neural circuit formation during early brain development. Even though such disruption occurs transiently early in life, its influence persists after maturation, and could lead to various neurodevelopmental disorders. Our recent study revealed that repeated MS reduces the number of inhibitory neurons and synapses in the medial prefrontal cortex (mPFC) and causes mPFC-related social deficits after maturation. However, how MS impedes mPFC development during early brain development remains poorly understood. Here, we focused on brain-derived neurotrophic factor (BDNF) involved in the development of inhibitory neurons, and examined time-dependent BDNF expression in the mPFC during the pre-weaning period in male rats exposed to MS. Our results show that MS attenuates BDNF expression only around the end of the first postnatal week. Likewise, mRNA expression of activity-regulated cytoskeleton-associated protein (Arc), an immediate-early gene whose expression is partly regulated by BDNF, also decreased in the MS group along with the reduction in BDNF expression. On the contrary, mRNA expression of tropomyosin-related kinase B (TrkB), which is a BDNF receptor, was scarcely altered, while its protein expression decreased in the MS group only during the weaning period. In addition, MS reduced mRNA levels of glutamic acid decarboxylase (GAD) 65, a GABA synthesizing enzyme, only during the weaning period. Our results suggest that repeated MS temporarily attenuates BDNF signaling in the mPFC during early brain development. BDNF plays a crucial role in the development of inhibitory neurons; therefore, transient attenuation of BDNF signaling may cause delays in GABAergic neuron development in the mPFC.

Universal Trauma Screening in an Adult Behavioral Health Setting

PURPOSE/OBJECTIVES

The Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (PCL-5) with Criterion A was universally used in admission screening to pilot a trauma-informed care process for quality improvement.

DESCRIPTION OF THE PROJECT

All adult inpatient behavioral health patients at a Mid-Atlantic county hospital were screened for trauma exposure on admission. Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition with Criterion A was provided to all adults admitted to a 27-bed inpatient behavioral health unit for 8 weeks. Quantitative descriptive statistics were calculated based on self-report PCL-5 scores; qualitative data were gathered from staff and stakeholders.

OUTCOME

During the pilot period, there was a 49.2% response rate. Fifty respondents (53.8%) screened positive for trauma as recorded on the Criterion A portion. Seventeen (18.3%) were negative for trauma self-report, and 26 (30.0%) did not complete this portion. Fifty-six (60.2%) completed screens scored 33 or greater on the PCL-5 portion. Staff found the timing of administration convenient but expressed concern over emotional cost to patient.

CONCLUSIONS

Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition with Criterion A served as guidepost for trauma-informed assessment, treatment, and referrals. Future considerations may include timing of presentation to patient, electronic translation of the tool to facilitate interdisciplinary collaboration, and tracking of screening completion.

Non-invasive vagal nerve stimulation decreases brain activity during trauma scripts

Background:

Traumatic stress can have lasting effects on neurobiology and result in psychiatric conditions such as posttraumatic stress disorder (PTSD). We hypothesize that non-invasive cervical vagal nerve stimulation (nVNS) may alleviate trauma symptoms by reducing stress sympathetic reactivity. This study examined how nVNS alters neural responses to personalized traumatic scripts.

Methods:

Nineteen participants who had experienced trauma but did not have the diagnosis of PTSD completed this double-blind sham-controlled study. In three sequential time blocks, personalized traumatic scripts were presented to participants immediately followed by either sham stimulation (n = 8; 0–14 V, 0.2 Hz, pulse width = 5s) or active nVNS (n = 11; 0–30 V, 25 Hz, pulse width = 40 ms). Brain activity during traumatic scripts was assessed using High Resolution Positron Emission Tomography (HR-PET) with radiolabeled water to measure brain blood flow.

Results:

Traumatic scripts resulted in significant activations within the bilateral medial and orbital prefrontal cortex, premotor cortex, anterior cingulate, thalamus, insula, hippocampus, right amygdala, and right putamen. Greater activation was observed during sham stimulation compared to nVNS within the bilateral prefrontal and orbitofrontal cortex, premotor cortex, temporal lobe, parahippocampal gyrus, insula, and left anterior cingulate. During the first exposure to the trauma scripts, greater activations were found in the motor cortices and ventral visual stream whereas prefrontal cortex and anterior cingulate activations were more predominant with later script presentations for those subjects receiving sham stimulation.

Conclusion:

nVNS decreases neural reactivity to an emotional stressor in limbic and other brain areas involved in stress, with changes over repeated exposures suggesting a shift from scene appraisal to cognitively processing the emotional event.

Social Defeat Stress in Adolescent Mice Induces Depressive-like Behaviors with Reduced Oligodendrogenesis

Strong stress related to adverse experiences during adolescence can cause mental disorders, as well as affecting brain structure and function. However, the underlying neurobiological mechanisms remain largely unknown. To investigate whether stress induced by adverse experience during adolescence affects oligodendrocyte (OL) remodeling, social defeat stress was applied to 6-week-old adolescent mice for 10 days, followed by behavioral tests and assessments of oligodendrogenesis. Socially defeated mice showed depressive-like behaviors in behavioral experiments. Stress led to a decrease in the number of newly born OLs in the anterior cortical region and the number of proteolipid protein-positive mature OLs in the corpus callosum and posterior cerebral cortex. Fewer bromodeoxyuridine-incorporated CC1-positive mature OLs were observed in these regions in socially defeated mice. To assess whether decreased oligodendrogenesis caused by social defeat stress is related to depressive-like symptoms under stress, clemastine, a drug that induces OL generation, was administered to socially defeated adolescent mice, resulting in the rescue of the behavioral abnormalities accompanied by increased oligodendrogenesis. These findings suggest that oligodendrogenesis in adverse environments during adolescence plays a role in psychiatric disorders, and clemastine may provide a potential therapeutic drug for adolescent mental disorders, targeting OLs.

The Prevalence and Consequences of Adverse Childhood Experiences in the German Population

BACKGROUND

Multiple studies have shown a link between cumulative adverse experiences in childhood and a wide variety of psychosocial problems in later life. There have not been any pertinent representative studies of the German population until now. The goal of this study is to determine the frequency of adverse childhood experiences (ACE), the extent to which they manifest themselves in patterns of co-occurrence, and their possible connection to psychosocial abnormalities in the German population.

METHODS

2531 persons (55.4% female) aged 14 years and up (mean [M] = 48.6 years, standard deviation [SD] = 18) were retro- spectively studied for ACE and psychosocial abnormalities by means of the Patient Health Questionnaire-4 (PHQ-4) and further questions on aggressiveness and life satisfaction. The frequency of ACE and their cumulative occurrence were analyzed in de- scriptive terms. Patterns of simultaneously occurring types of ACE were studied with latent class analysis. Associations between ACE and psychosocial abnormalities were tested with logistic regression analyses.

RESULTS

43.7% of the respondents reported at least one ACE; 8.9% reported four or more. The most commonly reported ones were parental separation and divorce (19.4%), alcohol consumption and drug abuse in the family (16.7%), emotional neglect (13.4%), and emotional abuse (12.5%). Four ACE patterns were identified by latent class analysis: no/minimal ACE, household dysfunction, child maltreatment, and multiple ACE. In the cumulative model, the high-risk group with four or more ACE displayed a significantly elevated risk for depressiveness (odds ratio [OR] = 7.8), anxiety (OR = 7.1), physical aggressiveness (OR = 10.5), and impaired life satisfaction (OR = 5.1).

CONCLUSION

Adverse childhood experiences are common, and their cumulation is associated with markedly increased negative sequelae for the affected persons. Preventive approaches are needed that extend beyond the area of child maltreatment alone and address other problems in the parental home, such as mental illness in the parents. Data acquisition by self-reporting is a limitation of this study.

Parenting stress and family resilience affect the association of adverse childhood experiences with children's mental health and attention-deficit/hyperactivity disorder

INTRODUCTION

Exposure to adverse childhood experience (ACE) has harmful consequences for children's health and well-being. However, it is less clear how different social processes may amplify or mitigate the effects of ACE on children's mental health. We examined how parenting stress mediates and family resilience moderates the associations of ACE with children's mental health and attention-deficit/hyperactivity disorder (ADHD) outcomes.

METHODS

This secondary data analysis included 44,684 children aged 6-17 years from the 2016-17 National Survey of Children's Health (NSCH). Logistic regression with survey weights was used to account for the complex survey design and obtain odds ratios (OR) and 95% CI adjusted for sociodemographics.

RESULTS

Overall, 7.3% of children had any mental health condition and 10.4% had ADHD. A higher ACE score (per 1-unit increase) was associated with a higher prevalence of any mental health condition (OR = 1.33, 95% CI: 1.27-1.40) and ADHD (OR = 1.21; 95% CI: 1.15-1.27) after adjustment for sociodemographics. Parenting stress mediated 57% of the total effect of ACE on any mental health condition and 60% of the total effect of ACE on ADHD diagnosis. The effect of ACE on mental health and ADHD outcomes was stronger among children with low levels of family resilience and connection index (FRCI) than among those with higher levels of FRCI.

CONCLUSIONS

Parenting stress may be a potential mechanism through which ACE impacts a child's mental health and behavioral outcomes. Family resilience can lessen the impact of ACE on children's mental health and behavioral disorders.

Confirmatory factor analysis of adverse childhood experiences (ACEs) among a community-based sample of parents and adolescents

Background

Despite increased understanding of Adverse Childhood Experiences (ACEs), very little advancement has been made in how ACEs are defined and conceptualized. The current objectives were to determine: 1) how well a theoretically-derived ACEs model fit the data, and 2) the association of all ACEs and the ACEs factors with poor self-rated mental and physical health.

Methods

Data were obtained from the Well-Being and Experiences Study, survey data of adolescents aged 14 to 17 years (n = 1002) and their parents (n = 1000) in Manitoba, Canada collected from 2017 to 2018. Statistical methods included confirmatory factor analysis (CFA) and logistic regression models.

Results

The study findings indicated a two-factor solution for both the adolescent and parent sample as follows: a) child maltreatment and peer victimization and b) household challenges factors, provided the best fit to the data. All original and expanded ACEs loaded on one of these two factors and all individual ACEs were associated with either poor self-rated mental health, physical health or both in unadjusted models and with the majority of findings remaining statistically significant in adjusted models (Adjusted Odds Ratios ranged from 1.16–3.25 among parents and 1.12–8.02 among adolescents). Additionally, both factors were associated with poor mental and physical health.

Conclusions

Findings confirm a two-factor structure (i.e., 1) child maltreatment and peer victimization and 2) household challenges) and indicate that the ACEs list should include original ACEs (i.e., physical abuse, sexual abuse, emotional abuse, emotional neglect, physical neglect, exposure to intimate partner violence (IPV), household substance use, household mental health problems, parental separation or divorce, parental problems with police) and expanded ACEs (i.e., spanking, peer victimization, household gambling problems, foster care placement or child protective organization (CPO) contact, poverty, and neighborhood safety).