Foundations for screening adverse childhood experiences: Exploring patterns of exposure through infancy and toddlerhood

Risks of adverse childhood experiences on healthcare utilization and outcomes in early childhood

BACKGROUND

The American Academy of Pediatrics recommends all pediatricians to be ready to implement trauma-informed care, including the mitigation of impacts of Adverse Childhood Experiences (ACEs) through screening and identification of at-risk population. Reliable survey tools and knowledge of the consequences of ACEs are needed.

OBJECTIVE

This study examines the healthcare utilization and diagnoses captured in insurance claims in association with the number of ACEs recorded by the Family Map Inventories (FMI). The FMI offers a comprehensive family assessment, which includes child ACEs (FMI-ACEs) using prospective, proxy risk indicators.

PARTICIPANTS AND SETTING

Low-income families (N = 1647) with children aged three to five years who completed the FMI were linked to their insurance records.

METHODS

Multivariable logistic and generalized linear regression models were fitted to explore the association between the number of ACEs (FMI-ACEs scores) and healthcare utilization and health outcomes.

RESULTS

Children were exposed at rates of 32.4 % to zero, 31.7 % to one, 19.7 % to two, and 16.3 % to three or more ACEs. The FMI-ACEs scores were associated with greater use of non-preventive outpatient visits, filled prescriptions, and overall use of healthcare. Incidences of adjustment disorders were 4 times and attention-deficit conducts were 2 times higher among children with the highest FMI-ACEs scores than those with zero FMI-ACEs.

CONCLUSIONS

This study marks the first effort to conduct insurance claims data review to ascertain association between a survey measure of ACEs and health utilization and diagnosed conditions. The association of ACEs risk screening and healthcare utilization and diagnoses was observed.

Promoting Temporal Investigations of Development in Context: a Systematic Review of Longitudinal Research Linking Childhood Circumstances and Learning-related Outcomes

Children’s learning and cognitive development have a distinct receptivity to the circumstances of childhood. However, not all children have equal opportunities and learning inequities continue to be influenced by the social and economic circumstances of childhood. Examining factors within the environments that children are growing up in, and the associations of these factors with learning, can help to identify leverage points for change, enabling more children to be supported to reach their potential. Specifically, turning attention to the timing and duration of exposure to specific social and economic factors across childhood can provide essential details to determine who is most susceptible to contextual effects and at what ages. This paper presents a systematic review of 75 longitudinal studies of families and children carried out between 2000 and 2021. These studies tracked social and economic circumstances between pregnancy and early adolescence in relation to educational and cognitive outcomes across the lifespan. The results of the included studies were examined and grouped into themes using reflexive thematic analysis. The findings largely suggest that the degree to which educational and cognitive outcomes are affected by specific social and economic circumstances depends on the duration, timing, and mobility across childhood. In particular, findings relating to the developmental timing of exposure, as well as persistent exposure, revealed distinct evidence of the effects of temporality. These findings provide detail into how much and in what instances temporality should be considered—results which can be used to inform avenues for reducing learning disparities.

Adverse Childhood Experiences and Adolescent Delinquency: A Theoretically Informed Investigation of Mediators during Middle Childhood

OBJECTIVE

The purposes of this study are twofold. First, we explore the associations between cumulative ACEs at ages 5 and 7 and delinquency at age 14 in a national sample of youth in the United Kingdom (UK). Second, we explore the role of five theoretically relevant mediators in explaining this relationship.

METHODS

Analyses were based on data from the UK Millennium Cohort Study-a prospective, longitudinal birth-cohort study of more than 18,000 individuals in the United Kingdom.

RESULTS

The results indicate that early ACEs are significantly associated with adolescent delinquency, with effects becoming significantly larger as ACEs accumulate. Findings also reveal that child property delinquency, substance use, low self-control, unstructured socializing, and parent-child attachment at age 11 all significantly mediate the relationship between early ACEs and delinquency in adolescence, with early delinquency and low self-control emerging as the most robust mediators.

CONCLUSIONS

Findings point to a need for early ACEs screening and a Trauma-Informed Health Care (TIC) approach in early delinquency prevention efforts. Early intervention efforts that bolster child self-control and curtail early-onset problem behaviors may also disrupt pathways from ACEs to adolescent delinquency.

Evolving Our Understanding: Housing Instability as an ACE for Young Children

We investigated the conceptualization and impact of adverse childhood experiences (ACEs) in a sample of 231 children ages 3-5 living in poverty and experiencing homelessness, focusing specifically on caregiver well-being and housing instability. Data was collected using the Neurodevelopmental Ecological Screening Tool (NEST), which screens for developmental risk and resilience across three domains (neurodevelopmental, caregiver, and environment). We used structural equation modelling (SEM) to test the association between domains and ACE scores and assessed the impact on neurodevelopmental constructs. Fifty-five percent of the sample had high ACE scores (> 3), which were associated with lower attention, social skills, and emotional regulation. ACEs were strongly associated with 0.17 standard deviation units of higher levels of caregiver distress (p < .001), which was also associated with 0.26 standard deviation units of lower levels of child neurodevelopmental functioning (p = .001). For each unit increase in housing instability, there was a three-fourths increase in ACE (0.78 ACE at p = .004); four or more moves were associated with the worst neurodevelopmental outcomes (53% of the sample). We must use an ecological, developmental lens to understand how early adversity impacts children, at what age, and in what context. Housing stability plays a critical role in developmental well-being and should be accounted for in conceptualizations of child ACE scales. Caregiver and child relationships are reciprocal, and so the impacts of ACEs are also bidirectional. Our policies and practices at individual, community, and systemic levels should account for these dynamics to improve child well-being.

Maternal care and child physical health: Impact of the exposure to adverse experiences during the first year of life of vulnerable children

INTRODUCTION

Adverse childhood experiences (ACEs) can negatively affect children's current and future health.

OBJECTIVES

This study aims to analyse the impact of ACE on the health of 12-month-old infants assessed by a Physical Health and Maternal Care Indicator (ISCM).

METHODS

We conducted a retrospective cohort including 170 infants born in two public services for high-risk births in Brazil. ISCM gathers information that reflects maternal care and the child's health throughout the first year of life, such as vaccination, nutrition, growth, illnesses and accidents. The ACE impact on ISCM was analysed by multiple linear regression, and the d-Cohen test estimated its effect size. Spearman's correlation was used to analyse the cumulative ACE effect, measured by a score reflecting events such as family dysfunction, maternal mental health, poverty and exposure to violence.

RESULTS

Most infants were born prematurely (71.7%), had low birthweight (64.7%) and were exposed to three ACEs on average. The ISCM was lower in children exposed to maternal depression (P < 0.001, d-Cohen = 0.08), substance abuse by family members (P = 0.02, d-Cohen = 0.6) and marital conflicts (P = 0.03, d-Cohen = 0.7). The Spearman's correlation showed that the greater the exposure to ACEs, the lower the ISCM (r = -0.40, P < 0.0001).

CONCLUSION

Exposure to ACE, especially in the family environment, had negative effect on maternal care and child health. The impact could be detected in the first year of life and had cumulative effect. Our findings indicate the need for a broader approach to child health to minimize ACE's impacts.

Adversity in early childhood: Long-term effects on early academic skills

BACKGROUND

The dimensional adversity model (McLaughlin & Sheridan, 2016) proposes that deprivation and threat affect child development differently. However, empirical support for the dimensional adversity model stems predominately from adolescent samples.

OBJECTIVE

We aimed to examine if deprivation and threat experiences in infancy have differential effects on pre-academic skills in early childhood. Furthermore, we addressed the effect of chronic vs. temporary adversity exposure in infancy.

PARTICIPANTS AND SETTING

The population-based sample consisted of 3481 infants (49% girls). New-borns and their families were followed longitudinally (6 months to 6 years of age).

METHODS

Based on parental information, we computed four deprivation variables and three threat variables. Pre-academic cognitive and social-emotional skills were measured with a math and a vocabulary test and parental questionnaires on emotion regulation and behavioral problems.

RESULTS

Results showed that infant deprivation (but not threat) is negatively associated with math scores (β = -0.06) and language skills (β = -0.04) in kindergarten. However, infant threat and deprivation were both associated with behavioral problems (β = 0.06; β = 0.04) and emotion-regulation difficulties (β = 0.04; β = 0.03) in kindergarten. Analyses comparing chronic vs. temporary adversity exposure showed that chronic exposure was strongly related to all cognitive and social-emotional outcomes.

CONCLUSIONS

We found partial support for the differential effects of deprivation and threat on pre-academic skills. Furthermore, the results suggest that particularly chronic adversity poses a potential risk for development - across domains of cognition and emotions.

Screening for Adverse Childhood Experiences in Children: A Systematic Review

CONTEXT

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

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

RESULTS

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

LIMITATIONS

There are few published control trials of moderate quality.

CONCLUSIONS

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

Sleep as a Moderator of Young Children's Traumatic Stress and Behavior Problems: a Treatment-Referred Sample

Empirical evidence suggests young children who have experienced trauma are at risk of developing sleep problems and behavior difficulties, but it is unclear of the specific relation between these behavioral health concerns. The primary purpose of the study is to determine whether sleep problems moderate the relation between traumatic stress and behavior problems in a sample of young children referred for treatment. A secondary purpose is to explore if sleep problems also moderate the relation between specific domains of traumatic stress (i.e., intrusion, avoidance, arousal) and behavior problems. Data from 170 preschoolers ages 3 through 5 referred for treatment were gathered at intake and utilized in this study. Results indicate sleep problems moderate the effect of overall traumatic stress on behavior problems. This statistical finding also was found with intrusive symptoms, and the moderation analyses approached significance with avoidance and arousal. Our findings highlight the importance for clinicians to assess for sleep problems when young children who have experienced trauma are referred to them for treatment, particularly if a low level of overall traumatic stress is present.

Exploring maternal adversity and childhood outcomes among low-income rural families

BACKGROUND

Research has linked adversity among mothers to poorer outcomes among their offspring. However, additional inquiry is warranted particularly in rural communities where risk factors for adversity are prevalent.

OBJECTIVE

This study had two objectives: (1) to describe and compare relationships between individual and cumulative maternal adversity with childhood outcomes; and, (2) to determine if mother-child attachment mediated the relationship between maternal adversity and childhood outcomes.

PARTICIPANTS AND SETTING

A convenient sample of 140 women with low socio-economic status (SES) were recruited through Head Start programs in the rural Midwest.

METHODS

Data was gathered using a survey comprised of multiple measures to assess maternal adversity and childhood outcomes (i.e. behavior and attachment). Data were analyzed in SPSS using bivariate and multivariate analyses, including stepwise regression.

RESULTS

Nearly 80 % of respondents experienced at least one adverse childhood experience (ACE) and 48 % reported having one or more traumatic experiences. Higher levels of adversity were associated with increased attention problems, increased emotional reactivity, and decreased harmonious attachment (p < .05, d = 0.37-0.38). Maternal experiences of childhood physical abuse and sexual abuse, as well as witnessing trauma, significantly predicted childhood outcomes, however, the variance accounted for by each type of adversity was small (4%-6%). Maternal adversity was unrelated to mother-child attachment.

CONCLUSIONS

Low-SES mothers in rural communities have significant histories of adversity. It is important to consider individual and cumulative adverse experiences, as well as the mother's perception of events as traumatic. Factors associated with rural communities and Head Start programming, as well as implications for research and practice surrounding maternal adversity and childhood outcomes, are discussed.

Prebirth Household Challenges To Predict Adverse Childhood Experiences Score by Age 3

OBJECTIVES

With this study, we seek to understand the relationship between prebirth household challenges and the child's adverse childhood experiences (ACEs) score by age 3 in a statewide-representative birth cohort to inform primary prevention strategies.

METHODS

We used a longitudinally linked data set from the Alaska 2009-2011 Pregnancy Risk Assessment Monitoring System, its 3-year follow-up survey, and multiple administrative data sources. Using this linked data set, we predicted an expanded ACEs score by age 3 using maternal reported prebirth household challenges.

RESULTS

The number of household challenges reported during the 12 months before or during pregnancy predicted ACEs score in a graded, dose-response manner. On average, reporting 4+ prebirth household challenges was associated with an ACEs score 4.1 times that of those reporting 0 challenges. Homelessness was associated with the greatest increase in ACEs score (relative rate ratio = 3.0). Prebirth household challenges that were independently associated with an elevated ACEs score in our final model included problems paying bills, someone close to the mother having a drinking and/or drug problem, homelessness, mother or husband or partner being in jail, husband or partner losing job, separation or divorce, and being checked or treated for anxiety or depression.

CONCLUSIONS

The accumulation and certain prebirth household challenges are strongly associated with the accumulation of childhood ACEs. Addressing and reducing household challenges during the prebirth period may serve as a primary point of ACEs prevention. Many evidence-based, multidisciplinary intervention strategies can and should be implemented in the prebirth period to strengthen the household unit before the introduction of a new child.

Resetting Policies to End Family Homelessness

Homelessness is a devastating experience for children and their families. Families, the majority of whose members are children, now comprise more than one-third of the overall US homeless population. Most of these children are less than six years old. Various assumptions have driven policy and the allocation of resources to programs serving these families. Although decades of research and field experience suggest strategies for preventing and reducing this problem, perspectives differ, hindering the development of effective solutions. In this article, we explore some of these assumptions, including (a) definitions of homelessness used to count the numbers of families and determine resource allocation, (b) the needs of children and responses to the impact of adverse childhood experiences, and (c) whether services matter and should be integrated with affordable housing. We conclude by suggesting various directions to ensure that these children are protected and have the opportunity to grow and thrive.

Adverse Childhood Experiences of Urban and Rural Preschool Children in Poverty

Adverse childhood experiences (ACEs) have long-term health consequences. Young children in the southern part of the United States (US) are at greater risk than children in other parts of the US. This study assessed preschool children ACEs using a family-friendly tool, the Family Map (FMI), and compared children living in rural/urban areas while examining the potential moderation of race. The FMI–ACE score was examined as a total and two sub-scores. We found that race did not moderate the FMI–ACE score but that Black children (Cohen’s d = 0.52) and children in urban and large rural areas were at highest risk (Cohen’s d = 0.38). However, the subscale FMI–ACEs parenting risk was moderated by race such as that Black children were less at risk in rural areas than urban (Cohen’s d = 0.62). For FMI–ACEs environmental risk, race moderated risk such that Black children were most at risk in large rural areas but less so in small rural areas (Cohen’s d = 0.21). Hispanic children were most at risk in small rural areas and least in large rural environments. Findings from this study suggest that targeting the most at-risk children for interventions should consider the context including race and location.

Measuring Adverse Child Experiences Among Young Adolescents Globally: Relationships With Depressive Symptoms and Violence Perpetration

PURPOSE

The purpose of the study was to develop a measure of ACEs applicable for young adolescents in low- and middle-income countries (ACEs) and to analyze the relationships of ACEs against two outcomes: depressive symptoms and violence perpetration. There is a paucity of research on the consequences of adverse child experiences (ACEs) on adolescent health and behavior from low- and middle-income countries and virtually no multinational studies.

METHODS

As part of the Global Early Adolescent Study, an 11-item measure of ACEs was developed and piloted with 1,284 adolescents aged 10-14 years in 14 urban communities in an equal number of countries. With one exception where interviewers were used, data were self-reported anonymously using tablets. Results compared a summative ACEs index score and latent class analysis.

RESULTS

Findings show high rates of ACEs exposure experienced by young adolescents in resource-poor neighborhoods in low- and middle-income countries; disproportionate exposures of boys and strong associations between ACEs and both depressive symptoms and violence perpetration. Latent class analysis provided modest refinement over a summed ACEs score.

CONCLUSION

While interventions tend to focus on behavioral outcomes, evidence suggests that ACEs exposure is a strong antecedent related to both depressive symptoms and violence perpetration.

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.

Adverse experiences in infancy and toddlerhood: Relations to adaptive behavior and academic status in middle childhood

Findings from the Adverse Childhood Experiences (ACE) study articulated the negative effects of childhood trauma on long-term well-being. The purpose of the current study is to examine the associations between ACEs experienced in infancy and toddlerhood and adaptive behavior and academic status in middle childhood. We used data collected from a sample of low-income families during the impacts study of Early Head Start (EHS). Data were collected by trained interviewers demonstrating at least 85% reliability with protocols. Data come from 1469 socio-demographically diverse mothers and children collected at or near ages 1, 2, 3, and 11. At ages 1, 2, and 3, an EHS-ACEs index was created based on interview and observation items. The EHS-ACEs indices were averaged to represent exposure across infancy and toddlerhood. At age 11, parents were asked about school outcomes and completed the Child Behavior Checklist. Across development, children were exposed to zero (19%), one (31%), two (27%), and three or more ACEs (23%). Logistic regression analyses, controlling for EHS program assignment, and parent, school, and child characteristics, showed ACEs were significantly associated with parental report of the child: having an individualized educational program since starting school and in the current school year, having been retained a grade in school, and problems with externalizing and internalizing behavior, as well as attention. Findings suggest that ACEs influence children's behavioral and academic outcomes early in development.

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

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