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

Resilience and mental health among perinatal women: a systematic review

Objective

This review aimed to assess the current evidence on the relationship between resilience and mental health employed in response to the impacts of mental health.

Method

This review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA). The protocol of this review was registered on the International Prospective Register of Systematic Reviews (PROSPERO: CRD42023470966). Three authors searched peer-reviewed articles using several electronic databases, including Scopus, PubMed/MEDLINE, Psych Info, EMBASE, and Web of Science, from September to October 2023 and included all the studies from any time until November 1, 2023. The review included all eligible quantitative observational and qualitative studies, irrespective of geographical boundaries.

Result

Depression, anxiety, and post-traumatic stress disorders were found to be the most common, but not the only, mental health disorders during the perinatal period, and higher maternal resilience during perinatal periods was found to reduce mental health disorders. It was also found that pregnant women were more resilient to mental health disorders than postpartum women. Tolerance of uncertainty and a positive cognitive appraisal, women's self-behavior and family functioning, and protective psychosocial resources such as dispositional optimism, parental sense of mastery, self-esteem, gratitude, and forgiveness were found to be the most common mechanisms of resilience among perinatal women. Older age, having an adolescent partner, family income, and distress were found to affect resilience.

Conclusion

Noting that women's resilience is an important tool to prevent perinatal mental health disorders, maternal healthcare providers need to counsel perinatal women on resilience-boosting mechanisms, such as applying self-behavior and having social support or close family relationships. It is recommended to counsel or provide psychosocial interventions for the woman's companion or partner to give strong support for the woman in each of the perinatal periods.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=470966, identifier CRD42023470966.

Patient and Caregiver Perspectives on Implementation of ACE Screening in Pediatric Care Settings: A Qualitative Evaluation

INTRODUCTION

This qualitative research study explored the perspectives of adolescents, 12 to 19-years-old, and caregivers of children under 12-years-old on the acceptibility of adverse childhood experiences (ACEs) screenings in five pediatric clinics.

METHOD

A constructivist grounded theory approach was utilized. One-on-one semistructured phone interviews were conducted with 44 adolescents and 95 caregivers of children less than 12 years old. Interviews were analyzed using thematic analysis.

RESULTS

Most participants reported feeling comfortable discussing ACEs with their providers. Some reported that screening helped build trust. Others expressed privacy concerns and did not receive information about the reason for screening. Adolescent patients shared conflicting feelings-of both comfort and discomfort. Caregivers attending to multiple children, foster parents, and monolingual Spanish speakers disclosed unique challenges to ACEs screening. We found no evidence of lasting adverse effects.

DISCUSSION

Participants generally found ACEs screenings acceptable. Some adolescents identified benefits from the experience. However, clinics planning to adopt routine ACEs screening should ensure clear messaging on why screening is occurring, anticipate and address privacy concerns, and adopt workflows to discuss screening results.

Clinician and Staff Perspectives on Implementing Adverse Childhood Experience (ACE) Screening in Los Angeles County Pediatric Clinics

PURPOSE

To understand clinician and clinical staff perspectives on the implementation of routine Adverse Childhood Experience (ACE) screening in pediatric primary care.

METHODS

We conducted a qualitative evaluation in 5 clinics in Los Angeles County, California, using 2 rounds of focus group discussions: during an early phase of the initiative, and 7 months later. In the first round, we conducted 14 focus group discussions with 67 participants. In the second round, we conducted 12 focus group discussions with 58 participants. Participants comprised clinic staff involved in ACE screening, including frontline staff that administer the screening, medical clinicians that use screening to counsel patients and make referrals, and psychosocial support staff who may receive referrals.

RESULTS

Themes were grouped into 3 categories: (1) screening acceptability and perceived utility, (2) implementation and quality improvement, and (3) effects of screening on patients and clinicians. Regarding screening acceptability and perceived utility, clinicians generally considered ACE screening to be acceptable and useful. In terms of implementation and quality improvement, significant barriers included: insufficient time for screening and response, insufficient training, and lack of clarity about referral networks and resources that could be offered to patients. Lastly, regarding effects of screening, clinicians expressed that ACE screening helped elicit important patient information and build trust with patients. Further, no adverse events were reported from screening.

CONCLUSIONS

Clinic staff felt ACE screening was feasible, acceptable, and beneficial within pediatric care settings to improve trauma-informed care and that ACE screening could be strengthened by addressing time constraints and limited referral resources.

Patient navigation models for mental health of parents expecting or caring for an infant or young child: A systematic review

Patient navigation (PN) aims to improve timely access to healthcare by helping patients to "navigate" complex service provision landscapes. PN models have been applied in diverse healthcare settings including perinatal mental health (PMH). However, the practice models and implementation of PN programs vary widely, and their impact on engagement with PMH services has not been systematically investigated. This systematic narrative review study aimed to (1) identify and describe existing PMH PN models, (2) understand their effectiveness in improving service engagement and clinical outcomes, (3) review patient and provider perceptions, and (4) explore facilitators and barriers to program success. A systematic search of published articles/reports describing PMH PN programs/service delivery models targeting parents in the period from conception to 5 years postpartum was conducted. In total, 19 articles describing 13 programs were identified. The analysis yielded a number of commonalities and differences across program settings, target populations, and the scope of the navigator role. While there was promising evidence to support the clinical efficacy and impact on service utilization of PN programs for PMH, the current evidence base is sparse. Further research evaluating the efficacy of such services, and facilitators and barriers to their success, is warranted.

Assessment of Screening for Adverse Childhood Experiences and Receipt of Behavioral Health Services Among Children and Adolescents

IMPORTANCE

Screening for adverse childhood experiences (ACEs) in primary care settings has been increasing as a response to the overwhelming and consistent evidence of the deleterious associations between ACEs and later physical and mental health. However, there is little empirical guidance on the appropriate implementation of ACEs screening in pediatric primary care.

OBJECTIVE

To test the use of a pilot intervention for ACEs screening and referral on the receipt of behavioral health care for children and adolescents within a large integrated health care delivery system.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study was conducted in a large integrated health care system serving Southern California. Child and adolescent members of the target health care system younger than 18 years between July 1, 2018, and November 30, 2021, who received a positive screening for ACEs at the pilot clinic were included. This pilot clinic implemented an intervention that included additional screening questions and incorporated social workers into the process of evaluation and referral for behavioral health needs following ACEs screening.

EXPOSURES

ACEs screening.

MAIN OUTCOMES AND MEASURES

Visit to a behavioral health care service within 90 days of a positive ACEs screen determined as a score of 1 or higher and behavioral symptoms.

RESULTS

The cohort consisted of 4030 children (mean [SD] age, 9.94 [4.55] years) with positive ACEs screening, 48% adolescents (11-17.99 years), approximately equal gender (51% females), 73% Hispanic, and 33% with Medicaid insurance. After the intervention, children were more likely to have a behavioral health services visit within 90 days of the screening than before the intervention (from 4.33% to 32.48%; incidence rate ratio, 7.50; 95% CI, 1.55-36.2).

CONCLUSIONS AND RELEVANCE

In this cohort study, the implementation of a new ACEs screening and referral process was associated with increased receipt of behavioral health services among children with a positive ACEs screening. This could be useful strategy for other health care systems responding to state and local mandates to screen and provide care for children with ACEs.

Clinical Application of a Peer Coaching Intervention to Enhance Self-Management for Adolescents and Young Adults With Inflammatory Bowel Disease

Objective

The purpose of this article is to characterize the current evidence base related to peer support interventions for adolescents and young adults (AYAs) with inflammatory bowel disease (IBD) and to describe a peer support program to enhance self-management for AYAs with IBD through a case study. There is strong theory and compelling evidence suggesting that AYAs with IBD could benefit from and are interested in receiving peer support to enhance self-management; however, literature on peer support interventions for AYAs with IBD is lacking.

Methods

This study (a) presents a topical review describing qualitative factors AYAs with IBD would seek in a peer support program as well as existing peer support programs for this population, (b) presents an innovative one-to-one peer support program targeting self-management through a case study, and (c) discusses clinical implications and directions for future research.

Results

Peer support offers a promising approach for AYAs with IBD that is feasible and acceptable to patient populations. However, results from the present topical review identified only two studies that examined peer support interventions for AYAs with IBD. The case study demonstrates how a theoretically driven program uses peer support to promote self-management and adaptive behavioral change.

Conclusions

The paucity of literature in this area reveals a critical opportunity for future research and clinical programming to improve existing practices by leveraging peer support. We present the application of an innovative mobile-based peer coaching intervention that has the potential to support AYAs with IBD in their self-management.

Does screening or routine enquiry for adverse childhood experiences (ACEs) meet criteria for a screening programme? A rapid evidence summary

BACKGROUND

Adverse childhood experiences (ACEs) are traumatic events in childhood that can have impacts throughout life. It has been suggested that ACEs should be 'screened' for, or routinely enquired about, in childhood or adulthood. The aim of this work is to review evidence for this against the United Kingdom National Screening Committee (UKNSC) programme criteria.

METHODS

A rapid review of evidence on ACEs screening was conducted using the approach of the UKNSC.

RESULTS

Good quality evidence was identified from meta-analyses for associations between ACEs and a wide range of adverse outcomes. There was no consistent evidence on the most suitable screening tool, setting of administration, and time or frequency of use. Routine enquiry among adults was feasible and acceptable to service users and professionals in various settings. A wide range of potentially effective interventions was identified. Limited evidence was available on the potential for screening or routine enquiry to reduce morbidity and mortality or possible harms of screening.

CONCLUSIONS

Based on the application of available evidence to UKNSC screening criteria, there is currently insufficient evidence to recommend the implementation of a screening programme for ACEs. Further research is needed to determine whether routine enquiry can improve morbidity, mortality, health and wellbeing.

Parent-to-parent peer support for children and youth with special health care needs: Preliminary evaluation of a family partner program in a healthcare system

PURPOSE

Children and youth with special health care needs (CYSHCN) have complex care and coordination needs that are often managed by parents or primary caregivers. This study describes a parent-to-parent peer support pilot program for parents of CYSHCN implemented in both outpatient and inpatient settings across a large health system.

DESIGN & METHODS

Retrospective data from the Family Partner Program documentation in patient health records are described. Descriptions about the encounters and types of support provided are also reviewed using qualitative descriptive analysis.

RESULTS

Three Family Partners conducted 203 encounters with parents of 90 CYSHCN over six months. Family Partners provided both emotional and tangible support. Primary themes discussed included the persistent care, coordination and management needs related to parenting a child with complex care needs, the subsequent worry and stress about their child and family, and the need for stress management and self-care.

CONCLUSION

This study provides early evidence that implementation of a parent-to-parent peer support program for parents of CYSHCN in a large, academic medical center is feasible. Family Partners enhanced their healthcare team's ability to provide patient- and family-centered support for pediatric patients and their families through the provision of emotional and tangible support.

PRACTICE IMPLICATIONS

Family Partners, who are trained in effective use of the shared experience, the health coach model, and healthcare systems, and who are supported by a strong supervisory team, are ideally suited to support families and patients as they address their concerns and unmet needs and navigate complex health circumstances.

Utility of screening for adverse childhood experiences (ACE) in children and young people attending clinical and healthcare settings: a systematic review

OBJECTIVE

To examine and synthesise the literature on adverse childhood experience (ACE) screening in clinical and healthcare settings servicing children (0-11) and young people (12-25).

DESIGN

A systematic review of literature was undertaken.

DATA SOURCE

PsycInfo, Web of Science, Embase, PubMed and CINAHL were searched through June 2021. Additional searches were also undertaken.

ELIGIBILITY CRITERIA

English language studies were included if they reported results of an ACE tool being used in a clinical or healthcare setting, participants were aged between 0 and 25 years and the ACE tool was completed by children/young people or by parents/caregivers/clinicians on behalf of the child/young person. Studies assessing clinicians' views on ACE screening in children/young people attending health settings were also included.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data and assessed for risk of bias using the Mixed Methods Appraisal Tool. Results were synthesised qualitatively.

RESULTS

Initial searches identified 5231 articles, of which 36 were included in the final review. Findings showed that the most commonly used tool for assessing ACE was the ACE questionnaire; administering ACE tools was found to be feasible and acceptable; there were limited studies looking at the utility, feasibility and acceptability of assessing for ACE in First Nations people; and while four studies provided information on actions taken following ACE screening, no follow-up data were collected to determine whether participants accessed services and/or the impact of accessing services.

CONCLUSION

As the evidence stands, widespread ACE screening is not recommended for routine clinical use. More research is needed on how and what specific ACE to screen for and the impact of screening on well-being.

PROSPERO REGISTRATION NUMBER

University of York Centre for Reviews and Dissemination (CRD42021260420).

How do Lay Health Worker Engage Caregivers? A Qualitative Study to Enhance Equity in Evidence-Based Parenting Programs

Engaging caregivers in their children's mental health treatment is critical for delivering high quality, evidence-based care, particularly for young children with externalizing behaviors. Lay health workers (LHWs), including peer providers and promotoras de salud, have been identified as important workforces in addressing structural and stigma-related barriers to engagement in mental health services. Importantly, research has suggested that LHWs may be integral in efforts to address engagement disparities in evidence-based behavioral parent training programs (BPTs) for Latinx caregivers. The purpose of the study was to understand how different LHW workforces engage caregivers within their usual services, in order to inform strategies that improve access to and engagement in BPTs. Qualitative interviews were conducted with two different LHW workforces: volunteer LHWs (i.e., promotoras de salud) (n = 14), who were part of a community-embedded network, and paid LHWs (i.e., parent support partners, home visitors) (n = 9) embedded within children's mental health agencies. Participants were predominately Latinx (79%) and female (96%). Qualitative analyses revealed three primary themes related to engagement strategies used by LHWs to address barriers to care: 1.) Building Trust, 2.) Empowerment, 3.) Increasing Access. Although the majority of themes and sub-themes were consistent across the two LHW workforces, agency-embedded LHWs often discussed having the means to provide resources through their organizations, whereas community-embedded LHWs discussed acting as a bridge to services by providing information and conducting outreach. Findings have implications for partnering with different workforces of LHWs to increase equity in access to BPTs.

Future Directions in Lay Health Worker Involvement in Children's Mental Health Services in the U.S

Nearly half of children meeting criteria for a mental health disorder in the United States (U.S.) do not receive the treatment they need. Unfortunately, lack of access to and engagement in mental health services can be seen at even higher rates for historically marginalized groups, including low-income, racial, and ethnic minority youth. Lay Health Workers (LHWs) represent a valuable workforce that has been identified as a promising solution to address mental health disparities. LHWs are individuals without formal mental health training who oftentimes share lived experiences with the communities that they serve. A growing body of research has supported the mobilization of LHWs to address service disparities around the globe; however, challenges persist in how to scale-up and sustain LHW models of care, with specific barriers in the U.S. In this paper, we describe LHWs' different roles and involvement in the mental health field as well as the current state of the literature around LHW implementation. We integrate the RE-AIM Framework with a conceptual model of how LHWs address disparities to outline future directions in research and practice to enhance equity in the reach, effectiveness, adoption, implementation, and maintenance of LHW models of care and evidence-based practices for historically marginalized communities within the U.S.

Screening for adverse childhood experiences in preventive medicine settings: a scoping review

Aim

Adverse childhood experiences (ACEs) are associated with numerous adverse mental and physical health outcomes. While interest in routine screening for ACEs is growing, there is still significant opposition to universal screening. This review explores the feasibility of implementing routine screening for ACEs in primary care settings.

Subject and methods

We searched PubMed, CINAHL, and PsycINFO, reference-mined relevant reviews, and consulted with key experts (June 2020). Studies from 1970 to date evaluating screening for childhood trauma, adversity, and ACEs in a routine healthcare setting, reporting quantitative or qualitative data were eligible. The project is registered in Open Science Framework (osf.io/5wef8) and reporting follows PRISMA-ScR guidelines.

Results

Searches retrieved 1402 citations. Of 246 publications screened as full text, 43 studies met inclusion criteria. Studies evaluated provider burden, familiarity with ACEs, practice characteristics, barriers to screening, frequency of ACE inquiry, reported or desired training, patient comfort, and referrals to support services.

Conclusions

This review found that the following factors increase the likelihood that ACE screenings can be successfully integrated into healthcare settings: staff trainings that increase provider confidence and competence in administering screenings, accessible and robust mental health resources, and organizational support. Further research should examine the scalability and sustainability of universal screening.