Association of maternal and paternal adverse childhood experiences with emotional and behavioral problems among preschool children

Although maternal adverse childhood experiences (ACEs) are known to be related to the emotional and behavioral problems (EBPs) of offspring, few studies have surveyed the intergenerational effects of paternal ACEs. In addition, no study has yet explored the combination and interaction effects of maternal and paternal ACEs on preschool children's EBPs in China, and the gender differences in these relationships also remain to be explored. A total of 3,575 preschool children from 12 preschools from Hefei city of Anhui province were included in this study. We used a binomial logistic regression to examine the relationship between maternal ACEs, paternal ACEs and children's EBPs. Logistic regression analysis indicated that maternal and paternal ACEs were significantly related to EBPs in children, respectively. The high maternal ACEs + high paternal ACEs group had the greatest association with children's EBPs. Interaction analysis results showed that, compared with the reference group (low maternal ACEs×low paternal ACEs), the other group (high maternal ACEs×high paternal ACEs ) were significantly related to children's EBPs (OR = 1.84, 95%CI: 1.55-2.19). We found that there were no gender differences in the combination and interaction effects (P>0.05). When fathers and mothers were jointly exposed to high levels of ACEs, children had a higher risk of developing EBPs than when they were exposed independently. Future studies should fully explore the intergenerational health effects of parental ACEs so that references for promoting the physical and mental health of preschool children can be developed.

Caregiver Report of Adverse Childhood Events: Comparison of Self-Administered and Telephone Questionnaires

Adverse childhood experiences (ACEs) are traumatic experiences that increase people's susceptibility to adverse physical health, mental health, and social consequences in adulthood. Screening for ACEs in primary care settings is complicated by a lack of consensus on appropriate methods for identifying exposure to ACEs. It is unclear whether self-report methods could increase disclosure of ACEs as compared to interview-based methods. This study compares data on the prevalence of ACEs from two publicly available surveys conducted on the same population of children's caregivers: the 2019 Ohio subsample of the web/mail-based National Survey of Children's Health and the telephone-based 2019 Ohio Medicaid Assessment Survey. We find higher disclosure of caregiver-reported child exposure to ACEs in the telephone interview survey, highlighting the importance of the role of verbal communication in developing a safe and trusting relationship in the disclosure of trauma.

Opening Pandora's box - key facilitators of practice change in detecting and responding to childhood adversity - a practitioner perspective

BACKGROUND

Childhood adversities worsen physical and mental health across the lifespan. Health and social care practitioners play a key role in identifying and responding to childhood adversity, however, may be reluctant to do so due to a perceived lack of services to refer to, time pressures and a deficit of training and confidence. We aimed to (1) quantify changes in practitioner comfort and confidence to identify and respond to childhood adversity following a multimodal intervention within an integrated child and family health and social care hub and (2) to understand barriers and facilitators of practice change.

METHODS

Hub practitioners were surveyed about their competence and comfort to directly ask about and confidence to respond to adversity at baseline and then at six and twelve months post training. Interviews were undertaken to explore practitioner barriers and enablers of practice change. Interviews were recorded, transcribed verbatim, and analysed using reflexive thematic analysis. The theoretical domains framework was used to identify the key drivers of practice change.

RESULTS

Fifteen of 18 practitioners completed all three surveys and 70% reported increased competence and comfort to directly ask, and confidence to respond across a range of adversities over the 12-month intervention. Twenty-one practitioners completed interviews. Six themes were identified as either facilitators or barriers to practice change. Facilitator themes included (1) connection matters, (2) knowledge provides assurance, (3) confidence in ability and (4) choosing change. Barrier themes were (1) never enough time and (2) opening Pandora's box. Following analysis, key drivers of practice change were 'social influence', 'belief in capability', 'knowledge' and 'behaviour regulation' while barriers to practice change were 'environmental context and resources' and 'emotion'.

CONCLUSIONS

Practitioners reported improved confidence in identifying and responding to adversity through a multimodal intervention delivered in an integrated Child and Family Hub. Changing practice requires more than just education and training. Opportunities for social connection and coaching to improve self-confidence and perceived competence are needed to overcome the fear of opening Pandora's box.

Early Life Adversity, Microbiome, and Inflammatory Responses

Early life adversity has a profound impact on physical and mental health. Because the central nervous and immune systems are not fully mature at birth and continue to mature during the postnatal period, a bidirectional interaction between the central nervous system and the immune system has been hypothesized, with traumatic stressors during childhood being pivotal in priming individuals for later adult psychopathology. Similarly, the microbiome, which regulates both neurodevelopment and immune function, also matures during childhood, rendering this interaction between the brain and the immune system even more complex. In this review, we provide evidence for the role of the immune response and the microbiome in the deleterious effects of early life adversity, both in humans and rodent models.

A Short Adverse Experiences Measure Among Mothers of Young Children

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Utilizing screening as a trauma-responsive approach in pediatric health care settings

Given the widespread impact of child trauma, it is important that child- and family-serving systems adopt trauma-informed care. Because of their integral relationships with families, pediatricians and family medicine physicians play critical roles in disrupting negative societal and developmental cascades for trauma-exposed youth through their potential for early identification and intervention. When implemented alongside organization-wide trauma-informed care practices, trauma screening is one concrete trauma-informed care practice that has shown both feasibility and positive impacts on pediatric healthcare. In support of this practice, the Care Process Model for Pediatric Traumatic Stress (CPM-PTS) helps pediatric care providers to identify and respond to children and adolescents who may need trauma-focused supports. In this paper we discuss the importance of pediatric physicians adopting trauma-informed care and how evidence-based screening practices in pediatric settings is a trauma-responsive approach with great potential for meeting unmet needs among trauma-exposed children and families.

Black people's experiences of being asked about adverse childhood experiences in the UK: A qualitative study

INTRODUCTION

The objectives for this study were to explore Black people's experiences of being asked about ACEs by mental health or counselling professionals, both broadly, and also as part of routine enquiry with a commonly used ACE questionnaire. An additional aim was to understand their perspectives on how services should be asking about ACEs.

METHODS

This study used a qualitative methodology, with a critical realist reflexive thematic analysis approach. Ten people who identified as Black and had been asked about ACEs by a mental health professional or counsellor, were interviewed about their experiences and perspectives using semi-structured interviews.

RESULTS

Four overarching themes, some with subthemes, were established: Trust and safety as individual and systemic (subthemes: Distrust in the system; Distrust in the clinician; Racism in health care; Keeping safe); It is the person, not the questions (subthemes: Being heard and understood; Similarity and difference); Engaged client, 'hard-to-reach' clinician? and People are not tick-boxes.

CONCLUSIONS

The results highlight that people find it important and useful to be asked about ACEs, if it is done in an appropriate manner. Establishing trust and a therapeutic relationship is key to fostering this. Participants stated that the ACE questionnaire might miss important context, and they relayed a preference for being asked about ACEs using more inclusive definitions of ACEs.

Racial and Ethnic Differences in Patient-Reported Acceptability of Adverse Childhood Experience (ACE) Screening in Adult Primary Care

BACKGROUND

Given the dose-response relationship between adverse childhood experiences (ACEs) and worse health outcomes, there has been a growing push for routine ACE screening in healthcare settings.

OBJECTIVE

This study explored differences in patient-reported acceptability of ACE screening among adult primary care patients.

PARTICIPANTS AND SETTING

Participants were adult primary care patients at an academic safety-net internal medicine clinic. Of the 136 patients who elected to participate in this study, 131 (96%) submitted completed surveys.

METHODS

Adult primary care patients at an academic safety-net internal medicine clinic completed an ACE screener and follow-up survey assessing their reported acceptability of ACE screening. Patients were also asked to specify their race, ethnicity, gender, and age. Chi-square analysis and Fisher's exact tests were used to examine associations between variables.

RESULTS

Among 131 patients, 37% reported 4 or more ACEs. Black/African American patients and Hispanic/Latinx patients were overrepresented in the high ACE score (4 +) group (p < 0.05). Over one in three of all patients did not find ACE screening to be an acceptable part of their primary care. After a Bonferroni adjustment, patient-reported acceptability was not statistically associated with patients' ACE score or patients' race, ethnicity, gender, or age. Notably, however, in our small sample of Native American and Hispanic/Latino patients, over half did not find ACE screening to be acceptable.

CONCLUSIONS

There is insufficient evidence to conclude that patients find ACE screening to be an acceptable part of their primary care. Our study is the first to explore how patient-reported acceptability may vary with patient demographics. While our findings revealed no significant associations between patient demographics and acceptability, trends observed within our study suggest that future studies with larger and more representative samples are needed. We consider routine ACE screening to be unsubstantiated and premature, and instead encourage the development of comprehensive trauma-informed practices for which a disclosure of childhood adversity is not necessary.

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.

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

Background

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

Methods

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

Findings

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

Interpretation

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

Funding

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

Implementing Parenting Programs in Primary Care: A Framework and a Call for Action

Healthy parent-child relationships are clearly critical to healthy child development. Parenting programs develop caregivers' skills to support the health and well-being of children. Rigorous evidence has demonstrated the efficacy of these programs. Rising rates of child and youth depression, anxiety, grief, and suicide, both prior to and compounded by the COVID-19 pandemic, provide further reasons to implement parenting programs that support all parents in their essential roles. Parents can act as a buffer to stressors and support for children's well-being when they have the knowledge and skills to do so. Pediatric primary care practices are a natural setting for parenting programs, but challenges, including stigma, technology, workflow issues, and funding, have prevented their broad dissemination, implementation, and sustainability. In this article, we develop a framework for implementing parenting programs in primary care and present key considerations for selecting programs that fit the needs of parents, providers, patients, and the practice. We offer lessons from our experiences in overcoming these challenges, using the updated Consolidated Framework for Implementation Research to structure our discussion. We also provide an initial stepwise process which readers may use to plan their own parenting program implementation. Pediatric clinicians and practices can use this article and associated resources to plan, implement, and evaluate parenting programs in their practices as a strategy to help address the growing youth mental health crisis. Improving parenting behaviors can reduce the need for current or future mental health interventions by supporting optimal child development, emotional regulation, and parent-child relationships.

Coordination challenges and promising practices for pediatric healthcare-community partnerships: A multi-site study

There have been delays integrating universal screening and referral for social needs in pediatric practice. The study investigated two frameworks for clinic-based screen-and-refer practice in eight clinics. The frameworks depict different organizational strategies to bolster family access to community resources. We conducted semi-structured interviews with healthcare and community partners at two timepoints (n = 65) to investigate start-up and ongoing implementation experiences, including continuing challenges. Results highlighted common within-clinic and clinic-community coordination challenges across diverse settings as well as promising practices supported by the two frameworks. In addition, we identified ongoing implementation challenges that face efforts to integrate these approaches and to translate screening results into activities that help children and families. Assessing the existing service referral coordination infrastructure of each clinic and community in early implementation is critical to screen-and-refer practice as this influences the continuum of supports available to meet family needs.

Pediatric Trauma and Posttraumatic Symptom Screening at Well-child Visits

Adverse childhood experiences (ACEs), including abuse or neglect, parental substance abuse, mental illness, or separation, are public health crises that require identification and response. We aimed to increase annual rates of trauma screening during well-child visits from 0% to 70%, post-traumatic stress disorder (PTSD) symptom screening for children with identified trauma from 0% to 30%, and connection to behavioral health for children with symptoms from 0% to 60%.

Methods

Our interdisciplinary behavioral and medical health team implemented 3 plan-do-study-act cycles to improve screening and response to pediatric traumatic experiences. Automated reports and chart reviews measured progress toward goals as we changed screening methods and provider training.

Results

During plan-do-study-act cycle 1, a chart review of patients with positive trauma screenings identified various trauma types. During cycle 2, a comparison of screening methods demonstrated that written screening identified trauma among more children than verbal screening (8.3% versus 1.7%). During cycle 3, practices completed trauma screenings at 25,287 (89.8%) well-child visits. Among screenings, 2,441 (9.7%) identified trauma. The abbreviated Post Traumatic Stress Disorder Reaction Index was conducted at 907 (37.2%) encounters and identified 520 children (57.3%) with PTSD symptoms. Among a sample of 250, 26.4% were referred to behavioral health, 43.2% were already connected, and 30.4% had no connection.

Conclusions

It is feasible to screen and respond to trauma during well-child visits. Screening method and training implementation changes can improve screening and response to pediatric trauma and PTSD. Further work is needed to increase rates of PTSD symptomology screening and connection to behavioral health.

Impacts on children's health of adverse childhood experiences of their mothers: A gender-specific mediation analysis using data from the China Health and Retirement Longitudinal Study

BACKGROUND

Numerous people have suffered adverse childhood experiences (ACEs) that can have lasting negative consequences. However, few studies have focused on maternal ACEs' effect on their children's health. This study aimed to evaluate the impact on children's health of ACEs that their mothers experienced.

METHODS

Data from the China Health and Retirement Longitudinal Study (CHARLS) 2018 combined with the CHARLS 2014 Life History Survey were analyzed. The logistic regression was used to investigate maternal ACEs' impact on their children's health. Based on the stepwise regression model and bias-corrected bootstrap, we estimated the mediating effects.

RESULTS

Maternal ACEs could result in harm to the health of children (P < 0.05). If the types of maternal ACEs increased by one unit, the odds ratio of their children's poor health would rise by 9.6 %. Moreover, if the types of maternal ACEs increased by one unit, the odds ratio of daughters' and sons' poor health would increase by 8.3 % and 10.2 %, respectively. Three mediating mechanisms of mothers' education, physical health, and mental health were confirmed by empirical tests.

LIMITATIONS

We could not employ objective indicators to measure children's health. Meanwhile, maternal ACEs were all self-reported from the mothers' recollection, which might descend the accuracy due to memory bias.

CONCLUSION

Maternal ACEs harmed the health of both their sons and daughters. The children's health would deteriorate as the maternal ACEs increased. Mother's education, physical health, and mental health mediated the relationships between maternal ACEs and children's health.

Potential Points of Intervention to Minimize the Impact of Parents' Adverse Childhood Experiences on Child Mental Health

OBJECTIVE

Children of parents who experienced adverse childhood experiences (ACEs) are at elevated risk for mental health (MH) issues. The goal of this study was to explore the relationships between parent ACEs and child MH and to identify potential mediators and points of psychosocial intervention.

METHODS

Participants were 1307 children aged 5 to 9 years from diverse backgrounds and their primary caregivers. Using cross-sectional questionnaire data, we used structural equation modeling to examine the research questions.

RESULTS

Parent ACEs were directly related to child MH issues (β = 0.189, p < 0.001). This relationship was fully mediated by parent MH (β = 0.374, p < 0.001; β = 0.246, p < 0.001) and positive parenting behaviors (β = -0.237, p < 0.001; β = -0.556, p < 0.001). High parent ACEs were negatively associated with parent MH (β = 0.374, p < 0.001), which was then negatively associated with parenting behaviors (β = -0.500, p < 0.001), which was then negatively associated with child MH (β = -0.600, p < 0.001). Parent MH maintained a significant, though attenuated, direct relationship with child MH (β = 0.102, p < 0.05).

CONCLUSION

Parents with high ACEs but who have good mental health and positive parenting behaviors demonstrated no impact of their ACEs on their children's mental health. Providing MH care to parents and parenting programs may be strategies for improving children's MH. Parenting behavior assessment is recommended for clinicians when pediatric patients present with MH concerns.

A Virtual Reality Curriculum to Enhance Residents' Behavioral Health Anticipatory Guidance Skills: A Pilot Trial

OBJECTIVE

Effective educational strategies to train and assess residents' skills in behavioral health competencies have been limited. We hypothesized that a training curriculum using virtual reality (VR) simulations would enhance residents' evidence-based skills related to behavioral health anticipatory guidance (BHAG) and motivational interviewing (MI).

METHODS

We conducted a randomized controlled pilot trial of our curriculum within an urban academic clinic. Intervention and control groups received four 15-minute, monthly didactics on BHAG and MI followed by VR simulations to 1) deliberately practice delivering BHAG by verbally counseling avatars, who responded real-time (intervention group) or 2) assessing pediatric respiratory distress (control group). Two months post-VR training, all residents participated in a unique VR behavioral health scenario which was recorded and coded by pediatric psychologists via an observation instrument to assess residents' skills. Differences in BHAG and MI competencies were assessed via independent samples t tests for continuous variables and Fisher's exact tests for categorical variables.

RESULTS

Sixty-six percent (n = 55) of eligible residents completed all study protocols comprising 35 intervention and 20 control participants. Intervention participants demonstrated an increase in BHAG skills (P = .002), percentage of open-ended questions asked (P = .04), and percentage of MI adherent behaviors (P = .04) when compared to the control group.

CONCLUSIONS

VR may be an effective educational strategy for residents to acquire BHAG and MI skills though deliberate practice. Next steps will focus on assessing the generalizability of the VR curriculum as well as exploring the opportunities to enhance its scalability through artificial intelligence.

Increasing awareness of adverse childhood experiences in nurse practitioner students

ABSTRACT

Adverse childhood experiences (ACEs) are reported in most children, and significant ACEs are associated with neurological changes and chronic conditions. Despite this, routine screening for early identification and intervention is rare. To increase screening frequency, education for providers including nurse practitioners is critical. This project provided asynchronous education on ACEs for family nurse practitioner (FNP) students with preeducation and posteducation survey links. The survey items focused on three key areas: knowledge, skills, and attitudes (KSAs). T-tests were run to determine improvements in knowledge and skills questions and for Likert scale ratings on the attitude questions. Statistical significance was found in skills questions and in knowledge questions for one implementation site, and overall increases were seen in all areas from preeducation to posteducation results. This improvement in KSAs toward ACEs for FNP students showed that increased knowledge and understanding of skills also increased the reported willingness to screen patients in primary care to improve overall health outcomes.

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 Perspectives on Adverse Childhood Experiences & Unmet Social Needs Screening in the Medical Home: A Qualitative Study

OBJECTIVES

To explore parental perspectives regarding disclosure of child and parental adverse childhood experiences (ACE) and family unmet social needs (USN) and to elicit parental recommendations for screening in the pediatric medical home.

METHODS

We conducted a qualitative study using a purposive sample of English- and Spanish-speaking parents in our urban academic community clinic. Between January 2018 and March 2019, each parent underwent one semistructured interview that was audiotaped, transcribed, and independently coded in Atlas.ti by 2 study team members. Data analysis was based in constructivist grounded theory methodology to identify common themes and subthemes.

RESULTS

We interviewed 25 English-speaking and 15 Spanish-speaking parents who were mostly female, racial/ethnic minorities with ≥1 ACE. English-speaking subjects were more likely to have a high school degree and be single parents. Four themes were identified: 1) Pediatricians should ask about ACE and USN. 2) Disclosure is a longitudinal process, not a discrete event. 3) Barriers to disclosure are significant, involving concrete and emotional risks for the family. 4) Trauma-informed providers and practices support disclosure.

CONCLUSIONS

Families support pediatricians addressing ACE and USN in the medical home despite significant barriers. Even if providers screen using trauma-informed principles, parents may prefer not to disclose ACE initially because they regard disclosure as a stepwise process. These findings contribute to a new conceptual framework for thinking of ACE screening not merely as a way to generate information, but as an interactive, therapeutic relationship-building activity irrespective of whether or when it produces disclosure.

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).

Establishing Trauma-Informed Primary Care: Qualitative Guidance from Patients and Staff in an Urban Healthcare Clinic

Patients present to primary care clinics with a variety of experiences, including exposure to adverse childhood experiences (ACEs) and other social determinants of health. The pervasive impact of early adversity on later healthcare outcomes has resulted in the development of trauma-informed care principles that can be applied to healthcare settings. The primary aim of this study is to improve understanding of patient and staff experiences within a trauma-informed urban healthcare setting to guide considerations and recommendations when implementing such a model. A phenomenologic approach was taken using an interpretivist paradigm to collect qualitative data by conducting patient and staff focus groups. The following themes were identified: the communal experience of significant trauma, lack of continuity of care and time for each appointment, the importance of a sense of community and standardization and normalization of asking about trauma, development of social support networks, and creating a safe and non-judgmental healthcare space. Based on findings, considerations for implementing a trauma-informed healthcare model are provided.

Addressing Adverse Childhood Experiences in Primary Care: Challenges and Considerations

This article draws attention to the overlapping literature on social determinants of health and adverse childhood experiences, and the growing clinical interest in addressing them to promote children's and parents' health and well-being. We address important considerations and suggest solutions for leaders and practitioners in primary care to address social determinants of health/adverse childhood experiences. Priorities include: begin with a few prevalent conditions for which there are helpful resources; focus on conditions that are current or recent and where parents may be more apt to engage in services; focus initially on families with children aged <6 given the frequency of well-child visits and the especially strong relationships between primary care professionals and parents during this period; ensure training of primary care professionals and staff to help them play this role competently and comfortably; and have good referral processes to facilitate additional evaluation or help.

A Systematic Review of the Effect of Parental Adverse Childhood Experiences on Parenting and Child Psychopathology

Adverse childhood experiences (ACEs) are defined as early exposure to maltreatment and household dysfunction. Researchers have demonstrated the link between ACEs and negative psychological, behavioral, interpersonal, and health outcomes. A growing area of interest in the ACE literature concerns the relationship between ACEs, parenting, and child psychopathology due to the intergenerational effect of ACEs. Emotional availability and discipline strategies are two domains of parenting that can increase understanding of the associations between ACEs, parenting, and child psychopathology from an attachment framework because they are both salient during early childhood and directly influence a child's later behavior. This paper utilized the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to elucidate the relationships between parental ACEs, parents' emotional availability and discipline strategies, and children's psychopathology. PubMed, PSYCINFO, and Psychology and Behavioral Sciences Collection were used to access the literature on June 16, 2020, and 26 studies met the inclusion criteria. Results from this review suggested that there is a direct association between ACEs and parental emotional availability and discipline techniques. Depression and dissociation were identified as potential mediators. There was support for the direct association between parental ACEs and children's internalizing and externalizing difficulties. Maternal anxiety and depressive symptoms, emotional availability, attachment, and children's maltreatment experiences were found to be possible mediators. Recommendations are proposed to address limitations within the literature to further expand upon the research of ACEs, parenting, and child psychopathology.

Evidence for Revising the Adverse Childhood Experiences Screening Tool: a Scoping Review

The relationship between adverse childhood experiences (ACEs) and risky behavior, chronic illness, and premature mortality is well documented. Despite this evidence, screening for ACEs in primary care settings remains limited. Objections to widespread screening include concerns that the original ACE screening tool limited childhood adversities to family and household dysfunction. The purpose of this scoping review is to describe current knowledge for expanding ACEs categories and revising the formatting and scoring of the screening tool. With the assistance of a medical librarian, we used a two-step process to conduct a systematic search in three databases (CINAHL, OVID Medline, PsycINFO). Our aim was to focus on articles that expanded ACE categories and/or revised the scoring or formatting of the ACE tool. Eighteen articles (reporting 19 studies) met criteria. A minimum of two authors extracted the relevant characteristics of the studies independently and conferred to reach agreement. The majority of studies broadened ACEs to include community and systemic categories; three studies revised the formatting or scoring of the ACE tool. Exposure to community violence (ECV) was the most frequently added category (15), followed by economic hardship in childhood (EHC) (13); bullying (10); absence/death of parent or significant others (9); and discrimination (7). This evidence supports the expansion of ACE screening tools for assessment of childhood trauma and timely treatment.

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.

Adverse Childhood Experiences and Healthcare Utilization of Children in Pediatric Emergency Departments

OBJECTIVE

To determine the prevalence of adverse childhood experiences (ACEs) and healthcare utilization patterns of children seen in pediatric emergency departments (PEDs).

STUDY DESIGN

In this cross-sectional study, caregivers of patients who presented to 2 urban PEDs completed a survey regarding their children's ACEs, health care utilization patterns, and acceptance of PED-based ACEs screening and resources. Inclusion criteria were English-speaking caregivers of patients 0-17 years of age not requiring acute stabilization. Prevalence estimates were compared with national and state data from the National Survey of Children's Health by calculating risk differences and 95% CIs. The association of cumulative ACEs with caregiver-reported health care utilization patterns was evaluated using ORs.

RESULTS

Among 1000 participants, 28.1% (95% CI 25.3-30.9) had 1 ACE; 17.8% (95% CI15.4-20.2) had ≥2 ACEs. Notably, children with higher cumulative ACEs were seen in the PED more frequently (0, 1, ≥2 visits) (OR 1.18, 95% CI 1.06-1.30, P = .002) and more likely to seek care in PEDs for sick visits (OR 1.16, 95% CI 1.04-1.30, P = .01). About 9% of children exposed to ACEs did not have a primary care provider. Over 85% of caregivers reported never discussing ACEs with their primary care provider. Most caregivers felt comfortable addressing ACEs in PEDs (84.4%) and would use referral resources (90.4%).

CONCLUSIONS

Given higher PED utilization in children with more ACEs and caregiver acceptance of PED-based screening and intervention, PEDs may represent a strategic and opportune setting to both assess and respond to ACEs among vulnerable populations.

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

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

Methods

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

Results

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

Conclusion

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

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

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

Provider Perspectives on Screening for Social Determinants of Health in Pediatric Settings: A Qualitative Study

INTRODUCTION

Pediatric settings often screen children and/or caregivers for social determinants of health (SDH) needs. Although SDH awareness rose with COVID, questions remain regarding best practices for SDH screening in pediatric settings.

METHOD

We assessed pediatric providers' perspectives on integrating SDH screening into patient care. Semistructured interviews were conducted with providers (n = 13) from 10 clinics. Interviews were transcribed, and themes were analyzed using the constant comparative method.

RESULTS

Themes highlighted providers' awareness of structural limitations to address social needs identified by screening; implementation concerns; the unique role of pediatric providers for child health and well-being; provider comfort with assessing patients' social needs; patient considerations; the importance of relational health between pediatric providers and families, and between providers and community supports for effective screening; and unintended consequences.

DISCUSSION

Pediatric providers endorse the need for SDH screening, but barriers in pediatric settings may hamper the process and reduce efficacy.

Assessing Cardiometabolic Health Risk Among U.S. Children Living in Grandparent-Headed Households

PURPOSE

We evaluated children's cardiometabolic health (CMH) risk indicators and adverse childhood experiences (ACEs) stratified by family structure type (grandparent-headed, two-parent headed, and single-parent headed households). Separately, we assessed whether family structure type and number of ACEs were independently associated with the CMH risk indicators.

DESIGN AND METHODS

Utilizing data from the 2017-2018 National Survey of Children's Health, we evaluated five CMH risk indicators (obesity, physical activity, secondhand smoke exposure, sleep, and sports participation). We used multivariable logistic regressions to assess the association of CMH risk indicators with family structure type and ACEs. We controlled for sex, age, race/ethnicity, health insurance, household poverty level, and overall health status.

RESULTS

Among children aged 10-17 years (n = 24,885), we found the number of ACEs differed by family structure type (P < 0.001) and was independently associated with obesity, secondhand smoke exposure, sleep, and sports participation. Adjusting for all covariates except ACEs, family structure type was significantly associated with children's CMH risk; but after controlling for ACEs that association was attenuated - except for sleep (less adequate sleep in grandparent-headed households) and exposure to secondhand smoke (less exposure in single-parent headed households).

CONCLUSIONS

ACEs were highest among children living in grandparent-headed households and independently associated with a majority of the CMH risk indicators. Findings suggest that children living in grandparent-headed households may be at elevated risk for poor CMH, potentially due to higher risk for ACEs.

PRACTICE IMPLICATIONS

It is recommended to consider ACEs and family structure type when assessing CMH risk in children.

Exploring women's perspectives on prenatal screening for adverse childhood experiences

OBJECTIVE

To learn more about women's views on screening for adverse childhood experiences (ACEs) during healthcare visits in pregnancy.

DESIGN

Mixed methods with an online survey.

SAMPLE

A convenience sample of 154 women with a history of one or more pregnancies was recruited through public health department social media pages in one predominantly rural region of a Midwest state.

MEASUREMENTS

Quantitative measures included demographic variables, ACE scores, and preferences regarding screening format, strategies, and resources. Additional perspectives were captured through open-ended questions.

RESULTS

Women's mean ACE score was 2.56 (SD = 2.37) with 68% reporting 0-3 ACEs and 32% reporting four or more. Routine screening for ACEs during prenatal care was supported by 67.5% of women with 9.1% indicating sometimes, 20.8% unsure, and 2.6% against. Strong preference was indicated for screening by one's physician or midwife (80.3%), in an exam room (83.1%), using an independently completed questionnaire (64.2%). Preferred approaches for screening and post-screening interventions also were identified with qualitative themes providing additional insights.

CONCLUSIONS

Findings inform strategies for efficiently and sensitively screening for ACEs during pregnancy, highlight the importance of using a trauma-informed approach, and provide direction for educational and interventional resource development.

Trauma-Informed Care

Most children will experience some type of trauma during childhood, and many children suffer from significant adversities. Research in genetics, neuroscience, and epidemiology all provide evidence that these experiences have effects at the molecular, cellular, and organ level, with consequences on physical, emotional, developmental, and behavioral health across the life span. Trauma-informed care translates that science to inform and improve pediatric care and outcomes. To practically address trauma and promote resilience, pediatric clinicians need tools to assess childhood trauma and adversity experiences as well as practical guidance, resources, and interventions. In this clinical report, we summarize current, practical advice for rendering trauma-informed care across varied medical settings.

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.

Preferences for disclosing adverse childhood experiences for children and adults with cystic fibrosis

INTRODUCTION

The 2017-2018 National Survey of Children's Health estimates that 30 million (42%) US children have experienced at least one adverse childhood experience (ACE), including abuse, neglect, and household dysfunction. ACEs negatively impact long-term health, and there has been no study of ACEs in cystic fibrosis (CF). We assessed willingness to disclose ACEs experienced by children with CF by surveying their parents and adults with CF.

METHODS

We anonymously surveyed parents of children with CF and adults with CF at the Northwestern University/Lurie Children's CF Center to determine their willingness to disclose ACEs.

RESULTS

The survey was completed by 46/157 (29%) parents and 36/105 (34%) adults with CF. Few parents (22%) and adults (17%) were willing to discuss most or all specific ACEs, more were willing to disclose the number of ACEs experienced in a category (57% parents, 47% adults), and the majority were willing to participate in anonymous research about ACEs (76% parents, 67% adults). Most parents (63%) and adults (50%) would prefer to have ACEs screened separately from their CF appointment, and most parents (63%) and adults (56%) wanted to learn more about ACEs from a member of their care team.

CONCLUSIONS

Participants preferred to disclose the number of categorical ACEs rather than specific ACEs and most were open to participating in anonymous ACEs research. More research is needed before implementing screening. Educating patients, parents, and providers about ACEs and appropriate interventions when ACES are identified is needed for both research and clinical applications of ACEs screening.

Defining the role of exposure to ACEs in ADHD: Examination in a national sample of US children

BACKGROUND

Clinical presentations of ADHD vary according to biological and environmental developmental influences. An emerging field of research has demonstrated relationships between exposure to adverse childhood experiences (ACEs) and ADHD prevalence, particularly in high-risk samples. However, research examining the combined role of traditional risk factors of ADHD and ACEs is limited, and reliance on high-risk samples introduces sampling bias.

OBJECTIVE

To examine the influence of ACEs on ADHD diagnosis using a large, nationally representative sample of US children.

PARTICIPANTS AND SETTING

Nationally representative samples (2017 and 2018) of 40,075 parents from the National Survey of Children's Health (NSCH).

METHODS

We conducted logistic regression models to examine the association of ACEs and ADHD diagnosis, controlling for child and parent demographic variables and other risk factors.

RESULTS

Exposure to ACEs was significantly associated with parent-reported ADHD diagnosis, controlling for known parental and child-risk factors of ADHD. The association followed a gradient pattern of increased ADHD prevalence with additional exposures. Compared to children with no ACEs, the odds of an ADHD diagnosis were 1.39, 1.92, and 2.72 times higher among children with one, two and three or more ACEs. The ACE most strongly associated with the odds of ADHD was having lived with someone with mental illness closely followed by parent/guardian incarceration.

CONCLUSIONS

Results further strengthen the evidence that ACEs exposure is associated with increased ADHD prevalence. Clinicians should assess ACEs in the diagnosis of ADHD. Furthermore, results of the study lend support to the efforts of agencies (both institutional and state-level) promoting routine screening of ACEs in children.

Adverse Childhood Experiences are associated with choice of partner, both partners' relationship and psychosocial health as reported one year after birth of a common child. A cross-sectional study

Adverse Childhood Experiences (ACEs) are common and known to have consequences for individuals' adult health, leading to a higher risk of illness. The aims of the study were to investigate the ACEs in couples, to examine the extent of assortative mating and to investigate the association between the relationship of the load of ACEs within couples and health outcomes, one year after the birth of a common child. At antenatal clinics in Sweden 818 couples were recruited and investigated one year after the birth of a common child answering a questionnaire including the exposure to ten ACE categories and several outcome variables. In total, 59% of both mothers and partners reported exposure to at least one of the ten ACE categories. Among the mothers 11% and among the partners 9% reported exposure to ≥4 ACE categories (p = 0.12). There was a correlation between the numbers of ACE categories reported by the mothers and their partners (Spearman's ρ = 0.18, p<0.001). This association pertained to six of the ten ACE categories. In multiple logistic regression analyses, there were associations between the ACE exposure load and unfavourable outcomes among the mothers, the partners and within the couples. Unfavourable outcomes concerning health were most prominent in couples where both members reported exposures to ≥4 ACE categories (self-rated bad health (OR 13.82; CI 2.75-69.49), anxiety (OR 91.97; CI 13.38-632.07), depression (OR 17.42; CI 2.14-141.78) and perceived stress (OR 11.04; CI 2.79-43.73)). Mothers exposed to ACEs tend to have partners also exposed to ACEs. Exposure to ACEs was associated with bad health and unfavourable life conditions within the couples, especially among couples where both members reported exposure to multiple ACEs. These results should stimulate incentives to find, to support and to treat individuals and couples where both members report multiple ACEs. The consequences for the children should be further studied as well as how these families should be treated in health care and society.

The social ecology of childhood and early life adversity

An increasing prevalence of early childhood adversity has reached epidemic proportions, creating a public health crisis. Rather than focusing only on adverse childhood experiences (ACEs) as the main lens for understanding early childhood experiences, detailed assessments of a child's social ecology are required to assess "early life adversity." These should also include the role of positive experiences, social relationships, and resilience-promoting factors. Comprehensive assessments of a child's physical and social ecology not only require parent/caregiver surveys and clinical observations, but also include measurements of the child's physiology using biomarkers. We identify cortisol as a stress biomarker and posit that hair cortisol concentrations represent a summative and chronological record of children's exposure to adverse experiences and other contextual stressors. Future research should use a social-ecological approach to investigate the robust interactions among adverse conditions, protective factors, genetic and epigenetic influences, environmental exposures, and social policy, within the context of a child's developmental stages. These contribute to their physical health, psychiatric conditions, cognitive/executive, social, and psychological functions, lifestyle choices, and socioeconomic outcomes. Such studies must inform preventive measures, therapeutic interventions, advocacy efforts, social policy changes, and public awareness campaigns to address early life adversities and their enduring effects on human potential. IMPACT: Current research does not support the practice of using ACEs as the main lens for understanding early childhood experiences. The social ecology of early childhood provides a contextual framework for evaluating the long-term health consequences of early life adversity. Comprehensive assessments reinforced with physiological measures and/or selected biomarkers, such as hair cortisol concentrations to assess early life stress, may provide critical insights into the relationships between early adversity, stress axis regulation, and subsequent health outcomes.

Pediatrics adverse childhood experiences and related life events screener (PEARLS) and health in a safety-net practice

BACKGROUND

Adverse Childhood Experiences (ACEs) are associated with behavioral, mental, and clinical outcomes in children. Tools that are easy to incorporate into pediatric practice, effectively screen for adversities, and identify children at high risk for poor outcomes are lacking.

OBJECTIVE

To examine the relationship between caregiver-reported child ACEs and related life events with health outcomes.

PARTICIPANTS AND SETTING

Participants (0-11 years) were recruited from the University of California San Francisco Benioff's Children Hospital Oakland Primary Care Clinic. There were 367 participants randomized.

METHODS

Participants were randomized 1:1:1 to item-level (item response), aggregate-level (total number of exposures), or no screening for ACEs (control arm) with the PEdiatric ACEs and Related Life Event Screener (PEARLS). We assessed 10 ACE categories capturing abuse, neglect, and household challenges, as well as 7 additional categories. Multivariable regression models were conducted.

RESULTS

Participants reported a median of 2 (IQR 1-5) adversities with 76 % (n = 279) reporting at least one adversity; participants in the aggregate-level screening arm, on average, disclosed 1 additional adversity compared to item-level screening (p = 0.01). Higher PEARLS scores were associated with poorer perceived child general health (adjusted B = -0.94, 95 %CI: -1.26, -0.62) and Global Executive Functioning (adjusted B = 1.99, 95 %CI: 1.51, 2.46), and greater odds of stomachaches (aOR 1.14; 95 %CI: 1.04-1.25) and asthma (aOR 1.08; 95 %CI 1.00, 1.17). Associations did not differ by screening arm.

CONCLUSION

In a high-risk pediatric population, ACEs and other childhood adversities remain an independent predictor of poor health. Increased efforts to screen and address early-life adversity are necessary.

Screening for Adverse Childhood Experiences: Literature Review and Practice Implications

Adverse childhood experiences (ACEs) are linked with negatively impacting child and adult health outcomes. Clinicians are integral in identifying childhood adversities and offering supportive measures to minimize negative effects. This systematic literature review included 13 ACE studies that examined the acceptability, feasibility, and implementation of ACE screenings from the perspectives of clinicians and patients. The findings of this review can assist clinicians in considering the appropriateness of ACE screenings for their patients and the ethical and practical issues that must be addressed for effective screening implementation.

The effects of adverse childhood experiences on pregnancy-related anxiety and acceptance of motherhood role

BACKGROUND

Adverse childhood experiences are a factor that may cause physical illness and deterioration of lifelong well-being in addition to many mental and psychiatric problems in the future. It is important to question and treat them.

OBJECTIVE

This study examined the effects of adverse childhood experiences on pregnancy-related anxiety and acceptance of motherhood role.

METHODS

This cross-sectional study was conducted on 536 pregnant women. The data were collected using the "Personal Information Form", the "Adverse Childhood Experience Questionnaire (ACEQ)", the "Acceptance of Motherhood Role (AoMR)" subscale of the "Prenatal Self Evaluation Questionnaire (PSEQ)" and the "Pregnancy-Related Anxiety Questionnaire-Revised 2 (PRAQ-R2)".

RESULTS

It was found that those with high levels of negative childhood experience had higher levels of anxiety in pregnancy and lower acceptance of maternal role than the other groups (p<0.05). Additionally, a one-unit change in the AoMR score led to a 0.23-unit decrease in the ACEQ score, whereas a one-unit change in the PRAQ-R2 score led to a 0.57-unit increase in the ACEQ score (p<0.001).

CONCLUSION

Adverse childhood events increase pregnancy-related anxiety and negatively affect acceptance of motherhood role.

Implementation of the adverse childhood experiences conversation in primary care

BACKGROUND

Research has focused on screening for adverse childhood experiences, rather than provision of education as a part of routine anticipatory guidance. An adverse childhood experiences 'conversation' is one method that has not been studied empirically but represents a complimentary or alternative approach to screening which could overcome many existing barriers.

OBJECTIVES

This study aims to examine parent/guardian and provider acceptability/feasibility of the adverse childhood experiences conversation during well-child visits in primary care.

METHODS

Providers engaged in a conversation with parents/guardians of patients during well-child visits in a family medicine residency clinic. Parents/guardians and providers were surveyed following the visit to examine acceptability and feasibility. Quarterly assessments to further examine provider perspectives were completed. Data were collected for 1 year.

RESULTS

In total, 238 parent/guardian and 231 provider surveys were completed. Most parents/guardians felt positively (76%) about and comfortable (81%) with the information discussed and 97% felt that the conversation should be had with their primary care provider specifically. Most providers (71%) indicated that parents/guardians were receptive to the conversation, that the conversations took 1-2 minutes (60%) and that there were few disclosures of adversity (9%), none of which required mandatory reporting.

CONCLUSIONS

Results suggest that the adverse childhood experiences conversation is well received by parents/guardians and providers and is feasible to implement into primary care. The conversation could be used as a complimentary or alternative method to screening to further spread knowledge of toxic stress and health, provide resources for families and promote resilience.

The Implementation of Screening for Adverse Childhood Experiences in Pediatric Primary Care

OBJECTIVE

To assess the implementation of screening, screening rates, and prevalence of adverse childhood experiences (ACEs) in a large integrated healthcare system.

STUDY DESIGN

Kaiser Permanente Southern California is a large integrated healthcare system with 15 medical centers/hospitals and 233 medical office buildings that serve approximately 1.5 million children. Screening for ACEs began in July 2018 at 1 medical center (Downey, Bellflower medical office) for 3- and 5-year-old well-child visits (yearly physical examination). It quickly expanded to 3 other medical centers (6 clinics in total) and now also includes the 10- and 13-year-old well-child visits.

RESULTS

Since July 2018 we have screened 3241 3-year-olds (53% of the target population), 2761 5-year-olds (53%), 545 10-year-olds (37%), and 509 13-year-olds (13%). Of the 3-year-olds who were screened, 15% had an ACEs score of 1 or higher. Of the 5-year-olds that were screened, 17.5% had an ACEs score of 1 or higher. Of the 10-year-olds, 30.5% had an ACEs score of 1 or higher and of the 13-year-olds, 33.8% had an ACEs score of 1 or higher.

CONCLUSIONS

Although we have encountered some challenges, particularly with follow-up for those screening positive for ACEs, screening was feasible. The data show an increasing trend of ACEs in 3- to 13-year-old children, highlighting the need for early education about ACEs to mitigate the effects of toxic stress.

Identifying adverse childhood experiences in pediatrics to prevent chronic health conditions

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

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.

Child Life Specialists' Experiences Addressing Social Determinants of Health: A Web-Based Survey

We used Google Forms to survey 110 child life specialists on their experiences addressing family psychosocial issues. Most respondents were female (99%) and white (95%), with mean age 34 ± 10 years. Ninety-five percent reported addressing family psychosocial issues during the previous 3 months, including parental separation/divorce (71%), poverty/financial needs (64%), parental mental illness (59%), substance abuse at home (54%), homelessness/housing problems (54%), bullying (49%), physical neglect (46%), physical abuse (46%), unemployment (46%), emotional neglect (45%), and hunger/food insecurity (42%). Eighty-five percent of respondents reported addressing family psychosocial issues once per month or more often, with 80% providing coping strategies, 76% providing family support, 66% providing therapeutic play, and 66% providing psychological preparation. These findings indicate that child life specialists frequently address a range of family psychosocial issues. Further research is needed to clarify the role and impact of child life services on social determinants of health.

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

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

Addressing adverse childhood experiences and health risk behaviors among low-income, Black primary care patients: Testing feasibility of a motivation-based intervention

OBJECTIVE

This pilot study tests the feasibility of implementing a two-session intervention that addresses adverse childhood experiences (ACEs), post-traumatic stress symptoms, and health risk behaviors (HRBs) among Black primary care patients. African Americans are disproportionately exposed to stressful and traumatic events and are at greater risk for PTSD than the general population.

METHOD

A prospective cohort, experimental (pre-post) design with 2 post-intervention assessments were used to evaluate the feasibility of a motivation-based intervention for Black primary care patients with one or more ACEs. Indicators of feasibility implementation outcomes were assessed by participant adherence to treatment; suitability, satisfaction, and acceptability of the intervention; in addition to clinical outcomes of stress, HRBs, and behavioral health referral acceptance.

RESULTS

Out of 40 intervention participants, 36 completed the intervention. Of the patients with one or more ACEs who participated in the intervention, 65% reported 4 or more ACEs and 58% had positive PTSD screens, and nearly two-thirds of those had at least one HRB. Satisfaction with the program was high, with 94% of participants endorsing "moderately" or "extremely" satisfied. The sample showed significant post-intervention improvements in stress, alcohol use, risky sex, and nutrition habits. Although stress reduction continued through 2-month follow-up, unhealthy behaviors rebounded. Almost one-third of participants were connected to behavioral health services.

CONCLUSIONS

Brief motivational treatment for ACEs is feasible in underserved primary care patients and could help individuals develop healthier ways of coping with stress and improve health.