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Lewis KN, McKelvey LM, Zhang D, Moix E, Whiteside-Mansell L. Risks of adverse childhood experiences on healthcare utilization and outcomes in early childhood. CHILD ABUSE & NEGLECT 2023; 145:106396. [PMID: 37573799 DOI: 10.1016/j.chiabu.2023.106396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 07/28/2023] [Accepted: 08/03/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND The American Academy of Pediatrics recommends all pediatricians to be ready to implement trauma-informed care, including the mitigation of impacts of Adverse Childhood Experiences (ACEs) through screening and identification of at-risk population. Reliable survey tools and knowledge of the consequences of ACEs are needed. OBJECTIVE This study examines the healthcare utilization and diagnoses captured in insurance claims in association with the number of ACEs recorded by the Family Map Inventories (FMI). The FMI offers a comprehensive family assessment, which includes child ACEs (FMI-ACEs) using prospective, proxy risk indicators. PARTICIPANTS AND SETTING Low-income families (N = 1647) with children aged three to five years who completed the FMI were linked to their insurance records. METHODS Multivariable logistic and generalized linear regression models were fitted to explore the association between the number of ACEs (FMI-ACEs scores) and healthcare utilization and health outcomes. RESULTS Children were exposed at rates of 32.4 % to zero, 31.7 % to one, 19.7 % to two, and 16.3 % to three or more ACEs. The FMI-ACEs scores were associated with greater use of non-preventive outpatient visits, filled prescriptions, and overall use of healthcare. Incidences of adjustment disorders were 4 times and attention-deficit conducts were 2 times higher among children with the highest FMI-ACEs scores than those with zero FMI-ACEs. CONCLUSIONS This study marks the first effort to conduct insurance claims data review to ascertain association between a survey measure of ACEs and health utilization and diagnosed conditions. The association of ACEs risk screening and healthcare utilization and diagnoses was observed.
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Affiliation(s)
- Kanna N Lewis
- University of Arkansas for Medical Sciences, Department of Family and Preventive Medicine, 4301 W. Markham St, #530, Little Rock, AR 72205-7199, USA.
| | - Lorraine M McKelvey
- University of Arkansas for Medical Sciences, Department of Family and Preventive Medicine, 4301 W. Markham St, #530, Little Rock, AR 72205-7199, USA
| | - Dong Zhang
- University of Arkansas for Medical Sciences, Department of Family and Preventive Medicine, 4301 W. Markham St, #530, Little Rock, AR 72205-7199, USA
| | - Elise Moix
- University of Arkansas for Medical Sciences, Department of Family and Preventive Medicine, 4301 W. Markham St, #530, Little Rock, AR 72205-7199, USA
| | - Leanne Whiteside-Mansell
- University of Arkansas for Medical Sciences, Department of Family and Preventive Medicine, 4301 W. Markham St, #530, Little Rock, AR 72205-7199, USA
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McBain RK, Levin JS, Matthews S, Qureshi N, Long D, Schickedanz AB, Gilgoff R, Kotz K, Slavich GM, Eberhart NK. The effect of adverse childhood experience training, screening, and response in primary care: a systematic review. EClinicalMedicine 2023; 65:102282. [PMID: 38106557 PMCID: PMC10725064 DOI: 10.1016/j.eclinm.2023.102282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 09/28/2023] [Accepted: 10/03/2023] [Indexed: 12/19/2023] Open
Abstract
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.
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Affiliation(s)
- Ryan K. McBain
- Department of Medicine, Brigham & Women's Hospital, Boston, MA, USA
- Division of Healthcare Delivery, RAND Corporation, Washington, DC, USA
| | - Jonathan S. Levin
- Division of Healthcare Delivery, RAND Corporation, Washington, DC, USA
| | - Samantha Matthews
- Division of Healthcare Delivery, RAND Corporation, Santa Monica, CA, USA
| | - Nabeel Qureshi
- Division of Healthcare Delivery, RAND Corporation, Santa Monica, CA, USA
| | - Dayna Long
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Adam B. Schickedanz
- Department of Pediatrics, David Geffen School of Medicine and Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Rachel Gilgoff
- UCLA-UCSF ACEs Aware Family Resilience Network, Los Angeles, CA, USA
| | - Krista Kotz
- UCLA-UCSF ACEs Aware Family Resilience Network, Los Angeles, CA, USA
| | - George M. Slavich
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA
| | - Nicole K. Eberhart
- Division of Healthcare Delivery, RAND Corporation, Santa Monica, CA, USA
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3
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Gentry SV, Paterson BA. Does screening or routine enquiry for adverse childhood experiences (ACEs) meet criteria for a screening programme? A rapid evidence summary. J Public Health (Oxf) 2022; 44:810-822. [PMID: 34231848 DOI: 10.1093/pubmed/fdab238] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 05/21/2021] [Accepted: 05/26/2021] [Indexed: 01/19/2023] Open
Abstract
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.
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Affiliation(s)
- S V Gentry
- Public Health England East of England Centre, Fulbourn, Cambridge CB21 5XA, UK.,Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
| | - B A Paterson
- Public Health England East of England Centre, Fulbourn, Cambridge CB21 5XA, UK
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Cibralic S, Alam M, Mendoza Diaz A, Woolfenden S, Katz I, Tzioumi D, Murphy E, Deering A, McNamara L, Raman S, Eapen V. Utility of screening for adverse childhood experiences (ACE) in children and young people attending clinical and healthcare settings: a systematic review. BMJ Open 2022; 12:e060395. [PMID: 36008078 PMCID: PMC9422820 DOI: 10.1136/bmjopen-2021-060395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 08/05/2022] [Indexed: 11/24/2022] Open
Abstract
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).
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Affiliation(s)
- Sara Cibralic
- Ingham Institute, Liverpool, New South Wales, Australia
| | - Mafruha Alam
- Ingham Institute, Liverpool, New South Wales, Australia
| | - Antonio Mendoza Diaz
- Department of Psychiatry, University of South Wales, Sydney, New South Wales, Australia
| | - Susan Woolfenden
- Sydney Local Health District, Camperdown, New South Wales, Australia
- Department of Paediatrics, University of New South Wales, Sydney, New South Wales, Australia
| | - Ilan Katz
- Department of Social Policy Research Centre, University of New South Wales, Sydney, New South Wales, Australia
| | - Dimitra Tzioumi
- University of New South Wales, Sydney, New South Wales, Australia
- New South Wales Ministry of Health, St Leonards, New South Wales, Australia
| | - Elisabeth Murphy
- New South Wales Ministry of Health, St Leonards, New South Wales, Australia
| | - April Deering
- New South Wales Ministry of Health, St Leonards, New South Wales, Australia
| | - Lorna McNamara
- New South Wales Ministry of Health, St Leonards, New South Wales, Australia
| | - Shanti Raman
- South Western Sydney Local Health District, Liverpool, New South Wales, Australia
| | - Valsamma Eapen
- Department of Psychiatry, University of South Wales, Sydney, New South Wales, Australia
- ICAMHS, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
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Perez Jolles M, Mack WJ, Reaves C, Saldana L, Stadnick NA, Fernandez ME, Aarons GA. Using a participatory method to test a strategy supporting the implementation of a state policy on screening children for adverse childhood experiences (ACEs) in a Federally Qualified Health Center system: a stepped-wedge cluster randomized trial. Implement Sci Commun 2021; 2:143. [PMID: 34930500 PMCID: PMC8685798 DOI: 10.1186/s43058-021-00244-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 11/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adverse childhood experiences (ACEs) are potentially traumatic events occurring before age 18, such as maltreatment or exposure to violence. ACE screening is increasingly recommended to prevent and address physical and mental health conditions associated with ACEs. To promote ACE screening uptake, the state of California issued the "ACEs Aware" policy that provides Medicaid reimbursement for ACE screening annually for child primary care visits. However, policy directives alone often do not translate into effective screening efforts and greater access to care. Few rigorous studies have developed and tested implementation strategies for ACE pediatric screening policies. This study will fill this gap by testing a multifaceted implementation strategy in partnership with a Federally Qualified Health Center (FQHC) system serving low-income families in Southern California to support the ACE Aware policy. METHODS We will use Implementation Mapping, with study process and consideration of determinants and mechanisms guided by the EPIS framework, to co-create and refine an implementation strategy. The proposed strategy is comprised of online training videos, a customized algorithm and use of technology to improve workflow efficiency, implementation training to internal FQHC personnel, clinic support and coaching, and written implementation protocols. A hybrid type 2, stepped-wedge cluster randomized trial design with five primary care clinics will test whether a multifaceted implementation strategy improves (a) fidelity to the ACE screening protocol, (b) reach defined as the proportion of eligible children screened for ACEs, and (c) the impact of the ACE policy on child-level mental health referrals and symptom outcomes. The study will use mixed methods with data to include electronic health records, surveys, and interviews with clinic personnel and caregivers. DISCUSSION This study is designed to increase the capacity of FQHCs' inner context to successfully implement an outer context-initiated ACE policy designed to benefit pediatric patients. It capitalizes on a rare opportunity to use a co-creation approach to develop, adapt, refine, and pilot test an implementation strategy to maximize the impact of a new state-wide policy intended to improve ACE assessment and subsequent care to improve child health, particularly those from underserved communities. TRIAL REGISTRATION Trial # NCT04916587 registered at ClinicalTrials.gov on June 4, 2021.
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Affiliation(s)
- Monica Perez Jolles
- Suzanne Dworak-Peck School of Social Work, Affiliate Gehr Family Center for Health Systems Science, University of Southern California, Los Angeles, CA, USA.
| | - Wendy J Mack
- Department of Population and Public Health Sciences, Keck School of Medicine, University of University of Southern California, Los Angeles, CA, USA
| | | | | | - Nicole A Stadnick
- Child and Adolescent Services Research Center, San Diego, CA, USA.,Department of Psychiatry, University of California San Diego, La Jolla, CA, USA.,Altman Clinical and Translational Research Institute Dissemination and Implementation Science Center, University of California San Diego, La Jolla, CA, USA
| | - Maria E Fernandez
- Center for Health Promotion and Prevention Research, University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
| | - Gregory A Aarons
- Child and Adolescent Services Research Center, San Diego, CA, USA.,Department of Psychiatry, University of California San Diego, La Jolla, CA, USA.,Altman Clinical and Translational Research Institute Dissemination and Implementation Science Center, University of California San Diego, La Jolla, CA, USA
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Gerlach B, LaBrenz CA, Barczyk AN, Larkin H, Van Diest H, Morris M, Faulkner M. ACE-Informed Responses in Central Texas: Findings from a Needs Assessment. SOCIAL WORK IN PUBLIC HEALTH 2021; 36:820-831. [PMID: 34380381 DOI: 10.1080/19371918.2021.1958118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The objectives of this study were to examine: a) adverse childhood experience (ACE) knowledge among healthcare professionals in Central Texas; b) prevalence of screening and patient disclosure of ACEs; c) implementation of ACE-informed response strategies; and d) the relationship between ACE knowledge and familiarity, and implementation of ACE-informed response strategies. A needs assessment was conducted using an online survey that included closed- and open-ended questions. Purposive and snowball sampling were utilized to recruit healthcare providers, with a focus on pediatric and women's healthcare providers. Eighty-five healthcare providers completed the survey. Most respondents were unfamiliar with the ACE study, but 59.6% had attended trainings on the impact of trauma on child health. Respondents screened most frequently for mental illness and drug/alcohol abuse in their practice. The most frequently reported ACE-informed response strategies included identifying strengths and utilizing on-site resources, while broader strategies such as creating an ACE-informed culture within their practice were implemented by less than 10% of respondents. ACE knowledge was correlated with two of the ACE-informed response strategies. Although many healthcare providers still lack familiarity with ACEs, awareness of trauma and its impact on child health may be more common. Given the positive correlation between ACE familiarity and ACE-informed response strategies, it appears more education and resources are needed to engage healthcare providers in responding to ACEs. Specific strategies, such as community-wide trainings, opportunities for provider collaboration and communication, and critical analysis of policies, may cultivate a more ACE-informed and ACE-responsive culture.
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Affiliation(s)
- Beth Gerlach
- University of Texas at Austin, Texas Institute for Child and Family Wellbeing, Austin, Texas, USA
| | - Catherine A LaBrenz
- School of Social Work, University of Texas at Arlington, Arlington, Texas, USA
| | - Amanda N Barczyk
- Department of Population Health, University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Heather Larkin
- School of Social Welfare, University at Albany, Albany, New York, USA
| | - Heather Van Diest
- Department of Health Social Work, Dell Medical School, Steve Hicks School of Social Work, the University of Texas at Austin, USA
| | - Marian Morris
- Department of Population Health, University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Monica Faulkner
- University of Texas at Austin, Texas Institute for Child and Family Wellbeing, Austin, Texas, USA
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