Assessment for and response to adverse childhood experiences

A call for health justice: Striving toward health equity at a community health center

Community health centers play a key role in promoting health justice and equity. Health justice, which is the attainment of health equity, or the fair, unambiguous, and non-arbitrary distribution of all health resources necessary for optimal health of the individual, family, and community, is necessary to optimize their wellbeing and to build healthy communities. Community-based health centers are well-positioned to lead in these efforts, as they connect with, seek to understand, and innovatively serve communities that experience complex health-related needs and are differentially impacted by structural vulnerabilities (i.e., racism). The purpose of this article is to present a nurse-led model of culturally responsive health care that is rooted in partnerships designed to address medical and health-related social needs. Current health inequities in the United States across constructs of race and socioeconomic status warrant comprehensive healthcare models that explicitly incorporate health justice, trauma-informed, and antiracist approaches into practice, especially when serving high/complex-need and under-resourced communities. Foundationally, it is imperative that these models of care strive toward equity regarding access to compassionate, affordable, culturally relevant health care; center community members' voices and guidance; promote growth and development of staff in understanding structural barriers and act to dismantle them; and create learning opportunities for students and staff to understand and address social determinants of health to provide high-quality care, with an ultimate goal to improve community health.

Honoring the past and charting the future: The International Society of Psychiatric Mental Health Nurses' commitment to advance diversity and equity in mental health care

For more than two decades, the International Society of Psychiatric Nurses has dedicated its efforts to improving mental health care services worldwide, focusing on leveraging the psychiatric nursing workforce and advocating to eradicate systemic health disparities. Part of this labor included creating a culturally centered initiative, the Position Statement on Diversity, Cultural Competence and Access to Mental Health Care to fortify the cultural awareness of ISPN members to improve health-care quality delivered to diverse individuals, families, and communities across the life span and to improve these populations' access to mental health care.

Knowledge and perceptions of adverse childhood experiences (ACEs) among prelicensure nursing students

OBJECTIVES

Adverse childhood experiences (ACEs) impact health outcomes in adulthood. Positive childhood experiences (PCEs) are associated with resiliency and improved mental and physical health outcomes. There is often a lack of content on ACEs in nursing education. The purpose of this project was to determine the knowledge and perceptions of ACEs and PCEs among prelicensure nursing students.

METHODS

A mixed-method pilot study was implanted. Prelicensure nursing students received didactic instruction on ACEs and PCEs and completed online, anonymous ten-item pre- and post-surveys about knowledge on ACEs and PCEs.

RESULTS

A positive percent change was observed with all ten statements from pre- to post-surveys. Six themes emerged from qualitative analysis, revealing the importance and benefits of education on ACEs and PCEs.

CONCLUSIONS

This study shows that nursing students valued education regarding ACEs, were willing to incorporate their knowledge of ACEs into their practice, and discovered they might have been exposed to ACEs themselves. Implications for International Audience: All nursing programs must include content on ACEs and PCEs to prepare better nurses to care for patients.

Legislating to Prevent Adverse Childhood Experiences: Growth and Opportunities for Evidence-Based Policymaking and Prevention

Since the landmark study of Adverse Childhood Experiences (ACEs; Felitti et al., American Journal of Preventive Medicine, 14(4):245-258, 1998), there has been a significant growth in efforts to address ACEs and their impact on individual health and well-being. Despite this growing awareness, there has been little systematic review of state legislative action regarding variation in focus or scope or of the broader context impacting the introduction and enactment of ACE-related policy efforts. To inform the role of psychologists and related professionals to contribute to these legislative efforts, we conduct a comprehensive mixed-method analysis of all state bills introduced over the past two decades to investigate the use and impact of ACE research in introduced and enacted state legislative language (51 states, N_{Total Bills} = 1,212,048, N_{ACE Bills} = 425). In addition, these analyses examine congressional office communications (N = 14,916,546 public statements) and voting records (N = 1,163,463 votes) to understand the relationship between legislative members' public discussion of ACEs and their voting behavior on these bills. We find that legislators' public discourse is significantly related to ACE-related policymaking above and beyond political affiliation or demographic characteristics. Furthermore, key legislative language related to domestic violence, evidence-based practice, and prevention were significant predictors of whether an ACE-related bill becomes law-above and beyond the political party in power. These analyses highlight the ways in which ACE-related research has informed state policy. Based upon this work, we offer recommendations for researchers and policymakers.

Multiple Maltreatment and Adverse Childhood Experiences: Exploring Cumulative Threats to Attachment Quality

Child maltreatment and other adverse childhood experiences (ACEs) often cooccur and are related to negative socioemotional outcomes; however, limited research differentiates how maltreatment versus other ACEs predict such outcomes. These efforts are necessary to determine whether cumulative ACE screening efforts best predict those at risk for poor outcomes. We examined cumulative childhood ACEs, cumulative maltreatment subtypes, and adult attachment quality in 379 young and middle-aged adults. This sample enabled comparison between emerging adults and older adults who have navigated additional developmental tasks that may counteract the effects of early ACEs. More ACEs and maltreatment experiences predicted insecure anxious, avoidant, and fearful attachment styles; however, maltreatment failed to predict unique variance in attachment quality beyond other ACEs. Results suggest that maltreatment may be best categorized as part of a general cumulative risk profile predicting poor socioemotional outcomes. Findings support burgeoning trends in medical and social service settings assessing ACEs using simple dichotomous screening tools to identify those requiring intervention and support services.

The evidence base for routine enquiry into adverse childhood experiences: A scoping review

BACKGROUND

Exposure to adverse childhood experiences (ACEs; e.g., maltreatment, household dysfunction) is associated with a multiplicity of negative outcomes throughout the life course. Consequently, increasing interest is being paid to the application of routine enquiry for ACEs to enable identification and direct interventions to mitigate their harms.

OBJECTIVE

To explore the evidence base for retrospective routine enquiry in adults for ACEs, including feasibility and acceptability amongst practitioners, service user acceptability and outcomes from implementation.

METHODS

A scoping review of the literature was conducted, drawing upon three databases (CINAHL, MEDLINE, PsycINFO) and manual searching and citation tracking. Searches included studies published from 1997 until end of April 2018 examining enquiry into ACEs, or the feasibility/acceptability of such enquiry across any setting. All included studies presented empirical findings, with studies focusing on screening for current adversities excluded.

RESULTS

Searches retrieved 380 articles, of which 15 met the eligibility criteria. A narrative approach to synthesize the data was utilized. Four studies examined practitioner feasibility and/or acceptability of enquiry, three reported service user acceptability and six studies implemented routine ACE enquiry (not mutually exclusive categories). Further, eight studies explored current practice and practitioner attitudes towards ACE enquiry.

CONCLUSIONS

Limited literature was found providing evidence for outcomes from enquiry. No studies examined impacts on service user health or service utilization. Few studies explored feasibility or acceptability to inform the application of routine ACE enquiry. The implementation of routine ACE enquiry therefore needs careful consideration. Focus should remain on evaluating developing models of ACE enquiry to advance understanding of its impact.

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.

Adverse childhood experiences and implementing trauma-informed primary care

Adverse childhood experiences (ACEs) include exposures such as abuse and household dysfunction. These exposures are associated with long-term sequelae and unfavorable health outcomes in adulthood. NPs working in primary care can help to reduce the impact of ACEs in adulthood by identifying individuals with these experiences and implementing trauma-informed care strategies.

Reduced levels of miRNAs 449 and 34 in sperm of mice and men exposed to early life stress

Exposure of male mice to early life stress alters the levels of specific sperm miRNAs that promote stress-associated behaviors in their offspring. To begin to evaluate whether similar phenomena occur in men, we searched for sperm miRNA changes that occur in both mice and men exposed to early life stressors that have long-lasting effects. For men, we used the Adverse Childhood Experience (ACE) questionnaire. It reveals the degree of abusive and/or dysfunctional family experiences when young, which increases risks of developing future psychological and physical disorders. For male mice, we used adolescent chronic social instability (CSI) stress, which not only enhances sociability defects for >1 year, but also anxiety and defective sociability in female offspring for multiple generations through the male lineage. Here we found a statistically significant inverse correlation between levels of multiple miRNAs of the miR-449/34 family and ACE scores of Caucasian males. Remarkably, we found members of the same sperm miRNA family are also reduced in mice exposed to CSI stress. Thus, future studies should be designed to directly test whether reduced levels of these miRNAs could be used as unbiased indicators of current and/or early life exposure to severe stress. Moreover, after mating stressed male mice, these sperm miRNA reductions persist in both early embryos through at least the morula stage and in sperm of males derived from them, suggesting these miRNA changes contribute to transmission of stress phenotypes across generations. Since offspring of men exposed to early life trauma have elevated risks for psychological disorders, these findings raise the possibility that a portion of this risk may be derived from epigenetic regulation of these sperm miRNAs.

Teen Mothers' Experience of Intimate Partner Violence: A Metasynthesis

Pregnant and parenting teens suffer higher rates of intimate partner violence (IPV) than older mothers. This qualitative metasynthesis explores teen mothers' experience with IPV during pregnancy and postpartum. Organized by the metaphor of a web, findings highlight how pervasive violence during childhood contributes to teen pregnancy and the risk of IPV as violence is normalized. The web constricts through the partner's control as violence emerges or worsens with pregnancy. Young mothers become increasingly isolated, and live with the physical and psychological consequences of IPV. Trauma-informed nursing practice is needed to support teen mothers in violent intimate relationships to spin a new web.

Nurse practitioner screening for childhood adversity among adult primary care patients: A mixed-method study

BACKGROUND AND PURPOSE

Researchers have demonstrated an association between experiencing childhood abuse and multiple chronic health conditions in adulthood, yet this evidence has not been routinely translated to practice. The purpose of this research study was to examine nurse practitioner (NP) practices, skills, attitudes, and perceived barriers associated with screening adult patients for childhood abuse to determine the extent to which evidence of the association between childhood abuse and negative health outcomes has been translated to NP practice.

METHODS

A mixed-method approach with web-based questionnaires and online focus groups was used to examine NP screening for histories of childhood abuse.

CONCLUSIONS

A total of 188 complete NP surveys were analyzed along with data from focus groups with 12 NPs. One third of the NPs regularly screened for childhood abuse and believed screening was their responsibility. Six barriers, including insufficient time and lack of confidence when inquiring about abuse, were significantly associated with NP screening practices. The focus group participants discussed how and when one should ask about childhood abuse, and the need for education about screening.

IMPLICATIONS FOR PRACTICE

Time constraints and NPs' lack of confidence in their ability to screen for histories of childhood abuse must be addressed to encourage routine screening in primary care practice.

Girlhood Betrayals of Women Childhood Trauma Survivors in Treatment for Addiction

PURPOSE

This research explored the understanding of trauma from the perspective of women who had experienced abuse and neglect in childhood. The goal was to better conceptualize potential avenues or interventions for prevention and treatment.

DESIGN

Qualitative description of the accounts of eight women who were childhood trauma survivors and in treatment for addiction. Open-ended interviews focused on key events or experiences during childhood and adolescence and the use of drugs and alcohol.

FINDINGS

Four levels of betrayal fit the accounts the participants gave as the dominant theme in their narratives. "Primary betrayal" referred to the direct victimization by a perpetrator; "secondary betrayal" referred to the complicity, denial, or indifference of another adult to the child's victimization; "tertiary betrayal" referred to failures of responsible individuals in community settings to protect the child; and "quaternary betrayal" represented self-betrayals. Substance misuse was an adolescent self-betrayal that provided initial solace yet ultimately threatened the integrity of the girls. We found an almost complete lack of support in family and community settings for the participants.

CONCLUSIONS

These findings on betrayal inform health care for trauma survivors and can be a framework for preventing violence against children.

CLINICAL RELEVANCE

Interventions for child and adolescent trauma survivors are critical to prevent the life-long health sequelae of childhood trauma. Pivotal times to engage these survivors include periods when they may be accessed in school and healthcare settings.