Inter-Clinician Variability in Primary Care Providers' Adverse Childhood Experience Knowledge, Training, Screening Practices, and Perceived Intervention Barriers: an Exploratory Cross-Sectional Study

The California adverse childhood experiences screening roll-out: a survey study of ACEs screening implementation in primary care

Background

California adopted universal screening of adverse childhood experiences (ACEs) in January 2020 and dedicated significant financial and human resources to "ACES Aware," a statewide campaign to scale ACEs screening throughout the state. Provider perspectives after the roll-out of ACEs Aware have been understudied. The aim of this study was to understand provider perspectives on universal ACEs screening in primary care. We explored indicators of acceptability, utility, and barriers and facilitators of screening for ACEs. We also investigated treatments offered for disclosed ACEs.

Methods

A cross-sectional survey with quantitative and qualitative components was distributed via Facebook, Twitter, and electronic listservs between March and April 2022, 2 years after the launch of ACEs Aware. The survey included the validated and reliable "Acceptability of Implementation Measure" and "Feasibility of Implementation Measure" as well as multiple choice, ranking, and free-text items to understand determinants of screening and treatment approaches.

Results

Eighty two primary care providers in California, working primarily in pediatrics (84%), completed the survey. The majority (78%) received training on assessing ACEs and 60% reported using the Pediatric ACEs and Related Life-events Screener (PEARLS). About 22% "strongly agree" that PEARLS is acceptable and 32% "strongly agree" that PEARLS is feasible. Only 17% "strongly agree" that they like PEARLS. The top barriers were: (1) insufficient time; (2) unclear treatment pathway for detected ACEs; and (3) inadequate staffing to perform screening. The top facilitators for screening were: (1) financial incentives for providers to screen; (2) financial incentives for organizational leadership to implement screening; and (3) leadership support of screeners. The top approaches for addressing ACEs were: (1) behavioral therapy; (2) case navigation; and (3) trauma-informed care.

Conclusion

This study provided a first look at provider perspectives on ACEs screening and treatment in a sample of California providers. Most responding providers report currently screening for ACEs and using PEARLS. Perceptions of feasibility were slightly higher than for acceptability. Facilitators were largely top-down and organizational in nature, such as financial incentives and leadership support. Future directions could include an exploration into why some providers may find ACEs unappealing and research to identify effective and accessible treatment approaches for ACEs.

Trauma Informed Care: Practical Application for Pediatric-Focused Advanced Practice Registered Nurses

Trauma-informed care (TIC) is an essential holistic framework for pediatric-focused advanced practice registered nurses (APRNs) to understand, recognize, and respond to children and families who have experienced trauma while resisting re-traumatization. TIC allows APRNs to engage with children with an understanding of how trauma impacts well-being. Universal adoption of TIC is prudent; it assumes all patients experience some degree of trauma and disclosure is limited. The National Association of Pediatric Nurse Practitioners Partners for Vulnerable Youth published an evidence-based TIC toolkit online for pediatric-focused ARPNs as a clinical guide for TIC application. This article reviews toolkit elements and demonstrates practical application of TIC.

Negative effects of adverse childhood experiences and absence of positive childhood experiences on healthcare employees: survey findings built on 10 years of trauma-informed development

Introduction

Existing data on how history of trauma and adversity affects healthcare professionals is limited. This study sought to describe the prevalence of Adverse Childhood Experiences (ACEs) and Positive Childhood Experiences (PCEs) and their association with present-day workplace and wellbeing outcomes among a sample of healthcare teammates overall, as well as specifically among nurses. The paper also describes local trauma-informed care initiatives that supported study feasibility.

Methods

Cross-sectional online survey data were collected in conjunction with promoting hospital-wide trauma-informed care training opportunities on two campuses that are part of an academic health system. Scales and items assessed independent variables PCEs and ACEs, and dependent variables including burnout, compassion fatigue, organizational belonging, adult resilience, access to support, and workplace violence (WPV). Demographic data were not collected to limit identifiability and encourage participation. Multivariable, hierarchical models regressed categorized total ACEs (ref 0, 1-3, 4-10) and total PCEs (ref 6-7, 3-5, 0-2) together on dichotomized dependent variables. Sub-analyses also adjusted for whether the participant was a nurse or reported serving in a different role.

Results

Participants included 349 clinical and non-clinical employees, of whom 61.1% had at least one reported ACE, but 24.9% reported 4-10 ACEs. 29.9% reported only having 3-5 PCEs in their childhood, while 23.2% reported 0-2 positive childhood experiences. Even when adjusting for ACEs, having 0-2 PCEs was associated with significantly reduced odds of getting needed emotional or social support (AOR = 0.14, 95% CI: 0.07, 0.29). Having 0-2 PCEs relative to 6-7 PCEs was also significantly associated with greater odds of past 2-week compassion fatigue, a lower resilience score, and decreased odds of reported organizational belonging measures. Adjusting for ACEs and PCEs, nurses reported lower resilience and higher workplace violence compared to all other participant roles combined.

Discussion

Teammate history of adversity was widespread and having fewer PCEs was associated with poorer adult workplace outcomes. These findings point to the value of a trauma-informed approach in healthcare, which offers healthcare organizations a framework for recognizing how trauma experiences affect wellbeing and intersect with the healthcare system, as well as how to create environments that are supportive of patients, staff, and providers.

Implementing an Adverse Childhood Experiences Screening Tool With Migrant Children: A Quality Improvement Project Using the PEARLS Screening Tool

BACKGROUND

Immigrants, asylum seekers, and refugees live with extreme stress, consistent vulnerability, and life-long health consequences. Children in these populations face an increased risk of poor mental health because of adverse childhood experiences (ACEs).

AIM

To implement an ACE screening questionnaire for all migrant children aged < 19 years in a community shelter.

METHOD

The Model for Improvement.

INTERVENTION

The Pediatric ACEs and Related Life Events Screener was implemented over 10 weeks in a community shelter.

RESULTS

All children screened had at least 1 ACE. Initiation of screening led to the recognition of adverse experiences, thus allowing for mental health support and referrals to mental health specialists.

CONCLUSIONS

This quality improvement project supports screening for ACEs in migrant children to uncover potential mental health concerns and provide targeted support, recognizing the long-term effects of trauma on their well-being.

Investigating child-facing practitioners' understanding of adversity and its impact on children's development and service provision

Adversity during childhood is a common risk factor for poorer outcomes across physical, mental, and social health. Despite growing evidence and policy around preventing adversity and its sequalae, the incidence of adversity in childhood remains high. Child-facing practitioners (CfPs) may be well-placed to identify adversity and address its impact on children. This study investigated the understanding of adversity and current practice of CfPs working in the Education system, Healthcare and Social Care in England. An anonymous online survey was completed by 113 CfPs between April and June 2022. Data were analysed using descriptive statistics. Participating CfPs' reported using a range of assessment tools and direct observation, but there was a lack of consistency in the extent to which different types of adversity were explored in assessments. CfPs working in the Education system and Healthcare reported only liaising with Social Care services when a current worker was known to be involved with the family, or to make a referral. Indeed, a quarter of respondents from the Education system and Healthcare only considered early life experiences when capacity allowed. Over half of the CfPs in this survey 'did not know' or 'did not agree' that public services offer interventions to support families experiencing domestic abuse, parental mental health difficulties and addiction, or the impact of these adversities on children's wellbeing. The study highlights that CfPs could benefit from further training about the prevalence and impact of adversity to inform service delivery. A review of CfPs' routine assessments is needed to ensure that children's exposure to adversity is routinely identified; this will facilitate families to access appropriate support to mitigate the impact of such experiences.

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).