Advertisement

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

Published:August 21, 2022DOI:https://doi.org/10.1016/j.acap.2022.08.002

      Abstract

      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.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Academic Pediatrics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Felitti VJ
        • Anda RF
        • Nordenberg D
        • et al.
        Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.
        Am J Prev Med. 1998; 14: 245-258
        • Burke NJ
        • Hellman JL
        • Scott BG
        • et al.
        The impact of adverse childhood experiences on an urban pediatric population.
        Child Abuse Negl. 2011; 35: 408-413
        • Oh DL
        • Jerman P
        • Silvério Marques S
        • et al.
        Systematic review of pediatric health outcomes associated with childhood adversity.
        BMC Pediatr. 2018; 18: 83
        • Garner A
        • Yogman M
        • COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, SECTION ON DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS, COUNCIL ON EARLY CHILDHOOD
        Preventing childhood toxic stress: partnering with families and communities to promote relational health.
        Pediatrics. 2021; 148https://doi.org/10.1542/peds.2021-052582
      1. Health Resources & Services Administration's Maternal and Child Health Bureau. NSCH data brief: adverse childhood experiences. National Survey of Children's Health. Published June 2020. Accessed March 11, 2022. https://mchb.hrsa.gov/sites/default/files/mchb/data-research/nsch-ace-databrief.pdf

        • Conn AM
        • Szilagyi M
        • Forkey H.
        Adverse childhood experience and social risk: pediatric practice and potential.
        Acad Pediatr. 2020; 20: 573-574
        • Jee S
        • Forkey H.
        Maximizing the benefit of screening for adverse childhood experiences.
        Pediatrics. 2022; 149https://doi.org/10.1542/peds.2021-054624
        • Purewal Boparai SK
        • Au V
        • Koita K
        • et al.
        Ameliorating the biological impacts of childhood adversity: a review of intervention programs.
        Child Abuse Negl. 2018; 81: 82-105
        • Garner AS
        • Shonkoff JP
        • Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, Section on Developmental and Behavioral Pediatrics
        Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health.
        Pediatrics. 2012; 129: e224-e231
      2. Shaw JS Duncan PM Hagan JF Bright Futures Guidelines. 4th ed. American Academy of Pediatrics, Itasca, IL2017
        • Kerker BD
        • Storfer-Isser A
        • Szilagyi M
        • et al.
        Do pediatricians ask about adverse childhood experiences in pediatric primary care?.
        Acad Pediatr. 2016; 16: 154-160
        • Ford K
        • Hughes K
        • Hardcastle K
        • et al.
        The evidence base for routine enquiry into adverse childhood experiences: a scoping review.
        Child Abuse Negl. 2019; 91: 131-146
        • Finkelhor D.
        Screening for adverse childhood experiences (ACEs): cautions and suggestions.
        Child Abuse Negl. 2017; https://doi.org/10.1016/j.chiabu.2017.07.016
        • Schilling S
        • Murray A
        • Mollen CJ
        • et al.
        Pediatric emergency department and primary care provider attitudes on assessing childhood adversity.
        Pediatr Emerg Care. 2019; 35: 527-532
        • Loveday S
        • Hall T
        • Constable L
        • et al.
        Screening for adverse childhood experiences in children: a systematic review.
        Pediatrics. 2022; 149https://doi.org/10.1542/peds.2021-051884
        • McLennan JD
        • MacMillan HL
        • Afifi TO
        • et al.
        Routine ACEs screening is NOT recommended.
        Paediatr Child Health. 2019; 24: 272-273
        • Rariden C
        • SmithBattle L
        • Yoo JH
        • et al.
        Screening for adverse childhood experiences: literature review and practice implications.
        J Nurse Pract. 2021; 17: 98-104
        • Mishra K
        • Atkins DE
        • Gutierrez B
        • et al.
        Screening for adverse childhood experiences in preventive medicine settings: a scoping review.
        J Public Health. 2021; https://doi.org/10.1007/s10389-021-01548-4
        • Kia-Keating M
        • Barnett ML
        • Liu SR
        • et al.
        Trauma-responsive care in a pediatric setting: feasibility and acceptability of screening for adverse childhood experiences.
        Am J Community Psychol. 2019; 64: 286-297
        • Conn AM
        • Szilagyi MA
        • Jee SH
        • et al.
        Parental perspectives of screening for adverse childhood experiences in pediatric primary care.
        Fam Syst Health. 2018; 36: 62-72
        • Selvaraj K
        • Ruiz MJ
        • Aschkenasy J
        • et al.
        Screening for toxic stress risk factors at well-child visits: the addressing social key questions for health study.
        J Pediatr. 2019; 205 (e4): 244-249
        • Sacks V
        • Murphey D.
        The prevalence of adverse childhood experiences, nationally, by state, and by race or ethnicity.
        Child Trends. 2018; (Accessed April 4, 2019)
        • Bennett KP
        • Blake LN.
        Self-reporting and social desirability: the implications for e-cigarette data collection.
        Can J Public Health. 2016; 107: e136
        • Flores G
        • Salazar JC.
        Immigrant Latino children and the limits of uestionnaires in capturing adverse childhood events.
        Pediatrics. 2017; 140https://doi.org/10.1542/peds.2017-2842
        • Cronholm PF
        • Forke CM
        • Wade R
        • et al.
        Adverse hildhood experiences: expanding the concept of adversity.
        Am J Prev Med. 2015; 49: 354-361
      3. Burke Harris N RTS. Center for Youth Wellness ACE-Questionnaire (CYW ACE-Q Child, Teen, Teen SR). Published online 2015.

        • Charmaz K.
        Constructing Grounded Theory: A Practical Guide Through Qualitative Analysis.
        SAGE Publications Inc, Thousand Oaks, CA2006
        • Trauma and Justice Strategic Initiative Workgroup
        SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. 14-4884. Substance Abuse and Mental Health Services Administration, Rockville, MD2014
        • Ford J WC
        SAMHSA’s Trauma and Trauma-Informed Care Experts Meeting. Substance Abuse and Mental Health Services Administration, Rockville, MD2012
        • Koita K
        • Long D
        • Hessler D
        • et al.
        Development and implementation of a pediatric adverse childhood experiences (ACEs) and other determinants of health questionnaire in the pediatric medical home: a pilot study.
        PLoS One. 2018; 13e0208088
        • Gillespie RJ
        • Folger AT.
        Feasibility of assessing parental ACEs in pediatric primary care: implications for practice-based implementation.
        J Child Adolesc Trauma. 2017; 10: 249-256
        • Garg A
        • Boynton-Jarrett R
        • Dworkin PH.
        Avoiding the unintended consequences of screening for social determinants of health.
        JAMA. 2016; 316: 813-814
        • McLennan JD
        • Macmillan HL
        • Afifi TO
        • et al.
        Problems with the recommendation to implement ACEs screening.
        Paediatr Child Health. 2020; 25: 64-65
      4. Screening Programmes: A Short Guide. Increase Effectiveness, Maximize Benefits and Minimize Harm.
        World Health Organization, Geneva, Switzerland2020
        • 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. 2021; https://doi.org/10.1093/pubmed/fdab238