Client and Provider Discomfort With an Adverse Childhood Experiences Survey

doi:10.1016/j.amepre.2019.02.026

American Journal of Preventive Medicine

Volume 57, Issue 2, August 2019, Pages e51-e58

https://doi.org/10.1016/j.amepre.2019.02.026 Get rights and content

Introduction

Many service providers report concerns that questions about adverse events may upset clients. Studies indicate that most survey respondents answer sensitive questions without experiencing distress, although little is known about the prevalence or correlates of clients’ discomfort when they are asked similar questions by direct care providers, such as home visitors.

Methods

This study used data collected between 2013 and 2018 from 1,678 clients and 161 providers in a network of home visiting programs in Wisconsin. Clients and home visitors completed an adverse childhood experience questionnaire that concludes by asking about discomfort with the questions. Analyses conducted in 2018 examined overall client discomfort and associations between discomfort and the endorsement of 10 distinct adverse childhood experiences. Multilevel regressions were performed to test whether client and provider factors were associated with client discomfort.

Results

More than 80% of clients were not at all or slightly uncomfortable with the adverse childhood experience questionnaire, and 3% reported extreme discomfort. Bivariate results showed that each adverse childhood experience, except parental divorce, was associated with greater discomfort; sexual abuse was the only adverse childhood experience associated with discomfort in a multivariate analysis. Multiple client variables were linked to increased discomfort, including higher adverse childhood experience scores (b=0.06, 95% CI=0.04, 0.08) and depression scores (b=0.01, 95% CI=0.00, 0.02). Home visitor discomfort was positively associated with client discomfort (b=0.16, 95% CI=0.01, 0.31).

Conclusions

Results indicated that most clients in home visiting programs tolerated an adverse childhood experience questionnaire well. The findings point to clients who may be more likely to report discomfort and highlight an important association between client and provider discomfort.

Section snippets

INTRODUCTION

Adverse childhood experiences (ACEs) are a common class of acute or recurring stressors that encompass multiple forms of child maltreatment and household dysfunction. More than half of U.S. adults have endured at least one ACE,1, 2, 3 and the prevalence is even higher in low-income groups.4, 5 Research also has shown that greater exposure to ACEs increases the risk of morbidity and mortality across SES.6, 7 Although the public health implications are becoming increasingly clear,⁸ the

Study Population

This was a study of clients and service providers in Wisconsin's Family Foundations Home Visiting (FFHV) Program, a statewide network of agencies that support pregnant women and parents with young children. All FFHV agencies receive federal funding from the Maternal Infant and Early Childhood Home Visiting Program, which currently allocates $400 million per year nationwide to evidence-based home visiting.²⁶ States, territories, and tribes dedicate Maternal Infant and Early Childhood Home

RESULTS

The sample included 1,678 women who were aged >16 years and had completed an ACE assessment with a home visitor between September 2013 and June 2018. Of all the participants, 44.6% were white, non-Hispanic; 20.9%, Hispanic; 19.3%, non-Hispanic African American; 10%, non-Hispanic American Indian; and 5.2%, of other race/ethnicity. The mean age of participants was 24.4 years (SD=6.0), and 26.8% had some postsecondary education. As shown in Table 1, the mean level of client discomfort was 1.7

DISCUSSION

This is one of the first studies of client discomfort with an ACE questionnaire in a direct care setting. More than 80% of 1,678 low-income women reported that they were not at all or slightly uncomfortable completing a brief ACE assessment with their home visitors, whereas 3% reported extreme discomfort. The results are comparable to a smaller study of mothers receiving child welfare services.²⁰ Taken together, the findings suggest that it is not uncommon for clients to experience some

CONCLUSIONS

This is the first study to show that there is an association between provider and client discomfort with an ACE questionnaire. The findings suggest that it may be possible to minimize client discomfort by ensuring that assessors are at ease with questions about ACE. It may be helpful for providers to learn that research participants typically respond to sensitive survey questions without experiencing major distress.16, 17, 18, 19 This study contributes to the literature by demonstrating that

ACKNOWLEDGMENTS

This work was supported by funding from the Maternal, Infant, and Early Childhood Home Visiting Grant Program, U.S. HHS, Health Resources and Services Administration (Awards: X10MC311790100, X10MC295120100).

No financial disclosures were reported by the authors of this paper.

REFERENCES (45)

VJ Felitti 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)
JP Mersky et al.
Poor mental health among low-income women in the U.S.: the roles of adverse childhood and adult experiences
Soc Sci Med
(2018)
N Slopen et al.
Racial disparities in child adversity in the U.S.: interactions with family immigration history and income
Am J Prev Med
(2016)
K Hughes et al.
The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis
Lancet Public Health
(2017)
RF Anda et al.
Building a framework for global surveillance of the public health implications of adverse childhood experiences
Am J Prev Med
(2010)
SR Dube
Continuing conversations about adverse childhood experiences (ACEs) screening: a public health perspective
Child Abus Negl
(2018)
D Finkelhor
Screening for adverse childhood experiences (ACEs): cautions and suggestions
Child Abus Negl
(2018)
EA Walker et al.
Does the study of victimization revictimize the victims?
Gen Hosp Psychiatry
(1997)
D Finkelhor et al.
Upset among youth in response to questions about exposure to violence, sexual assault and family maltreatment
Child Abus Negl
(2014)
V Bergink et al.
Validation of the Edinburgh Depression Scale during pregnancy
J Psychosom Res
(2011)

Z Kozinszky et al.

Validation studies of the Edinburgh Postnatal Depression Scale for the antenatal period

J Affect Disord

(2015)

D Finkelhor et al.

The lifetime prevalence of child sexual abuse and sexual assault assessed in late adolescence

J Adolesc Health

(2014)

CD Bethell et al.

Methods to assess adverse childhood experiences of children and families: toward approaches to promote child well-being in policy and practice

Acad Pediatr

(2017)

JG Green et al.

Childhood adversities and adult psychiatric disorders in the national comorbidity survey replication I: associations with first onset of DSM-IV disorders

Arch Gen Psychiatry

(2010)

L Bynum et al.

Adverse childhood experiences reported by adults – five states, 2009

MMWR Morb Mortal Wkly Rep

(2010)

KA Kalmakis et al.

Adverse childhood experiences: towards a clear conceptual meaning

J Adv Nurs

(2014)

L Weinreb et al.

Screening for childhood trauma in adult primary care patients: a cross-sectional survey

Prim Care Companion J Clin Psychiatry

(2010)

W Tink et al.

Adverse childhood experiences: survey of resident practice, knowledge, and attitude

Fam Med

(2017)

MM Bruce et al.

Trauma providers’ knowledge, views, and practice of trauma-informed care

J Trauma Nurs

(2018)

JM Lang et al.

Trauma screening in child welfare: lessons learned from five states

J Child Adolesc Trauma

(2017)

S Sprague et al.

Barriers to screening for intimate partner violence

Women Health

(2012)

J Langhinrichsen-Rohling et al.

Sensitive research with adolescents: just how upsetting are self-report surveys anyway?

Violence Vict

(2006)

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Childhood adversity contributes to poor physical and mental illness across the lifespan. Given its multifaceted nature, responding to childhood adversity requires action across health and social care; but such action is complex. This study aimed to explore the barriers for practitioners across health and social services in identifying and responding to adversity.
Individual and group semi-structured interviews with 26 practitioners working across health and social care providers in Melbourne, Victoria. Interviews explored challenges practitioners experienced identifying and responding to childhood adversity. Interviews were audio recorded, transcribed verbatim and analysed using reflexive thematic analysis.
Four main themes were identified. (1) “Get clues as you go along”. Practitioners relied on gut instinct or caregiver disclosure to identify adversity. (2) Out of my control. Practitioners identified systems barriers that were out of their control including lack of service availability and funding. (3) Navigating complex systems. Practitioners acknowledged challenges in knowing about available services and how to access these services. (4) “Opportunity to engage”. While practitioners identified trust as important for relationships with families, they could not describe how to improve trust.
Practitioners encounter a “multitude of barriers” across health and social care that impede identification of, and response to, childhood adversity. Improving practitioner confidence and capability to work relationally with families, including directly asking about adversity, is critical for overcoming these barriers to systematically identify adversity in practice. Improving practitioner knowledge about community services and service navigation will be a crucial starting point.
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As briefly discussed above, practitioners often hesitate to bring up traumatizing past events or history due to fear of the patient being retraumatized. Even though many patients answer sensitive questions without experiencing distress, this is a common reason why providers say they are not screening for ACEs.13 However, with education and training, and providing patients with resources and follow-up, screening for ACEs can be effective in providing holistic care.14
This pilot study provides a baseline understanding of nurse practitioners’ (NPs’) and NP students’ current knowledge and reported barriers to screening for adverse childhood experiences. A 23-question survey was distributed by email to NP and NP student members of 2 local chapters of a state NP organization. Results showed that a significant number of practitioners understood the importance of adverse childhood experiences screening but failed to perform screening due to multiple barriers. A review of barriers identified a need for improved screening methods, provider education, allocation of time, and follow-up resources as essential to improve current screening practices.
Client and staff experiences assessing adverse childhood experiences in a clinical setting: Results from the First Nations ACE Study
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This finding is notable, as there has been some debate about how the collection of ACE data is perceived by participants. Some propose that disclosing trauma within a health setting could harm individuals (Yeater & Miller, 2014), however, our findings support findings that most participants do not report discomfort (Jaffe, DiLillo, Hoffman, Haikalis, & Dykstra, 2015; Mersky, Lee, & Gilbert, 2019). One participant withdrew from research participation due to experiencing some distress completing study measures, and as per our research protocols, was supported to inform a representative of the university research ethics board.
Conducting culturally-relevant research with Indigenous populations requires a balance of approaches that benefit Indigenous communities, while perceiving and mitigating the potential risk of harm when engaging in research-related activities. Reducing the burden of research is especially useful for research with Indigenous populations as ongoing systemic marginalization and discrimination through historical colonial practices may result in a higher likelihood of experiencing harm from research activities. One way to ensure that stakeholder experiences with the research processes are not burdensome, and to understand how study implementation practices are perceived across research teams, supporting organizations, and individual participants is to build this into the study method.
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Directions for future research are discussed, including discussion of modifications that will be made to future iterations of the presented research study.
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Given that the CCE measure favors strengths-oriented question items, it may be a promising alternative to the risk-oriented ACE score in assessing parental childhood adversities known to be associated with the maltreatment of one's own children, and as an approach for identifying service needs related to childhood trauma in a maltreatment prevention context.
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Kia-Keating et al25 found clinicians’ initial uncertainty about ACE screening diminished as they quickly recognized the positive impact screening had on building rapport and increasing meaningful conversations. Clinicians have voiced concerns that discussing sensitive issues raised by ACE screening may cause intense distress for patients; however, most patients answered ACE questions without intense distress.19-22 Clinicians recognized that ACE screening highlighted the connection between physical and mental health, helping integrate health care.25
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.
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Research ArticleClient and Provider Discomfort With an Adverse Childhood Experiences Survey

Introduction

Methods

Results

Conclusions

Section snippets

INTRODUCTION

Study Population

RESULTS

DISCUSSION

CONCLUSIONS

ACKNOWLEDGMENTS

Am J Prev Med

Soc Sci Med

Am J Prev Med

Lancet Public Health

Am J Prev Med

Child Abus Negl

Child Abus Negl

Gen Hosp Psychiatry

Child Abus Negl

J Psychosom Res

J Affect Disord

J Adolesc Health

Acad Pediatr

Childhood adversities and adult psychiatric disorders in the national comorbidity survey replication I: associations with first onset of DSM-IV disorders

Arch Gen Psychiatry

Adverse childhood experiences reported by adults – five states, 2009

MMWR Morb Mortal Wkly Rep

Adverse childhood experiences: towards a clear conceptual meaning

J Adv Nurs

Screening for childhood trauma in adult primary care patients: a cross-sectional survey

Prim Care Companion J Clin Psychiatry

Adverse childhood experiences: survey of resident practice, knowledge, and attitude

Fam Med

Trauma providers’ knowledge, views, and practice of trauma-informed care

J Trauma Nurs

Trauma screening in child welfare: lessons learned from five states

J Child Adolesc Trauma

Barriers to screening for intimate partner violence

Women Health

Sensitive research with adolescents: just how upsetting are self-report surveys anyway?

Violence Vict

Research Article
Client and Provider Discomfort With an Adverse Childhood Experiences Survey