Development and implementation of a pediatric adverse childhood experiences (ACEs) and other determinants of health questionnaire in the pediatric medical home: A pilot study.

Kadiatou Koita,Danielle Hessler,Karen Daley,Monica Bucci,Neeta Thakur,Nadine Burke Harris,Dayna Long,Mindy Benson,Wen-Jun Tu

doi:10.1371/journal.pone.0208088

Abstract

Adverse Childhood Experiences (ACEs) are associated with poor health outcomes, underlining the significance of early identification and intervention. Currently, there is no validated tool to screen for ACEs exposure in childhood. To fill this gap, we designed and implemented a pediatric ACEs questionnaire in an urban pediatric Primary Care Clinic. Questionnaire items were selected and modified based on literature review of existing childhood adversity tools. Children twelve years and under were screened via caregiver report, using the developed instrument. Cognitive interviews were conducted with caregivers, health providers, and clinic staff to assess item interpretation, clarity, and English/Spanish language equivalency. Using a rapid cycle assessment, information gained from the interviews were used to iteratively change the instrument. Additional questions assessed acceptability of screening within primary care and preferences around administration. Twenty-eight (28) caregivers were administered the questionnaire. Cognitive interviews conducted among caregivers and among 16 health providers and clinic staff resulted in the changes in wording and addition of examples in the items to increase face validity. In the final instrument, no new items were added; however, two items were merged and one item was split into three separate items. While there was a high level of acceptability of the overall questionnaire, some caregivers reported discomfort with the sexual abuse, separation from caregiver, and community violence items. Preference for methods of administration were split between tablet and paper formats. The final Pediatric ACE and other Determinants of Health Questionnaire is a 17-item instrument with high face validity and acceptability for use within primary care settings. Further evaluation on the reliability and construct validity of the instrument is being conducted prior to wide implementation in pediatric practice.

Highlights

Adverse Childhood Experiences (ACEs) are stressful or traumatic events experienced before the age of 18 years and were found to have a dose-response relationship with numerous poor health outcomes in a landmark study conducted by the CDC and Kaiser [1]
Drawing from the adult ACE and other adversity and trauma screening tools, a literature review, the WHO criteria and the team’s experience, we developed the first pediatric ACE and other determinants of health questionnaire
The collaborative approach supported by empirical evidence and a rapid cycle testing through cognitive interviews proved to be effective in developing a pediatric adversity questionnaire

Summary

Introduction

Adverse Childhood Experiences (ACEs) are stressful or traumatic events experienced before the age of 18 years and were found to have a dose-response relationship with numerous poor health outcomes in a landmark study conducted by the CDC and Kaiser [1]. Since the publication of the ACE Study in 1998, subsequent studies have demonstrated the broad prevalence of ACEs in the general population and have added to the evidence showing the graded association between ACEs and negative health and behavioral outcomes. Exposure to these adversities in childhood, without the buffering protection of a caregiver, may lead to changes in children’s developing brains resulting in a dysregulation of the stress response, impairment of executive functioning, changes to the endocrine and immune systems and to genetic regulatory mechanisms, increased risky behaviors, and difficulty with forming healthy relationships [2]. The temporality and intensity of ACEs occurrence during childhood is important and suggests that there is an opportunity to identify children at risk for accumulating ACEs and the associated negative health outcomes, to promote prevention and support the unfolding of resilience, and to develop targeted interventions for those identified as ‘at risk’

Methods

Results

Discussion

Conclusion