The impact of adverse childhood experiences on healthcare utilization in children.

BACKGROUND: Adverse childhood experiences (ACEs) are related to long-term negative outcomes. The impact of these experiences on healthcare utilization in children has been understudied. OBJECTIVE: To examine the impact of ACEs on children's healthcare utilization, medical diagnoses, and pharmacological treatment. PARTICIPANTS AND SETTING: Children aged 6 months to 17 years who were screened for ACEs in the Behavioral Health Department or in primary care locations as part of an initial consultation visit and who had at least one subsequent healthcare visit during the study period were included in the study. METHODS: Adverse childhood experiences were measured using the ACE screening questionnaire designed by Felitti et al. (1998). Data from the year following administration of the ACE screening tool were retrospectively extracted from the electronic health record. RESULTS: Overall, 1,183 children met study inclusion criteria. Children with any reported ACEs were more likely to no show appointments (1-3 ACEs incidence rate ratio (IRR) [95 % confidence interval (CI)]: 1.40 [1.11-1.77]; 4+ ACEs IRR [95 % CI]: 1.41 [1.08-1.84]) and to use emergency services (1-3 ACEs IRR [95 % CI]: 1.24 [1.00-1.53]; 4+ ACEs: IRR [95 % CI]: 1.42 [1.11-1.81) than children with no ACEs. Those with 4+ ACEs used the telephone nurse advisor less frequently (1-3 ACEs IRR [95 % CI]: 0.67 [0.53-0.84]; 4+ ACEs IRR [95 % CI]: 0.69 [0.53-0.90]). Although ACE scores were associated with healthcare utilization, insurance status was more robustly associated with healthcare utilization than ACE score. CONCLUSIONS: Healthcare systems may employ results from this study to adopt trauma-informed care initiatives. Ensuring that all patients have insurance may be a first step toward improving healthcare utilization.

Implementation of the adverse childhood experiences conversation in primary care.

BACKGROUND: Research has focused on screening for adverse childhood experiences, rather than provision of education as a part of routine anticipatory guidance. An adverse childhood experiences 'conversation' is one method that has not been studied empirically but represents a complimentary or alternative approach to screening which could overcome many existing barriers. OBJECTIVES: This study aims to examine parent/guardian and provider acceptability/feasibility of the adverse childhood experiences conversation during well-child visits in primary care. METHODS: Providers engaged in a conversation with parents/guardians of patients during well-child visits in a family medicine residency clinic. Parents/guardians and providers were surveyed following the visit to examine acceptability and feasibility. Quarterly assessments to further examine provider perspectives were completed. Data were collected for 1 year. RESULTS: In total, 238 parent/guardian and 231 provider surveys were completed. Most parents/guardians felt positively (76%) about and comfortable (81%) with the information discussed and 97% felt that the conversation should be had with their primary care provider specifically. Most providers (71%) indicated that parents/guardians were receptive to the conversation, that the conversations took 1-2 minutes (60%) and that there were few disclosures of adversity (9%), none of which required mandatory reporting. CONCLUSIONS: Results suggest that the adverse childhood experiences conversation is well received by parents/guardians and providers and is feasible to implement into primary care. The conversation could be used as a complimentary or alternative method to screening to further spread knowledge of toxic stress and health, provide resources for families and promote resilience.

The relationship between adverse childhood experiences, healthcare utilization, cost of care and medical comorbidities.

BACKGROUND: Prior research suggests that those experiencing adverse childhood experiences (ACEs) may be higher utilizers of the healthcare system. The frequency and financial impact of kept, cancelled and no-showed visits is largely unknown. OBJECTIVE: To examine the impact of adverse childhood experiences (ACEs) on healthcare utilization in a sample of US adults. PARTICIPANTS AND SETTING: Two thousand thirty-eight adult patients who completed an ACE screening within the behavioral health department of a medium sized, Midwestern healthcare system during 2015-2017 were included. METHODS: Data was extracted retrospectively from 1-year post ACE screen. RESULTS: Individuals with high ACEs (4+) made more but kept fewer appointments than those with no or moderate (1-3) ACEs (p < 0.0001). Individuals with high ACES had more late-cancelled and no-showed appointments compared to those with no ACEs (p's < .0001). Relationships were significant even after controlling for age, gender, and insurance type. Those with high ACEs had the greatest impact on potential lost revenue given that they late-cancelled and no-showed more appointments. Those with high ACEs also had more medical comorbidities, medications, and needed care coordinator than those with moderate or no ACEs (p's < .05) CONCLUSIONS: Results from this study should be used to inform providers and health care systems on the effects of adversity on patterns of utilization of health care and encourage innovative strategies to better address the needs of these patients.

A Short-Term Evaluation of a Hospital No Hit Zone Policy to Increase Bystander Intervention in Cases of Parent-to-Child Violence.

This study used a pre/post design to evaluate the implementation of a hospital-wide No Hit Zone (NHZ) bystander intervention around parent-to-child hitting. A total of 2,326 staff completed the pre-NHZ survey and received training about the NHZ policy; 623 staff completed the post-test survey 10 months later. A group of 225 parents participated in the pre-NHZ survey and a second group of 180 participated in the post-NHZ survey, also 10 months later. Compared to staff in the pre-NHZ group, staff in the post-NHZ group had more negative attitudes about spanking and more positive attitudes about intervention when parents hit children in the hospital. Few differences were found among the parent pre- and post-groups. This study demonstrated that NHZs are a feasible way to inform and train hospital staff in ways to intervene during incidents of parent-to-child hitting to promote a safe and healthy medical environment.

Adapting the Patient-Centered Medical Home to Address Psychosocial Adversity: Results of a Qualitative Study.

OBJECTIVE: The patient-centered medical home (PCMH) seeks to improve population health. However, PCMH models often focus on improving treatment of chronic diseases rather than on addressing psychosocial adversity. We sought to gather key stakeholder input about how PCMHs might feasibly and sustainably address psychosocial adversity within their patient populations. METHODS: We conducted 25 semistructured interviews with key stakeholders, such as physicians, nurses, medical assistants, and patients. The audiorecorded interviews focused on participants' perceptions of the best ways to modify the PCMH to address patients' psychosocial adversity. To facilitate information gathering, a fictional patient case was presented. Analyses were conducted using a 3-stage content-analysis process. RESULTS: Participants identified provider-related and systems-level changes necessary for addressing these psychosocial adversities effectively. On the provider level, participants thought that practitioners should foster trusting relationships with patients and should be emotionally present as patients describe their life experiences. Participants also emphasized that providers need to have sensitive conversations about adversity and resilience. On a systems level, participants discussed that documentation must balance privacy and include relevant information in the medical record. In addition, care should be delivered not by a single provider but by a team that has a longitudinal relationship with the patient; this care team should include behavioral health support. CONCLUSIONS: Participants provided practical strategies and highlighted provider and systems level changes to adequately address patients' prior psychosocial adversity. Future studies need to assess the degree to which such a trauma-informed approach improves patient access, outcomes, and care quality, and reduces cost.

Commitment, confidence, and concerns: Assessing health care professionals' child maltreatment reporting attitudes.

Given that childhood maltreatment is a significant international public health problem contributing to all major morbidity and mortality determinants, there is need to explore current practices and readiness of health care professionals (HCPs) to assess maltreatment, identify maltreatment risk factors, and complete mandated reporting. HCPs (N=114) completed a child maltreatment mandated reporting measure to assess level of comfort with mandated reporting, commitment to the reporting role, and confidence in the child protection system to take action as needed. Additional questions explored comfort discussing maltreatment and risk factors for maltreatment in a medical setting and knowledge of community resources. Results indicated that HCPs were committed to their mandated reporting role and did not perceive substantial potential negative consequences of reporting. However, there were concerns regarding lack of confidence in the system's ability to respond sufficiently to reports. Despite commitment to the reporting role, results showed that large proportions of HCPs do not routinely screen for maltreatment, feel uncomfortable discussing maltreatment history, and lack knowledge about community resources. Additional training efforts must be prioritized in health care systems to improve short- and long-term health outcomes.

Staff Responses When Parents Hit Children in a Hospital Setting.

OBJECTIVE: Physical punishment of children is a prevalent practice that is condemned by most medical professionals given its link with increased risk of child physical abuse and other adverse child outcomes. This study examined the prevalence of parent-to-child hitting in medical settings and the intervention behaviors of staff who witness it. METHOD: Staff at a children's medical center and a general medical center completed a voluntary, anonymous survey. We used descriptive statistics to examine differences in the experiences of physicians, nurses, and other medical staff. We used logistic regression to predict intervention behaviors among staff who witnessed parent-to-child hitting. RESULTS: Of the hospital staff who completed the survey (N = 2863), we found that 50% of physicians, 24% of nurses, 27% of other direct care staff, and 17% of nondirect care staff witnessed parent-to-child hitting at their medical center in the past year. A majority of physicians, nurses, and other direct care staff reported intervening sometimes or always. Nondirect care staff rarely intervened. Believing staff have the responsibility to intervene, and having comfortable strategies with which to intervene were strongly predictive of intervention behavior. Staff who did not intervene commonly reported that they did not know how to respond. CONCLUSION: Many medical center staff witness parent-to-child hitting. Although some of the staff reported that they intervened when they witnessed this behavior, the findings indicate that staff may need training to identify when and how they should respond.

Medical center staff attitudes about spanking.

Several medical professional organizations, including the American Academy of Pediatrics, recommend that parents avoid hitting children for disciplinary purposes (e.g., spanking) and that medical professionals advise parents to use alternative methods. The extent to which medical professionals continue to endorse spanking is unknown. This study is the first to examine attitudes about spanking among staff throughout medical settings, including non-direct care staff. A total of 2580 staff at a large general medical center and 733 staff at a children's hospital completed an online survey; respondents were roughly divided between staff who provide direct care to patients (e.g., physicians, nurses) and staff who do not (e.g., receptionists, lab technicians). Less than half (44% and 46%) of staff at each medical center agreed that spanking is harmful to children, although almost all (85% and 88%) acknowledged that spanking can lead to injury. Men, staff who report being religious, and staff who held non-direct care positions at the medical center reported stronger endorsement of spanking and perceived their co-workers to be more strongly in favor of spanking. Non-direct care staff were more supportive of spanking compared with direct care staff on every item assessed. All staff underestimated the extent to which their co-workers held negative views of spanking. If medical centers and other medical settings are to lead the charge in informing the community about the harms of spanking, comprehensive staff education about spanking is indicated.