Adverse Childhood Experiences and Chronic Diseases: Identifying a Cut-Point for ACE Scores.

Adverse Childhood Experiences (ACEs) contribute to many negative physiological, psychological, and behavioral health consequences. However, a cut-point for adverse childhood experience (ACE) scores, as it pertains to health outcomes, has not been clearly identified. This ambiguity has led to the use of different cut-points to define high scores. The aim of this study is to clarify a cut-point at which ACEs are significantly associated with negative chronic health outcomes. To accomplish this aim, a secondary analysis using data from a cross-sectional study was conducted. The Adverse Childhood Experiences-International Questionnaire (ACE-IQ) was used for data collection. Descriptive statistics, nonparametric regression, and logistic regression analyses were performed on a sample of 10,047 adults. Data from demographic and self-report health measures were included. The results showed that a cut-point of four or more ACEs was significantly associated with increased rates of chronic disease. Participants with at least one chronic disease were almost 3 times more likely (OR = 2.8) to be in the high ACE group. A standardized cut-point for ACE scores will assist in future research examining the impact of high ACEs across cultures to study the effect of childhood experiences on health.

Perceived stress, fatigue symptoms, and posttraumatic stress disorder symptoms among young adult college students.

PROBLEM: University students experience stress and fatigue often affecting their health, academic success, and social adjustment. Many also have histories of childhood trauma that may result in posttraumatic stress symptoms. The purpose of this study was to determine the associations between perceptions of stress, symptoms of fatigue, and symptoms of posttraumatic stress disorder (PTSD) among university students, many of whom report childhood adversity. METHODS: Sixty-nine students from one university campus participated in this study. A cross-sectional design was used to gather data across six self-report measures. FINDINGS: Childhood adversity was associated with PTSD symptoms and acute stress, and PTSD symptoms were related to all three measures of fatigue. PTSD symptoms mediated the relationship between stress and fatigue, but not other fatigue domains. CONCLUSIONS: The implications of an association between PTSD, stress, and fatigue are relevant to students' health and academic success. It is important to note that even subclinical levels of PTSD impact fatigue.

Beyond the discipline: Nurse practitioner members and leaders of interdisciplinary research teams.

ABSTRACT: Complex clinical questions and problems require expertise beyond one discipline to answer or resolve. Research teams that include members with different foundational perspectives across various disciplines are needed. In particular, the growing trend toward technological innovations to help patients self-manage health has been the impetus for the development of interdisciplinary research teams. The goal of this study was to provide guidance for nurse practitioners who are interested in developing effective and successful interdisciplinary teams to complete clinical research projects. A case example is used throughout the study to illustrate the process of interdisciplinary team building. The success of interdisciplinary teams requires team members who are fully invested in the project, available and willing to engage and communicate with other members of the team, and able to form relationships of trust and respect for each discipline's unique contributions to the project.

Adverse childhood experiences, post-traumatic stress disorder symptoms, and self-reported stress among traditional and nontraditional college students.

Objective: To investigate the relationships between adverse childhood experiences (ACEs), post-traumatic stress disorder symptoms (PTSD-S), and self-reported stress among college students. Participants: A total of 236 undergraduate students enrolled in nursing courses participated. Method: Using a correlational design, participants completed questionnaires online. To examine PTSD moderation between ACE and self-reported stress, multiple regression was employed. Stress outcomes were examined using a 4-group variable. Mean differences in stress response between these four groups were examined. Differences in ACE, PTSD-S, and stress response between traditional and nontraditional students were also examined. Results: PTSD-S moderated the relationship between ACEs, and self-reported stress. This indicates that students who report PTSD-S following childhood adversity perceive higher levels of stress. Nontraditional and traditional students differed in their responses to the ICLRE scale. Conclusion: Individuals who report PTSD-S following childhood adversity perceive higher levels of stress later in life. Stress reduction programs may be beneficial for students.

The Efficacy of a Resilience Intervention Among Diverse, At-Risk, College Athletes: A Mixed-Methods Study.

BACKGROUND: Adverse childhood experiences (ACEs) have been associated with psychological and physiological disease, and risky health behaviors. A person's ability to be resilient may protect them from these negative health outcomes, as resilience has been associated with increased emotional awareness, coping, belonging, and greater likelihood of good health and well-being. AIMS: The purpose of this pilot study was to assess the efficacy of a strengths-based resilience intervention to improve access to internal and external resources that effect perceptions of stress, resilience, emotional awareness, and belonging among student-athletes. METHODS: A mixed-methods design was used to examine variables of interest between intervention and control groups. A sample of 56 college athletes completed surveys and engaged in expressive writing during a 5-week resilience intervention. RESULTS: Self-report data indicated that student-athletes in the intervention group improved decision making, lowered perceived stress, and increased resilience compared with controls. Of note, participants with ACEs showed greater increments of positive change in emotional awareness scales than participants without ACEs. Descriptions of emotion management, authentic connections, and increased ability to request support from others were identified in the qualitative data. CONCLUSIONS: A strengths-based course designed to increase resilience-offered as academic and athletic stress is mounting-provided a unique opportunity to promote student-athlete success. Participants gained skills key to victory on and off the field, including health-promoting behaviors, a sense of belonging, persistence, and the ability to negotiate external resources.

Screening Adults With Substance Use Disorder for Adverse Childhood Experiences.

OBJECTIVE: The purpose of this study was to assess the incidence of adverse childhood experiences (ACEs) and the efficacy and feasibility of a trauma-informed screening for ACEs among individuals in a substance use disorder recovery program. METHOD: Individual interviews, questionnaires, and postinterview survey and reflections were used in this cross-sectional clinical translation project. Descriptive statistics were used to analyze demographics, ACE scores, protective childhood experiences, self-reported diagnoses, and postintervention survey data. Postinterview reflections were reviewed and grouped into common ideas as shared by participants, as well as interesting impressions, insights, and responses to the interviews. RESULTS: Thirty clients participated in the interview process. Among the 29 participants who completed the questionnaires, all reported at least one ACE, and 82.8% reported six or more ACEs. In addition, 96.6% reported experiencing more than four protective factors. Twelve (40%) clients were referred for further mental health counseling after the interviews. Notable findings from the interviews were the general lack of awareness of the relationship between ACEs and current substance use disorder among participants. Gaining knowledge about the impact of ACEs on their recovery seemed to provide a sense of relief and a feeling that they were "normal." CONCLUSIONS: The trauma-informed care approach is intended to promote mindfulness regarding the effect of ACEs on substance abuse in this population. Screening for ACEs is necessary if effective interventions are to be provided, with the goal of improving client outcomes.

Screening for childhood adversity among adult primary care patients.

BACKGROUND AND PURPOSE: Over half of Americans reports a history of adverse childhood experiences (ACEs), which have been associated with many chronic health conditions. Yet primary care providers infrequently screen patients for ACEs and fail to consider the relationship between ACEs and adult health. Therefore, the purposes of this study were to test the effectiveness and feasibility of a screening interview for ACEs and to confirm the prevalence of ACEs among individuals with chronic health conditions. METHODS: Screening interviews were conducted with 71 adults in a primary care setting. Patients' ACE history, nurse practitioner comfort with screening, time to screen, and patient follow-up care recommendations were gathered through questionnaires. Adverse childhood experience prevalence was analyzed by descriptive statistics. Relationships between ACEs, number of clinic visits, time to screen, and follow-up care recommendations were analyzed by bivariate statistics. CONCLUSIONS: Over half of participants reported more than four ACEs, with ACEs common among participants with chronic health conditions (93%). Adverse childhood experience scores were positively correlated with number of clinic visits, time to screen, and recommendations for follow-up care. Findings support screening primary care patients for ACEs. IMPLICATIONS FOR PRACTICE: Adverse childhood experiences are prevalent among primary care patients with chronic conditions. Using interviews to screen for ACEs in primary care settings is effective and feasible.

Web-Based, Pictograph-Formatted Discharge Instructions for Low-Literacy Older Adults After Hip Replacement Surgery: Findings of End-User Evaluation of the Website.

PURPOSE: The purpose of this study was to develop web-based, pictograph-formatted discharge instructions and evaluate the website with intended users to maximize the relevance and clarity of the website. DESIGN: A descriptive study. METHODS: Low-literacy text and 45 sets of pictographs were implemented in web-based instructions. The content, design, function, and navigation of the website were reviewed by 15 low-literate older adults following hip replacement surgery. FINDINGS: Participants observed that the simple line drawings with clear background were well suited to web pages and helped to convey the points made. They also suggested changes such as adding an additional alphabetical index menu to enhance easy navigation and removing hypertext links to avoid distraction. CONCLUSIONS: Web-based, pictograph-formatted discharge instructions were well received by low-literate older adults, who perceived the website easy to use and understand. CLINICAL RELEVANCE: A pictograph-formatted approach may provide effective strategies to promote understanding of lengthy, complex action-based discharge instructions in rehabilitation facilities.

Nurse practitioner screening for childhood adversity among adult primary care patients: A mixed-method study.

BACKGROUND AND PURPOSE: Researchers have demonstrated an association between experiencing childhood abuse and multiple chronic health conditions in adulthood, yet this evidence has not been routinely translated to practice. The purpose of this research study was to examine nurse practitioner (NP) practices, skills, attitudes, and perceived barriers associated with screening adult patients for childhood abuse to determine the extent to which evidence of the association between childhood abuse and negative health outcomes has been translated to NP practice. METHODS: A mixed-method approach with web-based questionnaires and online focus groups was used to examine NP screening for histories of childhood abuse. CONCLUSIONS: A total of 188 complete NP surveys were analyzed along with data from focus groups with 12 NPs. One third of the NPs regularly screened for childhood abuse and believed screening was their responsibility. Six barriers, including insufficient time and lack of confidence when inquiring about abuse, were significantly associated with NP screening practices. The focus group participants discussed how and when one should ask about childhood abuse, and the need for education about screening. IMPLICATIONS FOR PRACTICE: Time constraints and NPs' lack of confidence in their ability to screen for histories of childhood abuse must be addressed to encourage routine screening in primary care practice.

Adverse childhood experiences and chronic hypothalamic-pituitary-adrenal activity.

Inconsistencies exist in the current literature regarding hypothalamic-pituitary-adrenal (HPA) regulation following exposure to repeated stressful events. These inconsistencies stem, in part, from the limitations imposed by measuring cortisol in saliva or plasma (i.e. "point measures" of HPA activity). The present study used a cross-sectional, correlational design to examine the relationship between childhood stress (assessed using the adverse childhood experiences [ACEs] questionnaire) and hair cortisol (a biomarker of chronic HPA activity) in 55 healthy 18-24-year-old college students. Dichotomous ACE score for two models using different cut-points was significantly, inversely related to hair cortisol level (B = 1.03, p = 0.046 and B = 1.09, p = 0.031). These results are consistent with theoretical models where exposure to repeated stressful events results in chronic HPA dysregulation, which may include down-regulation under certain conditions.

Health consequences of adverse childhood experiences: a systematic review.

PURPOSE: Adverse childhood experiences (ACEs) have been associated with negative health outcomes, but the evidence has had limited application in primary care practice. The purpose of this study was to systematically review the research on associations between ACEs and adult health outcomes to inform nurse practitioners (NPs) in primary care practice. DATA SOURCES: The databases PubMed, CINAHL, PsycINFO, and Social Abstracts were searched for articles published in English between 2008 and 2013 using the search term "adverse childhood experiences." Forty-two research articles were included in the synthesis. The evidence was synthesized and is reported following the preferred reporting items for systematic reviews and meta-analysis procedure (PRISMA). CONCLUSIONS: ACEs have been associated with health consequences including physical and psychological conditions, risk behaviors, developmental disruption, and increased healthcare utilization. Generalization of the results is limited by a majority of studies (41/42) measuring childhood adversity using self-report measures. IMPLICATIONS FOR PRACTICE: NPs are encouraged to incorporate assessment of patients' childhood history in routine primary care and to consider the evidence that supports a relationship between ACEs and health. Although difficult, talking about patient's childhood experiences may positively influence health outcomes.

Adverse childhood experiences: towards a clear conceptual meaning.

AIM: To report an analysis of the concept of adverse childhood experiences. BACKGROUND: Adverse childhood experiences have been associated with negative physical and psychological health outcomes, but this phenomenon lacks the clear, consistent meaning necessary for use in nursing research, theory development and practice. DESIGN: Concept clarification. DATA SOURCES: The literature search was not limited a priori by date and included publications with abstracts in English from PubMed, CINAHL, PsychINFO and Social Abstracts. The search retrieved 128 articles published from 1970-2013. The search term 'adverse childhood experiences' was used, with similar terms permitted. A snowball approach was used to expand the search to relevant literature. METHODS: The articles were read and analysed following Norris's five steps for concept clarification to refine, elucidate and operationally define the concept and the context in which it occurred. RESULTS: Adverse childhood experiences were defined operationally as childhood events, varying in severity and often chronic, occurring in a child's family or social environment that cause harm or distress, thereby disrupting the child's physical or psychological health and development. CONCLUSION: This concept clarification should raise awareness and understanding of the diverse nature and shared characteristics of adverse childhood experiences that are believed to influence the health of individuals as they age. This clarified concept will help expand research on health consequences of adverse childhood experiences and interventions to improve health. We recommend promoting a model of primary care that pays attention to the social and familial influences on the health of individuals worldwide.

Struggling to survive: the experiences of women sexually assaulted while intoxicated.

Approximately half of all sexual assault cases involve substance abuse or misuse, yet no studies have focused specifically on women who were under the influence of a substance when assaulted. The aim of this study was to explore the experiences of women who were sexually assault while under the influence of a substance. A phenomenological approach was used to gather data using individual, in-depth interviews with women following a sexual assault while intoxicated. Interviews were conducted using open-ended and probing questions to explore participants' life experiences from childhood to the present. The study uncovered a continuous struggle to survive among the participants. Five themes including previous victimization, substance misuse, struggling with feelings, finding support, and struggling to break the cycle were found. This research revealed lives complicated by substance misuse and histories of victimization. Intoxication raises vulnerability and risk for sexual assault. Effective nursing interventions designed to address the women's history of victimization and substance misuse may benefit women sexually assaulted while intoxicated.

Cycle of sexual assault and women's alcohol misuse.

PURPOSE: To describe the complex relationship between sexual assault and alcohol misuse by female assault victims. DATA SOURCES: Drawing on recent research and theoretical models from other social sciences, the author interjects a nursing perspective for this complex patient problem. CONCLUSIONS: This review of theories and models, and the evidence that supports them, provides a way for nurses to conceptualize the relationship between sexual victimization and alcohol misuse as bidirectional or reciprocal. IMPLICATIONS FOR PRACTICE: The evidence and models discussed here suggest that when patients present with sexual assault or alcohol misuse, nurses should assess and address the possibility of both conditions being present.

Broadcasting simulation case studies to the didactic classroom.

To explore the potential of using simulation in new ways, it is time to think "outside the lab." To do this, the authors expanded the use of case-study simulations by broadcasting them to classrooms where didactic content could be reinforced with simulation content. Advantages included students' active classroom engagement, simultaneously sharing simulations with many students, modeling students' thinking in clinical situations, and connecting theory to practice.

From the sidelines: coaching as a nurse practitioner strategy for improving health outcomes.

PURPOSE: The purposes of this study were to explore coaching as a nurse practitioner (NP) strategy for improving patient health outcomes and to lay a foundation for validating coaching benefits. DATA SOURCES: Review of coaching literature in psychology, sports, business, and nursing. CONCLUSIONS: Coaching has been reported as successful in psychology, sports, business, and more recently nursing, for assisting people to achieve goals that are important to them. Coaching may be very effective in encouraging, inspiring, and empowering patients to reach their maximum health potential, particularly if lifestyle change is required; however, coaching research is in its early stages. Coaching is not well defined, so claims of coaching benefits must be viewed cautiously. Coaching is an expected NP role competency, but it is not well explicated in the literature. Defining the concept of coaching from multidisciplinary consensus, expanding knowledge of the coaching process, and consciously implementing coaching communication in the NP/patient primary care encounter may result in measurable outcomes that demonstrate coaching effectiveness. IMPLICATIONS FOR PRACTICE: Coaching fits well with the holistic, collaborative approach to patient care which NPs value. Coaching provides an opportunity to shift traditional thinking about patient/provider relationships and how to motivate patients toward behavior change. The challenge for NPs is to take the time to learn the coaching process, employ coaching communication strategies in the primary care encounter, and engage in research that measures coaching effectiveness.