Examining Racial/Ethnic Differences in Positive Childhood Experiences Among Respondents in a Southern State.

Adverse childhood experiences (ACEs) and positive childhood experiences (PCEs) may impact brain development in children and adolescents into adulthood. While prior research demonstrated racial-ethnic disparities in ACEs, less is known about racial and ethnic differences in PCEs, particularly among adults. To better understand racial and ethnic differences in positive childhood experiences, this study (1) examined the prevalence of PCEs in an adult population in South Carolina (SC), a representative southern US state and (2) examined whether PCE exposure differed across racial and ethnic groups. Data were drawn from the 2019 SC Behavioral Risk Factor Surveillance System survey (BRFSS). Descriptive statistics and bivariate analyses were used to calculate frequencies, proportions and unadjusted associations for each variable. Multivariable regression models were used to examine the association between race/ethnicity and PCEs. Our analyses revealed that people of color were less likely to be supported by friends, have an adult who took interest in them, and have a family who stood by them during difficult times. Education and poverty were significantly associated with feeling safe and protected, supported by friends, and having a family that stood by them during difficult times. Conclusions: Findings from this study may be used to promote health equity in early childhood through programs, policies, and practices that seek to address historic, systemic, and intergenerational trauma.

Safe Neighborhoods and Supportive Communities Protect Children from the Health Effects of Adverse Childhood Experiences (ACEs).

Protective factors such as safe, stable, nurturing relationships and environments can prevent the long-term effects of adverse childhood experiences (ACEs). Recently, policymakers and practitioners have sought to better understand environmental level influences on exposure to ACEs, given the crucial role of social determinants of health in alleviating racial health inequities. Thus, this study seeks to understand how ACEs can be mitigated through neighborhood-level factors; it examines the relationships among ACEs, safe and supportive neighborhoods, and overall health status by race/ethnicity using a national data sample. Data were obtained from 30,530 households with children who participated in the 2018 National Survey for Children's Health, a nationally representative survey. Using multivariable logistic regression, safe and supportive neighborhoods were assessed as potential moderators of the association between ACEs and overall health status by race/ethnicity. Two separate models were run for each moderator, controlling for sex, age, and gender of the child. The presence of a safe neighborhood weakened the association between ACEs and overall health status. This was demonstrated by lower odds of experiencing poor health. The presence of a supportive neighborhood showed a similar pattern. However, these patterns varied when disaggregating the data by race/ethnicity. This study underscores the importance of community-level prevention and intervention efforts to mitigate the health effects of ACEs. Public health efforts seeking to prevent poor health outcomes should consider the socio-environmental influences on health behaviors across the lifespan and continue to address the varying needs of historically disadvantaged populations.

The Unintended Consequence of Novel Coronavirus (COVID-19) Pandemic on Racial Inequities Associated With Adverse Childhood Experiences (ACEs): Findings From a Population-Based Study.

A rising concern is the COVID-19 pandemic effect on adverse childhood experiences (ACEs) due to increased parental stress and social/physical isolation. These pandemic effects are likely to be higher in already marginalized communities. The objective of this ecological study was to examine the relationship between COVID-19 cases and deaths, race/ethnicity, and the estimated number of adults with ACEs using data from South Carolina (SC). COVID-19 reported cases and death data were obtained from the SC Department of Health and Environmental Control. ACE data was used from the 2014-2016 SC Behavioral Risk Factor Surveillance System. Census data were used to obtain county population data. To measure the relationship between these variables, the Spearman rank-order correlation test was used because the data distribution was non-normal. There was a moderate relationship between the estimated number of adults with one or more ACEs and deaths (ρ = 0.89) and race/ethnicity-specific COVID-19 case counts by county (Black: ρ = 0.76; =White: ρ = 0.96; Hispanic: ρ = 0.89). Further, the Spearman correlation test showed the strongest relationship between COVID-19 deaths and race-ethnicity-specific county populations was with the Black adult population (ρ = 0.90). Given the known link between existing health inequities and exposure to COVID-19, these results demonstrate that the current pandemic could have unintended consequences on the well-being of children and caregivers. Response efforts should consider promoting protective factors for children and families and advocating for equitable policies and systems that serve children.

Who declines to respond to the reactions to race module?: findings from the South Carolina Behavioral Risk Factor Surveillance System, 2016-2017.

BACKGROUND: The inclusion of self-reported differential treatment by race/ethnicity in population-based public health surveillance and monitoring systems may provide an opportunity to address long-standing health inequalities. While there is a growing trend towards decreasing response rates and selective non-response in health surveys, research examining the magnitude of non-response related to self-reported discrimination warrants greater attention. This study examined the distribution of sociodemographic variables among respondents and non-respondents to the South Carolina Behavioral Risk Factor Surveillance System (SC-BRFSS) Reactions to Race module (6-question optional module capturing reports of race-based treatment). METHODS: Using data from SC-BRFSS (2016, 2017), we examined patterns of non-response to the Reactions to Race module and individual items in the module. Logistic regression models were employed to examine sociodemographic factors associated with non-response and weighted to account for complex sampling design. RESULTS: Among 21,847 respondents, 15.3% were non-responders. Significant differences in RTRM non-response were observed by key sociodemographic variables (e.g., age, race/ethnicity, labor market participation, and health insurance status). Individuals who were younger, Hispanic, homemakers/students, unreported income, and uninsured were over-represented among non-respondents. In adjusted analyses, Hispanics and individuals with unreported income were more likely to be non-responders in RTRM and across item, while retirees were less likely to be non-responders. Heterogeneity in levels of non-responses were observed across RTRM questions, with the highest level of non-response for questions assessing differential treatment in work (54.8%) and healthcare settings (26.9%). CONCLUSIONS: Non-responders differed from responders according to some key sociodemographic variables, which could contribute to the underestimation of self-reported discrimination and race-related differential treatment and health outcomes. While we advocate for the use of population-based measures of self-reported racial discrimination to monitor and track state-level progress towards health equity, future efforts to estimate, assess, and address non-response variations by sociodemographic factors are warranted to improve understanding of lived experiences impacted by race-based differential treatment.

Who Is Talking About Adverse Childhood Experiences? Evidence From Twitter to Inform Health Promotion.

BACKGROUND: Growing availability of research about addressing adverse childhood experiences (ACEs) has recently been embraced by the mainstream media and public. Social media, especially Twitter, provides a unique forum and platform for the public to access and share information about this topic. OBJECTIVE: This study aims to better understand how the public is framing, sharing, and using research about ACEs on Twitter and to examine the information being commonly discussed about ACEs. METHOD: We obtained tweets on the topics of ACEs, childhood resilience, and childhood trauma between January 1, 2018, and December 31, 2019. This timeframe was determined based on key related events in the mainstream media. Crimson Hexagon, a social media analytics system using Boolean logic, was used to identify salient topics, influencers, and conduct a content analysis. RESULTS: A total of 195,816 relevant tweets were obtained from our search. The weekly volume was approximately 1,864 tweets. Key topics included general use of the term ACEs (23%), trauma and ACEs (19%), long-term impact of ACEs (12%), preventing ACEs (11%), short-term effects of ACEs (8%), the 1997 ACE Study (5%), and students with ACEs (5%). The top two sentiments were fear and joy. Top conversation influencers included pediatricians, child health advocacy organizations, California's state government, the Centers for Disease Control and Prevention, and National Public Radio. CONCLUSION: This analysis provides insight to the ways the public is conversing about ACEs and related topics. Results indicated that conversations focus on increasing awareness of ACEs by content experts and public health organizations. This presents an opportunity to leverage social media tools to increase public engagement and awareness.

Perceived Persuasiveness of Evidence About Adverse Childhood Experiences: Results From a National Survey.

OBJECTIVE: Advocates must make decisions about the types of evidence they emphasize when communicating to cultivate support for adverse childhood experience (ACE) prevention policies. This study sought to characterize public perceptions of the persuasiveness of 12 ACE evidence statements and assess differences by ideology in the strength of these evidence messages as rationales for ACE prevention policies. METHODS: A web-based survey of a nationally representative sample of US adults was conducted using the KnowledgePanel (N = 503, completion rate = 60.5%). Respondents read ACE evidence statements and answered questions about the extent to which each was perceived as persuasive. Data were collected and analyzed in 2019. RESULTS: The evidence statements perceived as most persuasive (scoring range 3-17) were those about ACEs as risk factors for mental health and substance use conditions (mean = 12.39) and suicide (mean = 12.14); ACEs generating financial costs for society (mean = 12.03); and the consequences of ACEs being preventable by a supportive adult (mean = 11.97). The evidence statements perceived as least persuasive were about ACEs generating health care costs for individuals (mean = 9.42) and ACEs as risk factors for physical health conditions (mean = 9.47). A larger proportion of liberals than conservatives rated every statement as providing a "strong reason" for ACE prevention policies. These differences were largest for evidence about ACEs generating financial costs for society (84.6% vs 42.8%, P < .0001) and socioeconomic disparities in ACEs (65.1% vs 32.9%, P < .0001). CONCLUSIONS: Many ACE evidence statements commonly used in policy advocacy differ from those perceived as most persuasive among a nationally representative sample of US adults.

Community capacity coach: Embedded support to implement evidenced-based prevention.

Given the pervasive nature of child abuse and neglect, multilevel public health approaches are necessary. Implementation science can help in understanding the most effective ways to build infrastructure and support delivery of such approaches. In this theoretical paper, we describe the implementation of the Positive Parenting Program (Triple P), an evidence-based population-level parenting program in South Carolina. While implementation science has informed how to move population-level efforts to scale, we discuss challenges that persist in practice, such as when there is a need for multiple stakeholders to understand, support, and apply implementation best practices in a systematic and consistent way. To address this challenge, we introduce the role of a Community Capacity Coach, who lives in the local community and works towards the implementation of Triple P. The Coach is responsible for bridging gaps between the local community and statewide support systems. We detail the ways in which the Coach's role aligns with key intermediary functions, and how the Coach is embedded within the larger Triple P statewide support system. We then discuss the assessment of the Coach's impact; and conclude with future directions and next steps for this role within Triple P South Carolina.

Racial/Ethnic Disparities in Health Care Access Are Associated with Adverse Childhood Experiences.

There is a growing body of research documenting racial/ethnic differences in the relationship between adverse childhood experiences (ACEs) and negative health outcomes in adulthood. However, few studies have examined racial/ethnic differences in the association between ACEs and health care access. Cross-sectional data collected from South Carolina's Behavioral Risk Factor Surveillance System (2014-2016; n = 15,436) was used to examine associations among ACEs, race/ethnicity, and health care access among South Carolina adults. Specifically, logistic regression models were used to estimate the odds ratio (OR) and 95% confidence intervals (CI) for three health care access outcomes: having a personal doctor, routine checkup in the last 2 years, and delay in seeking medical care due to cost. Without adjusting for any covariates, in the overall population, the odds of having no personal doctor, no checkup in the last 2 years, and delay in medical care due to cost was significantly higher among those with at least one ACE, compared with those with no ACEs; and health care access varied by race, with significant relationships detected among Whites and Blacks. Among White adults, the odds of having no checkup in the last 2 years and delay in medical care due to cost was significantly higher among those with at least one ACE, compared with those with no ACEs. Among Black adults, a delay in medical care due to cost was significantly higher among those who reported ACEs compared with their counterparts. The results from this study suggest that ACEs may be an underrecognized barrier to health care for adults. Investing in strategies to mitigate ACEs may help improve health care access among adults.

Exploring practitioner and policymaker perspectives on public health approaches to address Adverse Childhood Experiences (ACEs) in South Carolina.

OBJECTIVE: We examined the perspectives of child and family-serving professionals (CFSP) and state policymakers on protective factors to develop policy and program recommendations including current and needed approaches for addressing ACEs. METHODS: In 2018, we conducted semi-structured, in-depth interviews with 23 CFSP and 24 state policymakers in South Carolina. Data were analyzed applying the Multiple Streams Theory using thematic analyses. RESULTS: CFSPs and policymakers had varying opinions on state government involvement and primary prevention for ACEs. Three protective factors emerged from their perspectives: 1) loving, trusting, and nurturing relationships; 2) safe home environments; and 3) opportunities to thrive. For each of these protective factors, participants suggested policy options that support existing community efforts, attempt to alleviate poverty, and improve child and family serving systems. CONCLUSION: This study suggests that CFSPs and policymakers recognize the importance of protective factors in a child's life to buffer the effect of ACEs. More awareness is needed about the feasibility and significance of primary prevention of ACEs. The study's findings can be used to strengthen advocacy priorities for a wide range of public health outcomes associated with ACEs and help further bridge the gap between research and policy.

Moderating the Effects of Adverse Childhood Experiences to Address Inequities in Tobacco-Related Risk Behaviors.

Adverse childhood experiences (ACEs) can increase the risk of engagement in unhealthy behaviors including tobacco use. Protective factors, such as safe, stable, and nurturing relationships (SSNRs) can potentially moderate the long-term impact of ACEs by helping children build resilience. However, there is limited research on whether the impact of these factors is stronger among Black children and families, who face disproportionately poorer health outcomes compared to their White counterparts. This study examined the relationships among protective factors in childhood, ACEs (one or more vs. none), and tobacco use (smoking tobacco, e-cigarette use) in adulthood, including whether these relationships differed by race. Data were obtained from the 2016 South Carolina administration of the Behavioral Risk Factor Surveillance System (n = 7,014). Using stratified, multivariate logistic regression, the presence of an SSNR in childhood (whether participants' basic needs were met and whether they felt safe and protected during childhood) was assessed as a potential moderator of the association between ACEs (one or more vs. none) and smoking tobacco or e-cigarettes stratified by race (Black and White). Control variables included sex, age, educational attainment, and income. Statistically significant moderating effects of an SSNR was present for White adults only: The relationship between ACEs and risk behaviors was weakened when an SSNR was present in childhood. Although SSNRs appear to prevent some risk behavior consequences from ACEs among some groups, additional research is needed to understand their potential utility across population subgroups.

The Empower Action Model: A Framework for Preventing Adverse Childhood Experiences by Promoting Health, Equity, and Well-Being Across the Life Span.

The empower action model addresses childhood adversity as a root cause of disease by building resilience across multiple levels of influence to promote health, equity, and well-being. The model builds on the current evidence around adverse childhood experiences and merges important frameworks within key areas of public health-the socio-ecological model, protective factors, race equity and inclusion, and the life course perspective. The socio-ecological model is used as the foundation for this model to highlight the multilevel approach needed for improvement in public health. Five key principles that build on the protective factors literature are developed to be applied at each of the levels of the socio-ecological model: understanding, support, inclusion, connection, and growth. These principles are developed with actions that can be implemented across the life span. Finally, actions suggested with each principle are grounded in the tenets of race equity and inclusion, framing all actionable steps with an equity lens. This article discusses the process by which the model was developed and provides steps for states and communities to implement this tool. It also introduces efforts in a state to use this model within county coalitions through an innovative use of federal and foundation funding.

Addressing Health and Well-Being Through State Policy: Understanding Barriers and Opportunities for Policy-Making to Prevent Adverse Childhood Experiences (ACEs) in South Carolina.

PURPOSE: As adverse childhood experiences (ACEs) become increasingly recognized as a root cause of unhealthy behaviors, researchers, practitioners, and legislators seek to understand policy strategies to prevent and mitigate its effects. Given the high prevalence of ACEs, policies that address ACEs can meaningfully prevent disease in adulthood and improve population health. We sought to understand barriers and opportunities for policies to prevent and mitigate ACEs by exploring state legislator perspectives. SETTING AND PARTICIPANTS: Twenty-four current state legislators in South Carolina. DESIGN: In 2018, we conducted semistructured interviews with 24 state legislators. Participants were recruited using maximum variation sampling. The researchers individually analyzed each interview transcript using focused coding qualitative techniques. A high inter-rater agreement was demonstrated (κ = .76 to .87), and discrepancies were resolved through discussion. METHOD: The data collection and analysis were guided by Multiple Streams Theory, which identifies 3 key components (attention to the problem, decisions about policy options, and the impact of political landscape) that can lead windows of opportunity for passing policies. RESULTS: Legislators identified several factors that can influence the passage of legislation on ACEs: awareness of ACEs; gaps in understanding about what can be done about ACEs; the use of data and stories that contextualize the problem of ACEs; capitalizing on the bipartisanship of children's issues; and linking to current ACEs-related issues on the policy agenda, such as school safety and violence prevention and the opioid epidemic. CONCLUSION: Public health researchers and practitioners should focus on the factors identified to advocate for policies that prevent ACEs and/or address their health consequences.

Homelessness in Childhood and Adverse Childhood Experiences (ACEs).

Objectives Research on adverse childhood experiences (ACEs) has provided a valuable framework for understanding associations between childhood maltreatment and family dysfunction and later poor health outcomes. However, increasing research suggests the number and types of childhood adversities measured warrants further examination. This study examines ACE exposure among adults who experienced homelessness in childhood, another type of childhood adversity. Methods This cross-sectional, descriptive study used the 2016 South Carolina (SC) Behavioral Risk Factor Surveillance System (BRFSS) survey and additional ACE modules to examine ACE exposure among SC adults and childhood homelessness. Standard descriptive statistics were calculated for each variable. Bivariate analysis compared types and number of ACEs by childhood homeless status. All analyses used survey sampling weights that accounted for the BRFSS sampling strategy. Results Data from 7490 respondents were weighted for analyses. Among the 215 respondents who reported homelessness in childhood, 68.1% reported experiencing four or more ACEs. In contrast, only 16.3% of respondents who reported no homelessness in childhood reported experiencing four or more ACEs. The percent of respondents was significantly higher for each of 11 ACEs among those who reported childhood homelessness, compared to those who did not. Conclusions for Practice Adults who reported homelessness in childhood also reported significantly greater exposure to higher numbers and types of ACEs than adults reporting no childhood homelessness. Study findings can be important in informing additional indicators important to the assessment of ACEs and to program developers or organizations that provide housing assistance to at-risk families and children.

Safe, Stable, and Nurtured: Protective Factors against Poor Physical and Mental Health Outcomes Following Exposure to Adverse Childhood Experiences (ACEs).

Protective factors can build resilience and potentially moderate the long-term impact of adverse childhood experiences (ACEs). To better understand the role of protective factors, this study examines the relationship of two protective factors focused on safe, stable and nurturing relationships, ACEs, and self-reported mental and physical health outcomes among a representative adult sample from the South Carolina Behavioral Risk Factor Surveillance System. Protective factors were assessed as potential moderators of ACEs and poor self-reported physical and mental health in multivariate logistic regression analyses. Respondents exposed to four or more ACEs who grew up with an adult who made them feel safe and protected were less likely to report frequent mental distress or poor health. The use of protective factors may be an effective prevention strategy for ACEs and its associated outcomes and may serve as a mechanism to "break the cycle" of childhood trauma.

Addressing Adverse Childhood Experiences Through the Affordable Care Act: Promising Advances and Missed Opportunities.

Adverse childhood experiences (ACEs) occur when children are exposed to trauma and/or toxic stress and may have a lifelong effect. Studies have shown that ACEs are linked with poor adult health outcomes and could eventually raise already high health care costs. National policy interest in ACEs has recently increased, as many key players are engaged in community-, state-, and hospital-based efforts to reduce factors that contribute to childhood trauma and/or toxic stress in children. The Affordable Care Act (ACA) has provided a promising foundation for advancing the prevention, diagnosis, and management of ACEs and their consequences. Although the ACA's future is unclear and it does not adequately address the needs of the pediatric population, many of the changes it spurred will continue regardless of legislative action (or inaction), and it therefore remains an important component of our health care system and national strategy to reduce ACEs. We review ways in which some of the current health care policy initiatives launched as part of the implementation of the ACA could accelerate progress in addressing ACEs by fully engaging and aligning various health care stakeholders while recognizing limitations in the law that may cause challenges in our attempts to improve child health and well-being. Specifically, we discuss coverage expansion, investments in the health workforce, a family-centered care approach, increased access to care, emphasis on preventive services, new population models, and improved provider payment models.

Prioritizing Possibilities for Child and Family Health: An Agenda to Address Adverse Childhood Experiences and Foster the Social and Emotional Roots of Well-being in Pediatrics.

OBJECTIVE: A convergence of theoretical and empirical evidence across many scientific disciplines reveals unprecedented possibilities to advance much needed improvements in child and family well-being by addressing adverse childhood experiences (ACEs), promoting resilience, and fostering nurturance and the social and emotional roots of healthy child development and lifelong health. In this article we synthesize recommendations from a structured, multiyear field-building and research, policy, and practice agenda setting process to address these issues in children's health services. METHODS: Between Spring of 2013 and Winter of 2017, the field-building and agenda-setting process directly engaged more than 500 individuals and comprised 79 distinct agenda-setting and field-building activities and processes, including: 4 in-person meetings; 4 online crowdsourcing rounds across 10 stakeholder groups; literature and environmental scans, publications documenting ACEs, resilience, and protective factors among US children, and commissioning of this special issue of Academic Pediatrics; 8 in-person listening forums and 31 educational sessions with stakeholders; and a range of action research efforts with emerging community efforts. Modified Delphi processes and grounded theory methods were used and iterative and structured synthesis of input was conducted to discern themes, priorities, and recommendations. RESULTS: Participants discerned that sufficient scientific findings support the formation of an applied child health services research and policy agenda. Four overarching priorities for the agenda emerged: 1) translate the science of ACEs, resilience, and nurturing relationships into children's health services; 2) cultivate the conditions for cross-sector collaboration to incentivize action and address structural inequalities; 3) restore and reward for promoting safe and nurturing relationships and full engagement of individuals, families, and communities to heal trauma, promote resilience, and prevent ACEs; and 4) fuel "launch and learn" research, innovation, and implementation efforts. Four research areas arose as central to advancing these priorities in the short term. These are related to: 1) family-centered clinical protocols, 2) assessing effects on outcomes and costs, 3) capacity-building and accountability, and 4) role of provider self-care to quality of care. Finally, we identified 16 short-term actions to leverage existing policies, practices, and structures to advance agenda priorities and research priorities. CONCLUSIONS: Efforts to address the high prevalence and negative effects of ACEs on child health are needed, including widespread and concrete understanding and strategies to promote awareness, resilience, and safe, stable, nurturing relationships as foundational to healthy child development and sustainable well-being throughout life. A paradigm-shifting evolution in individual, organizational, and collective mindsets, policies, and practices is required. Shifts will emphasize the centrality of relationships and regulation of emotion and stress to brain development as well as overall health. They will elevate relationship-centered methods to engage individuals, families, and communities in self-care related to ACEs, stress, trauma, and building the resilience and nurturing relationships science has revealed to be at the root of well-being. Findings reflect a palpable hope for prevention, mitigation, and healing of individual, intergenerational, and community trauma associated with ACEs and provide a road map for doing so.