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

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.

Screening for Childhood Adversity: Contemporary Challenges and Recommendations

“…For instance, the ACE International Questionnaire (ACE-IQ; World Health Organization [WHO], 2016) includes items related to peer violence, community violence, and collective violence. The Pediatric ACEs and Related Life-event Screener (PEARLS; Koita et al, 2018), the tool required in California for universal screening in medical settings, includes environmental adversities related to hardship (food insecurity, housing instability) and other significant life events (caregiver's serious physical illness or death, community violence, bullying, discrimination, parental separation due to foster care or immigration, death of a caregiver). However, the developers of both the ACE-IQ and the PEARLS acknowledge on their websites that these tools are not valid and reliable (validation studies are underway), and the PEARLS website advises that it should be one step in a comprehensive assessment that also considers child symptoms.…”

“…Importantly, the measure also includes items on trauma symptoms. A second approach to screening that incorporates symptomatology is to select one tool for exposure (e.g., PEARLS (Koita et al, 2018) (Greenwald & Rubin, 1999) or PTSD in Preschool Aged Children [PTSD-PAC] (Levendosky et al, 2002)), which provides additional flexibility for tailoring the types of exposure and symptoms assessed to the target population. But since there is often discordance between parent and caregiver reports of exposure and symptoms, careful consideration should be given to who the informant(s) should be (Shemesh et al, 2005;Stover, Hahn, Im, & Berkowitz, 2010).…”

Adverse Childhood Experiences: A 20‐Year Content Analysis of American Counseling Association and American School Counselor Association Journals

“…Third, since the publication of Felitti et al's (1998) study on ACEs, expansion of the three original domains (abuse, neglect, and household dysfunction) and corresponding experiences has occurred. For example, Koita et al (2018) considered social determinants of health as a fourth domain. Social determinants of health were represented by four items: (a) food insecurity, (b) housing instability, (c) violence outside of the home, and (d) experiences of discrimination.…”

Adverse childhood experiences: Mechanisms of risk and resilience in a longitudinal urban cohort

“…As such, if researchers do not measure broader contextual experiences, particularly those that are specific to an impoverished environment, they may be missing or masking the effects of influential adverse experiences (Brooks-Gunn, Duncan, Klebanov, & Sealand, 1993). An “Expanded ACE” framework with community-level indicators and indicators of experiences associated with socioeconomic status (e.g., community violence, foster care, Giovanelli et al, 2016; Finkelhor et al, 2013; difficulty affording basic necessities, Koita et al, 2018) is necessary to illuminate potential consequences, mechanisms, and moderators of ACEs for individuals in high-risk settings.…”