When health care providers screen their pediatric patients for ACEs, what interventions might help improve outcomes for children? Dr. Ariane Marie-Mitchell, a pediatrician in the Department of Preventive Medicine at Loma Linda University, and a colleague sought an answer to that question in a systematic review of studies that was published recently in the American Journal of Preventive Medicine.
As part of their inquiry, Marie-Mitchell and her co-investigator, Rashel Kostolansky, who was a master’s student in public health at Claremont Graduate University, wanted to see what studies examined interventions that could be done before a child showed signs of distress associated with ACEs exposure.
“If we identify risk factors, especially before a child has health problems, school problems, poor social outcomes, there’s an opportunity to prevent those poor outcomes. The question is how? What do we already know about helping families where there are ACEs?” said Marie-Mitchell. The pediatrician began screening pediatric patients at Loma Linda University Hospital for ACEs and providing support services in 2016.
They surmised that the most effective approach is to provide support to parents to strengthen the relationship between them and their children. With this in mind, the investigators looked at practices in pediatric clinics or health clinics that provide pediatric health services to find interventions that best improve the parent-child relationship.
The review included 20 studies involving 6,828 pediatric patients between the ages of a few months to 5 years who had been exposed to between 1 and 5 ACEs. These patients were identified through medical records, ACEs screening or other questionnaires. Each group receiving support was compared with a control group of patients receiving their usual care. The researchers found that the most common ACEs these children experienced were living with a parent with mental illness, living with a parent who is struggling with alcohol or other drug use, or living with a parent who has experienced domestic violence.
Most of the studies included a variety of supports for families. These supports included counseling for parents and children, nurse home-visiting programs that educated parents about child development and using navigators to help families access community-based services, said Marie-Mitchell. Handouts were also provided in a couple of the studies, such as SEEK (Safe Environments for Every Kid) pocket cards.
The review confirmed that several kinds of support made a difference in outcomes of children exposed to ACEs, said Marie-Mitchell, including parent education, social support and connecting families to community based services. “There is particularly good evidence to support the value of linking pediatric primary care screening for ACEs to nurse home-visiting programs, as well as evidence to support the value of integrating behavioral health services for both parents and children.”
One study in the review that highlights improvements associated with a home-visiting program included 157 healthy children between the ages of 36 months and six years who had been exposed to multiple ACEs, such as living in a household where a family member experienced domestic violence, incarceration, depression, or was abusing alcohol or drugs. Over a year, families received weekly – as needed -- home visits by both a care coordinator and a mental health clinician who educated the parent about child development, what services were available in the community and provided parent-child therapy, said Marie-Mitchell. The results showed that children in the intervention group were two times less likely to have child protective services referrals, four times more likely to demonstrate good language development and five times less likely to exhibit anger and aggression compared to the comparison group, said Marie-Mitchell.
But much less intensive interventions made a difference too, said Marie-Mitchell. One study in the review included 731 healthy toddlers who lived in households with a parent who experienced depression, and/or used alcohol or other drugs. During three visits, parents were videotaped interacting with their children and then given feedback to help them respond to their children’s behaviors, said Marie-Mitchell. “The intervention resulted in increased positive behavior support by the parents and this led to reduced child behavior problems at ages 3 and 4 years old,” she said.
The majority of studies that focused on improving the parent-child relationship provided home visits ranging from three visits to many over years. And despite the wide range, the studies showed outcomes that were beneficial to the interactions between parents and children, said Marie-Mitchell. “In other words, it’s not that hard to improve the quality of the parent-child relationship, which can reduce child maltreatment and long term [consequences],” she said.
While the review captured studies that confirmed that some interventions worked to help families and children exposed to ACEs, Marie-Mitchell said it also revealed what was missing in the research literature: “Given that ACEs can cause chronic stress that can cause poor outcomes, it seems logical that interventions to reduce the impact of ACEs should teach parents or children or both about stress management. It also seems logical that the ideal multi-factorial intervention would include mental health and substance treatment if needed for the parent or child.”
Notably, none of the studies indicated that parents were educated about ACEs or ACEs science, according to Marie-Mitchell. ACEs science includes the epidemiology of ACEs; the neurobiology of toxic stress; the health consequences of toxic stress, the epigenetics of toxic stress and resilience research.
The review also showed that there were a dearth of studies related to children over the age of 5, said Marie-Mitchell.
There was also a gap in research related to prevention, she noted. “We don’t know for sure that screening for ACEs in the pediatric setting can prevent poor outcomes, but we have a little bit of evidence (the SEEK trials) to suggest that this is possible. We also need to learn more about the details related to screening, like what age groups most benefit, what frequency is needed, and what other intervention components could increase the impact.”
The majority of studies in the systematic review showed improvements in the parent-child relationship after parents were educated about child development and educated about positive ways to respond to their children’s behaviors. “To me,” Marie-Mitchell said, “this highlights the value of expanding education about child development and parenting for pediatric providers.”
And in answer to a question about how pediatric providers can add educating their patients about child development and parenting to their already demanding workflow, Marie-Mitchell said, “Pediatricians and primary care providers are being pushed for economic reasons to see the highest volume of patients per day. This is leading to a burnout of professionals and a limited ‘band-aid’ approach to medical care. There is an opportunity within primary care practice to be preventive, and an adequate response to the literature on ACEs demands that we figure out a way to fix the system, rather than fitting a response to ACEs into a broken system,” she said.
“One such response is to provide more training for providers, along with more time and reimbursement for their visits, which would immediately result in better preventive care, and over time would result in better health care outcomes.”
(Marie-Mitchell uses an ACE screening tool that she and colleagues developed known as the Whole Child Assessment: It combines questions from the required Stay Healthy Assessment with ACE questions, and its second iteration was approved last November. See this story about it.)