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PACEs Research Corner — September 2023, Part 2


[Editor's note: Dr. Harise Stein at Stanford University edits a web site — — that focuses on the effects of abuse, and includes research articles on PACEs. Every month, she posts the summaries of the abstracts and links to research articles that address only ACEs, PCEs and PACEs. Thank you, Harise!! — Rafael Maravilla]

Human Trafficking

Shekhar AC, Macias-Konstantopoulos W.
Human Trafficking and Emergency Medical Services (EMS). Prehospital and disaster medicine. 2023:1-3. PMID: 37403463
Authors summarize the relevance of human trafficking to prehospital emergency care, best practices for the care of patients with suspected or confirmed ties to human trafficking, and outline future directions for education and research.

Conley AH, Carlyle KE, Cuddeback G, Kornstein SG.
Working with Survivors of Sex Trafficking: Mental Health Implications. Psychiatr Clin North Am. 2023;46(3):597-606. PMID: 37500253
“Sex trafficking survivors experience significant physical, emotional, and sexual trauma that places them at increased risk of poor health outcomes…Medical professionals should be familiar with screening protocols for trafficking and evidence based, trauma-informed mental health treatment interventions,” as well as coordination with law enforcement and social services.

Casassa K, Ploss A, Karandikar S.
"Drugs Can Be a Great Coercion": Service Providers' Perspectives on the Relationship between Substance Use and Trauma Bonding among Survivors of Sex Trafficking. Health Soc Work. 2023;48(3):198-208. PMID: 37279359
“A trauma bond refers to an emotional attachment that can develop between victims and their abusers.”  From interviews with sex trafficking survivors experiencing substance use, three themes emerged: “substance use as a tactic, substance use as a risk factor, and substance use as a potential trauma bond. These findings support the need to treat substance use and mental health concerns concurrently among sex trafficking survivors.”

Clark KR.
Human Trafficking: Red Flags, Common Myths, and Health Effects. Radiol Technol. 2023;94(6):471-5. PMID: 37433602
Succinct summary of human trafficking, with red flags for radiology technicians, including a case example of how a trafficked person sent from the ED for a sonogram for pelvic pain and bleeding and her trafficker might act in the exam room, and best options for care.

Panda P, Garg A, Grube A.
The Haven Clinic: The Planning and Implementation of a Medical Home for Child Trafficking Survivors. J Health Care Poor Underserved. 2023;34(2):833-44. PMID: 37464534
“The authors describe the planning and implementation of a survivor-informed medical home for child trafficking survivors. Key partnerships necessary for establishing clinical infrastructure are highlighted. The trauma-informed clinical practices are described in detail.”


Feil K, Riedl D, Böttcher B, et al.
Higher Prevalence of Adverse Childhood Experiences in Transgender Than in Cisgender Individuals: Results from a Single-Center Observational Study. Journal of clinical medicine. 2023;12(13). PMID: 37445536
Of 35 transgender adults with matched cisgender controls, transgender adults had higher ACE score (2.4 vs. 0.7), 4+ ACEs (28.6% vs. 5.7%), higher prevalence of depression (48.4% vs. 5.7%), posttraumatic stress disorder symptoms (59.4% vs. 13.8%), and anxiety (58.1% vs. 28.6%). For the transgender group, the most common forms of ACEs were parental abuse (54.3%) and peer abuse (54.3%). No significantly increased prevalence of sexual abuse was found.

Liang Y, Rees DI, Sabia JJ, Smiley C.
Association Between State Antibullying Policies and Suicidal Behaviors Among Lesbian, Gay, Bisexual, and Questioning Youth. JAMA Pediatr. 2023 May 1;177(5):534-536. PMID: 36877505
“In an attempt to reduce bullying, states have enacted anti-bullying laws (ABLs), which require school districts to provide teachers with training to recognize bullying, impose graduated sanctions on perpetrators, and improve monitoring of bullying incidents.”  Using national survey data, “The prevalence of whether a student seriously considered attempting suicide, made a suicide plan, and attempted suicide was higher for LGBQ-identifying students compared with heterosexual-identifying students. Among all LGBQ-identifying students, ABL adoption was associated with a 25.0% reduction in the odds of planning suicide and a 27.9% reduction in the odds of attempting suicide.”

Ison J, Forsdike K, Henry N, Hooker L, Taft A.
"You're just constantly on alert": Women and Gender-Diverse People's Experiences of Sexual Violence on Public Transport. J Interpers Violence. 2023:8862605231186123. PMID: 37465905
“Public transport is a key site of sexual violence and harassment experienced by women and gender-diverse people in Australia…including stalking, sexualized verbal assaults, sexual assault, physical violence, homophobic and transphobic verbal assaults, and racist verbal assaults. Participants reported a broad range of experiences not only on the mode of transport (tram, bus, train, and taxi/rideshare) but also on platforms, in transit, and during the last kilometer home. All participants reported that the perpetrator or perpetrators were male and unknown to the victim…sexual violence and harassment on public transport should be addressed…for primary prevention.”

Race/Cultural Concerns

Alegría M, Alvarez K, Cheng M, Falgas-Bague I.
Recent Advances on Social Determinants of Mental Health: Looking Fast Forward. Am J Psychiatry. 2023;180(7):473-82. PMID: 37392038
Authors review new knowledge about the importance of social determinants of health and their impact on mental health outcomes, including social conditions (e.g., food insecurity, housing instability), traumas associated with immigration, racism and minoritization, as well as psychosocial and community strengths.

Gray KD, Subramaniam HL, Huang ES.
Effects of Racial Bias in Pulse Oximetry on Children and How to Address Algorithmic Bias in Clinical Medicine. JAMA Pediatr. 2023 May 1;177(5):459-460. PMID: 36939724
Of 774 children who underwent cardiac catheterization and had measured arterial blood oxygen levels matched within a minute with an external pulse oximeter, of those children with true low oxygen levels (<88% saturation), 12% of Black or African American patients vs 4% of White patients had external pulse oximeter levels suggesting normal oxygen levels.  “Values suggest that pulse oximetry overestimated arterial oxygen saturation in children of Black or African American race. The discrepancy has been attributed to light absorption properties of melanin.”

Helton JJ, Asher BlackDeer A, Banks KH, et al.
Racial Discrimination of Adolescents With Special Healthcare Needs. J Adolesc Health. 2023;73(2):383-6. PMID: 37140518
From a large national children’s health survey, “Adolescents of color with SHCNs [special health care needs] were almost twice as likely to experience racial discrimination as peers of color without SHCNs. Asian youth with SHCNs were over 3.5 times likely to experience racial discrimination as peers without SHCNs. Youth with depression experienced highest rates of racial discrimination. Compared to peers without SHCNs, Black youth with asthma or a genetic disorder, and Hispanic youth with autism or intellectual disabilities, experienced higher rates of racial discrimination.”

LaBrenz CA, Littleton T, Shipe S, Bai R, Stargel L.
State Policies on Child Maltreatment and Racial Disproportionality. Children and youth services review. 2023;151. PMID: 37425655
“The racial disproportionality index (RDI) was calculated for Black children in each state and Washington DC (N = 51) based on the proportion of children who received a referral to CPS, a substantiated investigation, or entered foster care… Our results suggest there is an overrepresentation of Black children in CPS across the three decision points…Recommendations are provided for policy and research, including a suggestion for further exploration of state policies and county-level disproportionality indexes.”

Laster M, Kozman D, Norris KC.
Addressing Structural Racism in Pediatric Clinical Practice. Pediatr Clin North Am. 2023;70(4):725-43. PMID: 37422311
“Both structural and interpersonal racism can adversely impact a child’s biological and psychological functioning. By integrating strategies that address the impact of structural racism along the life course into clinical care, we can optimize our potential to mitigate both existing disparities and the intergenerational transmission of many health and social disadvantages, thereby improving the health of minoritized children, families, and communities.”


de Roos MS, Oliver C, Carré JR, Jones DN.
Mimicry Deception Theory applied to sexual abuse of children. Child Abuse Negl. 2023;143:106339. PMID: 37406466
From an analysis of US court appeal cases of child sexual abuse, authors suggest that Mimicry Deception Theory (Victim Selection, Community Integration, Complexity of Deception, Resource Extraction, and Detectability) can be useful in determining reasons for delayed or non-disclosure and conflicting emotions on the part of the survivor, as well as “how repeat offenders were likely to use the exact same methods of access, grooming, and remaining undetected across victims.”

Schittek A, Roskam I, Mikolajczak M.
Parental burnout and borderline personality stand out to predict child maltreatment. Scientific reports. 2023;13(1):12153. PMID: 37500720
“Parental burnout is a severe disorder resulting from the exposure to chronic stress in the parental role, that can translate into neglectful and violent parental behaviors towards the offspring.”  In this study of 1003 parents, looking at multiple predictors of child abuse potential, “When all predictors are entered together in the model, violence and neglect towards the offspring are best predicted by borderline personality and parental burnout…These results emphasize the importance of preventing parental burnout and supporting parents with borderline personality.”

Zgoba KM, Liu L, Matthews DT.
Advancing Research: An Examination of Differences in Characteristics of Sexual and Non-Sexual Offense Recidivism Using a 10-Year Follow-Up. Int J Environ Res Public Health. 2023;20(13). PMID: 37444060
“This study uses administrative data and comprehensive case files of of 626 individuals who were incarcerated for a sexual offense with a 10-year post-release follow-up. Findings reveal that ACEs, mental health challenges, and substance use disorder, along with a variety of other factors, affect the pathway to re-offending differently. Interestingly, despite the recent legislative push to utilize one standardized predictor of risk, individuals who commit sexual offenses had very different re-offending patterns based on historic life events.”

Police and Court Systems

Fitt K, Maylea C, Costello S, Kuyini B, Thomas S.
Independent non-legal advocacy in the child protection context: A descriptive review of the literature. Child Abuse Negl. 2023;143:106285. PMID: 37379729
From a research review, “two points were unanimously agreed: 1) parents' encounters with the child protection system are difficult or disempowering; and 2) parents' access to independent non-legal advocacy is advantageous…the purpose of this form of parent support was that it acted as a bridging role to facilitate system navigation, communication and parent empowerment…Despite resource constraints, independent non-legal advocacy programs have nevertheless shown a financial return and benefits to both the child protection system and parents.”


Strauch KA.
A Conceptual Model to Guide Patient-to-Provider Communication of Adverse Childhood Experiences in Primary Care: The PPC-ACE Model. ANS Adv Nurs Sci. 2023 Jul-Sep 01;46(3):265-276. PMID: 36083620
“Communicating with adults about childhood adversity is not an innate clinical skill nor is it a routine assessment element…This article presents the development of a conceptual model to guide patient-to-provider communication of adverse childhood experiences in primary care (the PPC-ACE model). This includes a description of the model and its associated foundational elements, underlying assumptions, implications for nursing practice, and opportunities to use this model to guide future ACEs-related research.”

Marans S.
Understanding and responding early to childhood trauma. The International journal of psycho-analysis. 2023;104(3):565-73. PMID: 37410069
Author describes a psychoanalytic approach to children who have experienced trauma.

Wei LC.
Utilizing Insights on Shame to Enhance Empathy and Support for CSA Survivors in Clinical Practice. J Child Sex Abus. 2023;32(5):533-5. PMID: 37194603
“Childhood sexual abuse (CSA) survivors often experience long-lasting shame, which can significantly impede their healing process and overall well-being.” In this letter to the editor, a psychiatrist advocates that by better understanding the dynamics of shame and its relationship with CSA, mental health professionals can provide more empathetic and effective care to their patients, emphasizing the importance “of creating a supportive and safe environment for patients to disclose their experiences and overcome the barriers that shame creates in their journey toward recovery”.

Derck JE, Livingston JD, Zhang A, et al.
Feasibility and Challenges with Measuring Adverse Childhood Experiences in the Pediatric Intensive Care Unit. Journal of child & adolescent trauma. 2023:1-4. PMID: 37359462
Of 432 parents of children aged 0-18 years admitted to a single medical-surgical PICU over a one-year period, 92.6% agreed to participate in a 10 question ACE screen. Most parents reported an ACE score of zero (68.9%) while 31% experienced at least 1 ACE, of whom 14.8% experienced ≥ 2 ACEs. There was not a statistically significant association between ACE score and length of stay or level of respiratory support in patients with asthma. The primary reasons for not approaching families were parent availability, non-English speaking parents, and social work concerns. This study demonstrates feasibility to collect sensitive psychosocial data in the PICU and highlights challenges to enrollment.”

Arrojo MJ, Bromberg J, Walter HJ, Vernacchio L.
Pediatric Primary-Care Integrated Behavioral Health: A Framework for Reducing Inequities in Behavioral Health Care and Outcomes for Children. Pediatr Clin North Am. 2023;70(4):775-89. PMID: 37422314
“Nearly half of US children and adolescents will suffer a behavioral health (BH) disorder, with substantially higher rates among more disadvantaged children such as racial/ethnic minorities, LGBTQ + youth, and poor children. The current specialty pediatric BH workforce is inadequate to meet the need, and the uneven distribution of specialists as well as other barriers to care, such as insurance coverage and systemic racism/bias, further exacerbate disparities in BH care and outcomes. Integrating BH care into the pediatric primary care medical home has the potential to expand access to BH care and reduce the disparities inherent in the current system.”

Pham C, Caso TJ, Cullen MJ, et al.
Adverse Childhood Experiences, Household Income, and Mentorship Among Interns Who Are Underrepresented in Medicine. J Grad Med Educ. 2023;15(3):309-15. PMID: 37363664
Between 2019 and 2021, a diversity survey was administered to incoming medical interns at the University of Minnesota-Twin Cities, with a 81.9% overall completion rate. “The odds of experiencing the cumulative burden of having a childhood household income of $29,999 or less, no physician mentor, and 4 or more ACEs was approximately 10 times higher among underrepresented in medicine (6.41%) than White (0.66%) interns (OR=10.38).”


Borg LE, Alhusen JL.
A Review of Factors that Serve to Protect Pregnant and Post-partum Women from Negative Outcomes Associated with Adverse Childhood Experiences. Matern Child Health J. 2023 Sep;27(9):1503-1517. PMID: 37294463
From a research review, the presence of social support, personal resiliency, and positive childhood experiences were protective factors against poor mental or physical outcomes associated with experiencing ACEs.

Aschengrau A, Winter MR, Shea MG.
Association between resilience promotion factors during childhood and risk of drug use disorder during adulthood. Addict Subst Abus (Middlet). 2023;2(1):1-10. PMID: 37427318
Of 618 Massachusetts adults followed from birth, “results suggest that the risk of developing criteria for drug use disorder decreases in a dose-response fashion according to the number of "outside" resilience promotion factors during childhood, and that family factors are associated with greater risk reductions than community factors, particularly among individuals with ACEs.”

Beebe R, Fish MC, Grasso D, et al.
Reducing Family Violence Through Child Welfare Intervention: A Propensity Score-Matched Study of Fathers for Change. J Interpers Violence. 2023:8862605231186121. PMID: 37470201
“Most children referred to child protective services (CPS) have witnessed IPV and are at increased risk for subsequent exposure, as well as repeat maltreatment. For CPS referred children, there is often a missed opportunity to interrupt family violence and prevent future occurrences. Fathers for Change (F4C) is a family level intervention designed to reduce IPV by improving emotion regulation and reflective functioning in fathers.” In a study of F4C fathers vs. a control group, “control fathers were 2.4 times more likely to have a repeat maltreatment report during the 12-month follow-up period than F4C fathers.”

Guterman NB, Bellamy JL, Banman A, et al.
Engaging fathers to strengthen the impact of early home visitation on physical child abuse risk: Findings from the dads matter-HV randomized controlled trial. Child Abuse Negl. 2023;143:106315. PMID: 37419071
For 204 families with home visitation, “Dads Matter Home Visitation enhancement improved home visitor relationships with fathers, but only for families receiving services initiated postnatally. For these families, the improved quality of the father-worker relationship predicted improved parents' support of one another and reduced bidirectional mother-father partner abuse at 4-month follow-up, which in turn lowered maternal and paternal physical child abuse risk at 12-month follow-up.”

Gross M, Bhagwat A, Cole R.
Effects of the Nurturing Parenting Program Nurturing Skills for Families on child safety and permanency. Child Abuse Negl. 2023;143:106338. PMID: 37437341
“Many child welfare agencies use the Nurturing Parenting Program Nurturing Skills for Families (NPP) program to strengthen parenting skills. NPP includes a flexible sequence of lessons that are tailored to meet each family's needs.”  In a study of 1102 children in Arizona, families who completed NPP were less likely to experience an investigation or have a substantiated investigation 4 months later, and less likely to experience a removal 16 months later. “Additional research is necessary to understand the supports that enable families to complete NPP and the specific components that are particularly effective.”

Han D, Dieujuste N, Doom JR, Narayan AJ.
A systematic review of positive childhood experiences and adult outcomes: Promotive and protective processes for resilience in the context of childhood adversity. Child Abuse Negl. 2023;144:106346. PMID: 37473619
From a research review, higher levels of positive childhood experiences (PCEs) were associated with more favorable outcomes reflecting mental health, psychosocial functioning, physical health and health behaviors, and psychosocial stress. “Individuals' childhood adversity and PCEs are somewhat independent sets of experiences; many individuals experience both, and the presence of one does not preclude the other…PCEs may more frequently directly promote positive outcomes rather than moderate the effects of adversity on outcomes.”

Girod SA, Leerkes EM, Zvara BJ.
Childhood maltreatment predicts maternal sensitivity to distress: Negative attributions during the transition to parenthood. J Fam Psychol. 2023;37(5):709-19. PMID: 37053420
In this study of first-time mothers and their 6-month-old children, “maternal childhood maltreatment history was significantly positively associated with negative attributions about infant crying [child spoiled, trying to make mother’s life difficult, etc.]… These effects were significant above and beyond the effects of coherence of mind, concurrent depressive symptoms, infant affect, maternal age, race, education, marital status, and income-to-needs ratio. The results suggest that altering negative attributions about infant crying may be an important area to intervene during the prenatal period to reduce continuity in maladaptive parenting across generations.”

Skolnick VG, Lynch BA, Smith L, et al.
The Association Between Parent and Child ACEs is Buffered by Forgiveness of Others and Self-Forgiveness. Journal of child & adolescent trauma. 2023:1-9. PMID: 37359460
For 150 parents and children enrolled in Head Start in an upper midwestern, rural state, “Parents with low and medium levels of self-forgiveness and forgiveness of others had a stronger positive correlation between their own experience of ACEs and their child's, whereas, for parents with high levels of self-forgiveness and forgiveness of others, the correlation between parent and child ACEs was reduced statistically to zero. The cycle of intergenerational transmission of ACEs may be interrupted, or at very least notably buffered, by forgiving oneself and others.”

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