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Parenting with PACEs. PACEs science & stories. Trauma-informed change.

PACEs Research Corner — May 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]

Domestic Violence – Effects on Children

Makris G, Eleftheriades A, Pervanidou P.
Early Life Stress, Hormones, and Neurodevelopmental Disorders. Horm Res Paediatr. 2023;96(1):17-24. PMID: 35259742
Authors review “the association of ELS [early life stress] and neurodevelopment disorders and the possible hormonal mechanisms through which prenatal maternal stress exerts its impact on neurodevelopment. We focus on the available evidence regarding children and adolescents diagnosed with ADHD or autism spectrum disorder. ELS exposure during developmental vulnerability windows may increase the risk for either subclinical neuropsychological alterations or clinical conditions.”

Langevin R, Kern A, Esposito T, Hélie S.
Homotypical and Heterotypical Intergenerational Continuity of Child Maltreatment: Evidence from a Cohort of Families Involved with Child Protection Services. Int J Environ Res Public Health. 2023;20(5). PMID: 36901161
This study included all children substantiated for child maltreatment with the Centre Jeunesse de Montréal between 1 January 2003, and 31 December 2020, with at least one parent who was also reported to that agency during their childhood (n = 5861 children).  In the majority of cases, the continuity of child maltreatment was “homotypical”, meaning the same type of abuse was seen in both generations.  “Homotypical continuity was found for: (1) physical abuse on the paternal side; (2) sexual abuse on the maternal side; and (3) exposure to domestic violence on the maternal side. Interventions helping maltreated parents overcome their traumatic past are essential to foster intergenerational resilience.”

Orr C, Kelty E, O'Donnell M, Fisher CM, Glauert R, Preen DB.
Reproductive and sexual health of Australian adolescents exposed to family and domestic violence. BMJ Sex Reprod Health. 2023 Mar 8:bmjsrh-2022-201684. PMID: 36889813
Using large Australian linked databases, “Children exposed to FDV [family DV] are at an increased risk of hospitalisation for sexually transmitted infection and termination of pregnancy as an adolescent. Effective interventions are needed to support children exposed to FDV.”

Gondek D, Howe LD, Gilbert R, et al.
Association of Interparental Violence and Maternal Depression With Depression Among Adolescents at the Population and Individual Level. JAMA network open. 2023;6(3):e231175. PMID: 36857050
“In this study, parental IPV and maternal depression were associated with depression in adolescence at the population level. However, estimation of an individual developing depression in adolescence based only on information about IPV or maternal depression is poor. Screening children for maternal depression and IPV to target interventions to prevent adolescent depression will fail to identify many children who might benefit and may unnecessarily target many others who do not develop depression.”

Shorey S, Baladram S.
"Does It Really Get Better After Dad Leaves?" Children's Experiences With Domestic Violence: A Qualitative Systematic Review. Trauma Violence Abuse. 2023:15248380231156197. PMID: 36927274
From a research review of children’s experiences of abusive fathers after parental separation, “findings highlighted that the experience of DV persisted post-separation through various forms of abuse. Children also struggled with mixed feelings and thoughts toward their fathers. They found it hard to trust their fathers and were cautious about their fathers' intentions regarding love and interest. Some children had difficulty interacting with their fathers and were exploited by them. Different stakeholders such as healthcare professionals and court officials can play a significant role in supporting and protecting children exposed to DV.”

Vass A, Haj-Yahia MM.
"I Have to Make Sure She Is Not Sad": Children's Perceptions of Their Mothers' Experiences in Shelters for Battered Women. Violence Against Women. 2023:10778012231159416. PMID: 36913742
32 children aged 7-12 years who were staying with their mothers in a women’s’ shelter after IPV were interviewed about their insights and feelings about their mothers’ experiences there.

Sakowicz A, Allen E, Alvarado-Goldberg M, et al.
Association Between Antenatal Depression Symptom Trajectories and Preterm Birth. Obstet Gynecol. 2023 Apr 1;141(4):810-817. PMID: 36897146
Of 732 pregnant people referred to a mental health care program, 71.4% had initial mild or more severe depressive symptoms.  Of the 35.0% whose symptoms improved during the course of pregnancy, the preterm birth (PTB) rate was 12.5%. (General population PTB rate is 10.5%.)  Of those women whose symptoms stayed the same, the PTB rate was 14.0%.  However, for the 5.3% of women whose symptoms worsened, the PTB rate was 30.8%.

Biggs LJ, Jephcott B, Vanderwiel K, et al.
Pathways, Contexts, and Voices of Shame and Compassion: A Grounded Theory of the Evolution of Perinatal Suicidality. Qual Health Res. 2023:10497323231164278. PMID: 36952603
“Perinatal suicidality is a complex multidimensional phenomenon, influenced by socio-cultural expectations of motherhood and interpersonal, systemic, and intergenerational experiences of trauma…including experiences of gender-based violence, adverse childhood experiences, and a history of mental health difficulties. When women feel that they are defective, are unworthy of love and belonging, and do not possess what it takes to be a good mother, they can conclude that their family is better off without them. Pathways beyond shame were facilitated by compassionate and rehumanising care from family, friends, and care providers.”

LGBTQ Concerns

Giano Z, Schwab-Reese L, Mishra AA, et al.
Intersectionality and Adverse Childhood Experiences: Comparing Subgroups of Sex, Race/Ethnicity, and Sexual Orientation. Am J Prev Med. 2023 Mar 2:S0749-3797(23)00038-7. PMID: 36870786
From a large national survey of ACEs analyzed by subgroups, “Generally, those identifying as sexual minority individuals had the highest number of ACEs (the top 14 of 30 subgroups), whereas 7 of the top 10 subgroups were female. Surprisingly, no clear patterns emerged by race/ethnicity, although the 2 largest groups (straight White females and straight White males) were 27th and 28th of 30.”

Hahn HA, Blosnich JR.
Adverse Childhood Experiences Among Lesbian, Gay, Bisexual, and Queer Veterans. Am J Prev Med. 2023 Apr 8:S0749-3797(23)00167-8. PMID: 37037327
Of 14,461 U.S. military veterans, “While accounting for sociodemographic factors, lesbian, gay, bisexual, and queer veterans were more likely to report as a child living with someone who experienced mental illness (AOR=2.17), emotional abuse (AOR=1.58), and sexual abuse (AOR=2.21) than non-lesbian, gay, bisexual, and queer veterans…With past work indicating that childhood abuse experiences are especially predictive of adverse health in adulthood, our findings suggest that a higher prevalence of ACEs among lesbian, gay, bisexual, and queer veterans may contribute to health disparities among this population.”

Race/Cultural Concerns

Nguyen AW, Qin W, Wei W, Keith VM, Mitchell UA.
Racial discrimination and 12-month and lifetime anxiety disorders among African American men and women: Findings from the National Survey of American Life. J Affect Disord. 2023;330:180-7. PMID: 36907462
From a national survey of African American US adults, everyday racial discrimination was associated with lifetime generalized anxiety disorder, agoraphobia (fear of leaving one’s home), PTSD, panic disorder, and social anxiety disorder.  Results were somewhat different for men and women.

Shapiro-Mendoza CK, Woodworth KR, Cottengim CR, et al.
Sudden Unexpected Infant Deaths: 2015-2020. Pediatrics. 2023 Apr 1;151(4):e2022058820. PMID: 36911916
Although the SIDS (sudden infant death) rate increased significantly from 2019 to 2020 (likely explained by diagnostic shifting), the overall SUID (sudden unexplained infant death) rate did not.  In 2020, <10 of the 3328 SUID had a COVID-19 code. The race and ethnicity analysis showed SUID rates increased significantly for non-Hispanic Black infants from 2019 to 2020, with reasons unknown.  Authors recommend continued monitoring and interventions to address persistent disparities.

Nelson JD, Martin LN, Izquierdo A, et al.
The role of discrimination and adverse childhood experiences in disordered eating. J Eat Disord. 2023;11(1):29. PMID: 36850009
Of 331 diverse undergraduate students, the frequency of daily discrimination predicted all ED [eating disorder] symptoms above and beyond history of ACEs.”

Borowsky HM, Willis A, Bullock JL, et al.
Opportunities and challenges in discussing racism during primary care visits. Health Serv Res. 2023 Apr;58(2):282-290. PMID: 36524295
From interviews with patients and primary care providers, authors summarize a variety of contexts and challenges in discussing racism. “Initiating conversations about racism with patients in primary care can be meaningful, but also has risks. More research is needed for deeper exploration of patients' perspectives and development of trainings. Improving how PCPs communicate with patients about racism represents an opportunity to advance antiracism in medicine and improve health outcomes for individuals who have historically been poorly served by our health care system.”

Yi Y, Edwards F, Emanuel N, et al.
State-Level Variation in the Cumulative Prevalence of Child Welfare System Contact, 2015-2019. Children and youth services review. 2023;147. PMID: 36874408
“Using 2015-2019 data from the National Child Abuse and Neglect Data System and Adoption and Foster Care Analysis and Reporting System, state-level investigation risks ranged from 14% to 63%, confirmed maltreatment risks from 3% to 27%, foster care placement risks from 2% to 18%, and risks of parental rights termination from 0% to 8%. Racial/ethnic disparities in these risks varied greatly across states, with larger disparities at higher levels of involvement. Whereas Black children had higher risks of all events than white children in nearly all states, Asian children had consistently lower risks.”

Breslin MA, Bacharach A, Ho D, et al.
Social Determinants of Health and Patients With Traumatic Injuries: Is There a Relationship Between Social Health and Orthopaedic Trauma? Clin Orthop Relat Res. 2023 May 1;481(5):901-908. PMID: 36455101
287 adult patients were seen in a Cleveland ED for traumatic musculoskeletal injury and interacted with trauma recovery services.  123 injuries were considered accidents and 164 were intentional (physical assault, sexual assault, gunshot wound, or stabbing).  Black race (compared with White race, odds ratio OR 2.71), Hispanic ethnicity (compared with White race, OR 5.32), and at-risk status for food insecurity (OR 4.27) were independently associated with intentional mechanisms of injury.

Velarde G, Bravo-Jaimes K, Brandt EJ, et al.
Locking the Revolving Door: Racial Disparities in Cardiovascular Disease. Journal of the American Heart Association. 2023:e025271. PMID: 36942617
“In this article…we explore potential factors that connote a revolving door phenomenon for those whose adverse outpatient environment puts them at risk for hospital readmissions. Additionally, we review promising strategies, as well as actionable items at the policy, clinical, and educational levels aimed at locking this revolving door.”

Ryan JE, McCabe SE, DiDonato S, et al.
Racial/Ethnic Disparities in Mental Healthcare in Youth With Incarcerated Parents. Am J Prev Med. 2023 Mar 12:S0749-3797(23)00133-2. PMID: 36918134
“Youth with incarcerated parents experience more adverse childhood experiences than other youth, placing them at higher risk for mental health and substance use disorders.”  In this adolescent study, 51% of youth with incarcerated parents reported 4+ACEs.  And while in general this group was more likely to have received mental health services (25% vs. 15% without incarcerated parents), Black and Latinx youth were less likely than White youth to report receiving mental health services.

Emani S, Rodriguez JA, Bates DW.
Racism and Electronic Health Records (EHRs): Perspectives for research and practice. J Am Med Inform Assoc. 2023 Mar 3:0cad023. PMID: 36869772
“This perspective provides a classification of racism at 3 levels -- individual, organizational, and structural -- and offers recommendations for future research, practice, and policy related to the implementation and use of electronic health records.“

Vo H, Campelia GD, Olszewski AE.
Addressing Racism in Ethics Consultation: An Expansion of the Four-Box Method. J Clin Ethics. 2023;34(1):11-26. PMID: 36940357
Authors propose an expanded version of the four-box method for clinical ethics consultation, which includes additional questions and changes to existing questions to ensure that racism is addressed within each box.  The four boxes cover the topics of medical indications, patient and caregiver preferences, quality of life, and contextual features.

Wang SXY, Chi K, Shankar M, et al.
Teaching Anti-Racism in the Clinical Environment: The Five-Minute Moment for Racial Justice in Healthcare. Am J Med. 2023;136(4):345-9. PMID: 36566895
Authors describe a structured framework on how to teach about racism in the clinical learning environment, which “can be an effective way to engage learners in real time as they encounter teachable moments with patients.”  The five steps include context, current standard, historical narrative, disparities, and steps to equity.  They provide an example of a student presenting a pigmented lesion on a person of color, discussing the present standard of care for skin lesions, the story of Bob Marley who died of an aggressive melanoma that was not originally recognized, how skin lesions may need to be evaluated differently with different skin pigments, and resources for inclusive dermatology atlases.

Police and Court Systems

Schultz ML, Winn M, Derse AR, Kaczor F, Levas MN.
Interactions With Police in the Emergency Care of Children: Ethical and Legal Considerations. Pediatr Emerg Care. 2023 Apr 1;39(4):226-229. PMID: 36727807
“We review 4 patient scenarios, based on real cases experienced by the authors, to demonstrate the legal and ethical issues that may arise when LEP [law enforcement personnel] are involved in the emergency care of a child. These scenarios discuss parental/guardian visitation for children in police custody in the emergency department (ED), the practice of making arrests on hospital grounds, and police interviews of children in the ED. Using the ethical principles of autonomy, beneficence, and justice, we offer recommendations for emergency providers on how to advocate for their pediatric patients in LEP custody within the constraints and protections of the law. We also suggest best practices for hospital systems to develop policies surrounding LEP activity in the ED.”

Javdani S, Berezin MN, April K.
A Treatment-To-Prison-Pipeline? Scoping Review and Multimethod Examination of Legal Consequences of Residential Treatment Among Adolescents. J Clin Child Adolesc Psychol. 2023:1-20. PMID: 36862081
Residential treatment centers (RTC), to which nearly a quarter of all 2.2 million children and adolescents confined by the US family court system are sent, “are populated by youth with significant mental health challenges who have been or may be unsuccessful in less restrictive settings”.  In this research review, “Across studies, we find evidence for a potential treatment-to-prison pipeline through which youth in RTCs incur new arrests and are charged with crimes during and following treatment. This pattern is pronounced for Black and Latine youth and especially girls, for whom use of physical restraint and boundary violations are recurring challenges.”

Wen A, Gubner NR, Garrison MM, Walker SC.
Racial disparities in youth pretrial detention: a retrospective cohort study grounded in critical race theory. Health & justice. 2023;11(1):14. PMID: 36882535
“Pretrial detention makes up 75% of juvenile detention admissions and contributes to the disproportionate contact of minoritized youth in the juvenile carceral system…With a sample of over 44,000 juvenile cases in a northwest state…After factoring in gender, age, crime severity, previous offenses, and variation between counties, our analyses show that Black, Hispanic/Latinx, and American Indian/Alaskan Native youth are more likely to experience pretrial detention than white youth. The likelihood of pretrial detention for Asian youth and for youth identified as "Other" or "Unknown" was not significantly different from white youth.”


Berman S, Brown T, Mizelle C, et al.
Roadmap for Trauma-Informed Medical Education: Introducing an Essential Competency Set. Acad Med. 2023 Mar 1:e005196. PMID: 36862618
“Research has established that trauma is nearly universal and a root cause of numerous health and social problems, including 6 of the 10 leading causes of death, with devastating consequences across the life course. Scientific evidence now recognizes the complex injurious nature of structural and historical trauma (i.e., racism, discrimination, sexism, poverty, and community violence). Meanwhile, many physicians and trainees grapple with their own trauma histories and face direct and secondary traumatization on the job. These findings substantiate the profound impact of trauma on the brain and body and why trauma training is critical to the education and practice of physicians…the National Collaborative on Trauma-Informed Health Care Education and Research (TIHCER) formed a task force charged with developing and validating a summary of core trauma-related knowledge and skills for physicians.”

Arya S, Zutshi A.
Trauma-Informed Care in the Neonatal Intensive Care Unit: Through the Lens of the COVID-19 Pandemic. Cureus. 2022 Oct 14;14(10):e30307. PMID: 36407229
“Trauma is rooted in an individual's experience of an event that leads to physical or mental harm and can have a long-lasting, unfavorable effect on their well-being and functioning. Being aware of the effects of trauma, recognizing its signs, understanding how it informs individual responses, and actively trying to prevent re-traumatization are the tenets of trauma-informed care. Admission to the neonatal intensive care unit (NICU) is widely considered to be an extremely stressful time for parents and infants alike. With the emergence of the coronavirus disease 2019 (COVID-19) pandemic, there were significant changes in healthcare delivery. Widespread closures, restrictions due to infection control measures, the spread of misinformation, increased psychosocial hardships, and amplification of cultural, gender, and racial biases intensified NICU-related stressors. Adoption of the principles of trauma-informed care to the NICU can help buffer some of these stressors.”

LoGiudice JA, Tillman S, Sarguru SS.
A Midwifery Perspective on Trauma-Informed Care Clinical Recommendations. J Midwifery Womens Health. 2023 Mar;68(2):165-169. PMID: 36658770
“We believe firmly in the adoption of TIC as the baseline standard of care for all patients seeking health care services. Previous TIC publications have focused heavily on tailoring care only for known survivors. However, research repeatedly references that survivors may never disclose their history or be asked by a provider. Moreover, survivors may not realize the breadth of trauma and compounding traumatic events that may impact their care and their lives. True TIC reconceptualizes interpersonal and structural interactions for all patients regardless of known history, highlighting the broader need for TIC as the standard of care.”

Ross WT, Snyder B, Stuckey H, et al.
Gynaecological care of women with chronic pelvic pain: Patient perspectives and care preferences. Bjog. 2023;130(5):476-84. PMID: 36457127
From focus groups of women aged 18-55 years with chronic pelvic pain, “Participants with chronic pelvic pain, with or without a history of sexual trauma, experienced delay in diagnosis and repetitive dismissals by clinicians. Participants' experiences of dismissals included: clinicians not listening, insufficient allocation of time for appointments and perceived redundant medical testing (i.e. sexually transmitted infection testing, urine cultures, ultrasounds). Participants identified clinician interactions as pivotal in coping with both pelvic pain and sexual abuse. Participants also provided feedback regarding trauma-informed practices.”

Renkiewicz GK, Hubble MW.
Secondary trauma response in emergency services systems (STRESS) project: quantifying and predicting vicarious trauma in emergency medical services personnel. Br Paramed J. 2023;7(4):23-34. PMID: 36875827
In a study of 691 US emergency medical services (EMS) personnel, with 44.4% female and 12.3% minorities, “Overall, 40.9% had VT [vicarious trauma]…Compared to those without VT, more than four times as many EMS professionals with VT self-reported as currently in counselling (9.2% v. 2.2%). Approximately one in four EMS professionals (24.0%) had considered suicide, while nearly half (45.0%) knew an EMS provider who had died by suicide. There were multiple predictors of VT, including female sex (odds ratio [OR] 1.55) and childhood exposure to emotional neglect (OR 2.28) or domestic violence (OR 1.91). Those with other stress syndromes, such as burnout or compassion fatigue, were 2.1 and 4.3 times more likely to have VT, respectively.”


Kong F, Zhu N, Ye Y, Li C, Zhang L, Li W.
Childhood emotional but not physical or sexual maltreatment predicts prosocial behavior in late adolescence: A daily diary study. Child Abuse Negl. 2023;139:106123. PMID: 36863204
For 240 Chinese college students, childhood emotional abuse, but not physical or sexual abuse, predicted a lack of prosocial behavior (voluntary behavior intended to benefit another, such as helping, sharing, donating, co-operating, and volunteering).  However, a sense of gratitude improved prosocial behavior despite a history of emotional abuse.

Darwiche SM, Scribano PV.
Anti-Poverty Interventions and Their Importance in Childhood Abuse Prevention. Pediatrics. 2023;151(3). PMID: 36748237
In this editorial, “Borrowing from the oncologic Knudson hypothesis, also known as the 2-hit hypothesis, poverty can be thought of as the first hit placing children at risk for poor physical, mental, and economic well-being, with abuse providing the second hit that cinches the transgenerational nature of these poor outcomes…The emerging evidence of the prevention benefits of the expanded child tax credit should serve as a call to action for pediatricians to double-down on advocacy efforts for antipoverty programs, such as childcare subsidies, tax credits, cash transfer programs, low-income housing infrastructure, and expanded Medicaid assistance, which will bolster the economic resources of families and reduce the risk of maltreatment across the life course.”

Guastaferro K, Font SA, Miyamoto S, et al.
Provider Attitudes and Self-Efficacy When Delivering a Child Sexual Abuse Prevention Module: An Exploratory Study. Health education & behavior. 2023;50(2):172-80. PMID: 33660554
“Provider self-efficacy is an important element of implementation fidelity. This exploratory study demonstrated that, though providers may approach CSA [child sexual abuse] content with wariness and trepidation, adequate skills-oriented training can reduce negative attitudes and increase perceived efficacy in the actual delivery of CSA prevention content to parents.”

Schneiderman JU, Mennen FE, Palmer Molina AC, et al.
Adults with a child maltreatment history: Narratives describing individual strengths that promote positive wellbeing. Child Abuse Negl. 2023;139:106133. PMID: 36921502
From interviews with 21 adults (mean age 27.8 years) who had experienced child abuse, identifying strengths included: The first theme was seeing oneself in a good light, highlighting self-worth and helper roles. The second theme, moving forward, included letting go of their past and a future orientation. Coping with life, the third theme, included boundaries for people around them, routines, and self-sufficiency. Meaning making, the fourth theme, included insights on the effect of their maltreatment and foster care, and reflections on appreciating life and adapting to changing circumstances…Study themes highlight how these strengths allow adults to make meaning of their experiences and move forward successfully in life.”


Freudenberg N, Israel B.
Integrating Public Health Research and Teaching With Social Justice Activism: Lessons From 80 Years of Practice. Health education & behavior. 2023:10901981231158403. PMID: 36847337
“In this commentary, we reflect on the lessons we have learned from our successes and failures in aligning the roles of scholars and activists. Our hope is to provide insights that can guide public health students, faculty, practitioners, and activists seeking to chart their professional, political, and personal futures in today's polarized and catastrophe-burdened world.”

Racine N, Greer K, Dimitropoulos G, et al.
Youth engagement in child maltreatment research: Gaps, barriers, and approaches. Child Abuse Negl. 2023;139:106127. PMID: 36907118
“We provide an overview of the potential for youth engagement within the field of child maltreatment research, identify barriers to youth engagement, provide trauma-informed strategies for engaging youth in the context of research, and review existing trauma-informed models for youth engagement…youth engagement in research can contribute to improvements in the design and delivery of mental health care services for youth exposed to traumatic experiences and should be prioritized in future research endeavors.”

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