Parent Report of Forward Actionable Positive Childhood Experiences (FA-PCE) Improves the Clinical Utility and Prediction of the ACE

Background: Adverse childhood experiences (ACEs) are known to have a dose-response association with later mental and physical health problems and are associated with damaging pathophysiologic “toxic stress” and epigenetic processes in childhood. Universal ACE screening of parents in pediatric care is recommended but resisted by PCPs as irrelevant and possibly traumatic and rarely done. This study is to determine if pre-visit parental report of their own forward-actionable positive childhood experiences (FA-PCE) obtained before early health supervision visits (HSV) improves prediction of infant exposure to family stressors, beyond a report of parental ACE alone. If so, screening with FA-PCE as well as ACE could have utility in refining guidance and referral as well improving adoption of ACE screening.

Methods: 74 parents indicated acceptability via feedback on exerpts of transcripts of discussion of parent ACE and FA-PCE during simulated HSV that included potential teleprompter language and also preferred graphic illustrations of results. Subsequently, before early HSV (usually at 1-2 months of age), 2833 parents used an online system to complete a 10-item questionnaire about their own positive childhood experiences with some forward-actionable items they could do with their baby such as being sung to, read to, or praised as well as the 10-item ACE. Before subsequent visits during the first-year of life, a screen was completed for current family stressors (FASS) including depression, extreme stress, food insecurity, substance abuse, and harsh punishment, all risks for child maltreatment. Rasch analyses of the FA-PCE placed items and respondents on an interval scale to classify results into comparable low-moderate-high ratings.

Results: The FA-PCE measure is internally consistent (0.82), with adequate test-retest reliability using the concordance correlation coefficient of 0.65 (n=55). There were statistically and clinically significant differences (p <.05) in mean FA-PCE scores between those experiencing any family stressor on the FASS, and specifically food insecurity, intimate partner violence, and extreme stress, as well as developmental outcomes (fail any ASQ-3 subscale). For parents with high (>=4) ACE scores, probability of a positive FASS result was reduced linearly as FA-PCE scores increased. In each case, parents with >=1 FASS stressor had lower mean FA-PCE measures. Most PCPs (69%) reported use of both ACE and FA-PCE was acceptable and planned to continue using both.

Conclusion: Parent reports of their own positive childhood experiences significantly enhanced the predictive utility of the standard ACE for current family stressors and child developmental problems. Collecting past childhood positive experiences in addition to ACE may balance discussion of parenting tendencies and positive patterns to repeat with the child, strengthen the doctor-parent relationship, and refine determination of need for referral. The FA-PCE illustrates an approach to improve the acceptability of doctor-parent conversations about ACEs and shows promise for improvements in preventive strategies to break the cycle of ACE.