Parent Perspectives on Adverse Childhood Experiences & Unmet Social Needs Screening in the Medical Home: A Qualitative Study.

OBJECTIVES: To explore parental perspectives regarding disclosure of child and parental adverse childhood experiences (ACE) and family unmet social needs (USN) and to elicit parental recommendations for screening in the pediatric medical home. METHODS: We conducted a qualitative study using a purposive sample of English- and Spanish-speaking parents in our urban academic community clinic. Between January 2018 and March 2019, each parent underwent one semistructured interview that was audiotaped, transcribed, and independently coded in Atlas.ti by 2 study team members. Data analysis was based in constructivist grounded theory methodology to identify common themes and subthemes. RESULTS: We interviewed 25 English-speaking and 15 Spanish-speaking parents who were mostly female, racial/ethnic minorities with ≥1 ACE. English-speaking subjects were more likely to have a high school degree and be single parents. Four themes were identified: 1) Pediatricians should ask about ACE and USN. 2) Disclosure is a longitudinal process, not a discrete event. 3) Barriers to disclosure are significant, involving concrete and emotional risks for the family. 4) Trauma-informed providers and practices support disclosure. CONCLUSIONS: Families support pediatricians addressing ACE and USN in the medical home despite significant barriers. Even if providers screen using trauma-informed principles, parents may prefer not to disclose ACE initially because they regard disclosure as a stepwise process. These findings contribute to a new conceptual framework for thinking of ACE screening not merely as a way to generate information, but as an interactive, therapeutic relationship-building activity irrespective of whether or when it produces disclosure.

Screening for Toxic Stress Risk Factors at Well-Child Visits: The Addressing Social Key Questions for Health Study.

OBJECTIVES: To determine the prevalence of and demographic characteristics associated with toxic stress risk factors by universal screening, the impact of screening on referral rates to community resources, and the feasibility and acceptability of screening in a medical home setting. STUDY DESIGN: We developed the Addressing Social Key Questions for Health Questionnaire, a 13-question screen of adverse childhood experiences (ACEs) and unmet social needs. Parents/guardians of children 0-17 years of age received this questionnaire at well-child visits at 4 academic clinics from August 1, 2016 to February 28, 2017. Providers reviewed the tool and referred to community resources as needed. A subset of families completed demographic and satisfaction surveys. Prevalence of ACEs and unmet social needs, community referral rates at 1 site with available data, and family acceptability data were collected. Analyses included frequency distributions, χ2 tests, and Poisson regression. RESULTS: Of 2569 families completing an Addressing Social Key Questions for Health Questionnaire, 49% reported ≥1 stressor; 6% had ≥1 ACE; 47% had ≥1 unmet social need. At 1 site, community referral rates increased from 2.0% to 13.3% (P < .0001) after screening implementation. Risk factors for having a stressor include male sex and African American or Hispanic race. 86% of 446 families want clinics to continue screening. CONCLUSIONS: Universal screening for toxic stress risk factors in pediatric primary care improved identification and management of family needs. Screening was feasible and acceptable to families. Prevalence of unmet social needs but not ACEs was comparable with prior studies. Further evaluation and modification of the screening protocol is needed to increase screening and identification.

Exploring caregiver understanding of medications immediately after a pediatric primary care visit.

OBJECTIVE: Assess accuracy of caregiver understanding of children's prescribed medications and examine factors associated with accurate recall. METHODS: Cross-sectional, observational study of English- or Spanish-speaking caregivers of primary care patients aged 0-7 years. Child and visit characteristics and caregiver health literacy (short test of health literacy in adults) were assessed. Post-visit, caregivers completed questionnaires on medications prescribed. Caregiver and medical record agreement on medication name and administration (dose and frequency) were examined using chi square and logistic regression. RESULTS: Analyses included 68 caregivers (28% low health literacy); 96% of children had public insurance. Caregivers indicated that the doctor provided clear medication information (100%) and they could follow instructions (98%). 101 medicines were prescribed; 6 were recalled by caregiver only. 71% of medications were accurately named; 37% of administration instructions were accurately recalled. Accurate naming was more often found for patients 3-7 years, without conditions requiring repeat visits, and new medications. Accurate administration responses were associated with having only 1 child at the visit. CONCLUSION: Unperceived medication instruction understanding gaps exist at physician visits for caregivers of all literacy levels. Communication and care delivery practices need further evaluation. PRACTICE IMPLICATIONS: Clinicians should be aware of the frequency of caregiver medication misunderstanding.