Use of Metaphor as an Explanation Tool in Adverse Childhood Experiences Simulation Training.

INTRODUCTION: Adverse childhood experiences (ACEs) have profound implications for adult health. Health care practitioners need effective communication tools for trauma-sensitive inquiries with patients. This study aimed to describe characteristics of effective metaphor use by health care trainees when discussing ACEs and health with adult patients, and to provide example metaphors for clinicians to use to sensitively address ACEs. METHODS: Trainees engaged in a videorecorded simulation as part of a model to teach health care practitioners communication skills related to ACEs. Videos were identified in which the trainee used a metaphor to help explain ACEs during the encounter. Encounter segments that used metaphors were transcribed and metaphor type, duration, and recurrence were coded using a standardized rubric. Each metaphor was scored for effectiveness and basic statistical analysis was conducted. RESULTS: Of the 122 videos reviewed, 24 types of metaphors were used, with the most common being the overloaded backpack (n = 24). Mean metaphor duration was 37 s (SD = 24 s). Metaphors rated as effective were shorter and less variable in duration (31.8 s, SD = 14.7 s) than those rated as ineffective (39 s, SD = 34 s). No one metaphor performed significantly better and most of the metaphors were evaluated as being adequate or effective. CONCLUSION: Literary devices like metaphors may be efficient and effective explanatory tools to improve clinician communication skills and patient understanding in addressing sensitive topics, such as ACEs. Minimal time investment is required to employ metaphors in ACEs discussions. The authors found no single metaphor that to be clearly superior, indicating that patient-centered metaphor use may improve communication between clinicians and patients who experienced childhood trauma.

Detecting and Addressing Trauma-related Sequelae in Primary Care.

Objective: The associations between the sequelae of complex trauma symptoms and adult health status, patient engagement in treatment, and the potential impacts on primary care providers are underappreciated despite the potential for adverse outcomes. This study examined the correlations among adult primary care patients' reports of posttraumatic stress symptoms (PTSS), adverse childhood experiences (ACE), and the impacts of social determinants of health (SDH) with provider diagnoses in the electronic health record.Methods: Patients in 3 primary care clinics were surveyed. Self-report measures included demographics, trauma symptoms, ACE, and SDH elements. Participant health status and diagnoses were obtained from their electronic health records.Results: The final sample of 354 participants reported high levels of trauma including PTSS and ACE. Educational attainment, health literacy, material hardship, access to health care, and ACE were all statistically associated with reports of PTSS (P < .05 for all). Despite the prevalence of symptoms and adverse experiences reported by the participants, only 5% were diagnosed with a trauma-related disorder in the electronic health record.Conclusions: Data analyses revealed a significant discrepancy between participants' reports of symptoms with a diagnosis of posttraumatic stress disorder by their primary care doctor. Trauma-impacted patients often present with complicated health problems that may influence the encounter in negative ways, including diminishing the primary care doctor's sense of efficacy and competency if they are not addressed effectively in the encounter. The common nature of ACE, PTSS, and SDH effects indicate that both patients and physicians would benefit from detection and training in strategies for routinely implementing trauma-informed practices.

Influence of race/ethnicity and income on the link between adverse childhood experiences and child flourishing.

BACKGROUND: The impact of early adversity increases the risk of poor outcomes across the life course. Identifying factors that protect against or contribute to deleterious life outcomes represents an important step in resilience promotion among children exposed to adversity. Informed by resilience science, we hypothesized that family resilience mediates the relationship between adverse childhood experiences (ACEs) and child flourishing, and these pathways vary by race/ethnicity and income. METHODS: We conducted a secondary data analysis using the 2016-17 National Survey of Children's Health data reported by parents/guardians for 44,686 children age 6-17 years. A moderated-mediation model estimated direct, indirect, and total effects using a probit link function and stacked group approach with weighted least square parameter estimates. RESULTS: The main variables were related in expected directions. Family resilience partially mediated the ACEs-flourishing association. Although White and socioeconomically advantaged families were more likely to maintain family resilience, their children functioned more poorly at high-risk levels relative to Black and Hispanic children and across income groups. CONCLUSION: Children suffer from cumulative adversity across race/ethnicity and income. Partial mediation of family resilience indicates that additional protective factors are needed to develop comprehensive strategies, while racial/ethnic differences underscore the importance of prevention and intervention programs that are culturally sensitive. IMPACT: The key message of the article reinforces the notion that children suffer from cumulative adversity across race/ethnicity and income, and prevention of ACEs should be the number one charge of public policy, programs, and healthcare. This is the first study to examine family resilience in the National Survey Children's Health (NSCH) data set as mediating ACEs-flourishing by race/ethnicity and family poverty level. Examining an ACEs dose-response effect using population-based data within the context of risk and protective factors can inform a public health response resulting in a greater impact on prevention efforts.

An evaluation of a simulation and video-based training program to address adverse childhood experiences.

Adverse Childhood Experiences (ACEs) are multiple sources of maltreatment and household dysfunction with tremendous impact on health. A trauma-informed (TI) approach is preferred when working with patients with ACEs. The Professional ACEs-Informed Training for Health© (PATH©) educational program and simulation experience using standardized patients (SP) was developed to help healthcare professionals address ACEs with adults. PATH© is a 3-4 hour curriculum comprised of lecture and discussion, video-based demonstration, simulation experience, and debriefing. It was first developed for primary care (PC) residents in family medicine and internal medicine, and subsequently modified for occupational therapy (OT) and physical therapy (PT) students. This study evaluates a preliminary dataset focusing on PATH© skills of PC residents and OT and PT students during simulation. Recordings of 53 learner-SP encounters from 15 OT and PT students and 38 PC residents were coded using standardized behavioral codes. A subset of ten recordings of PC residents who participated in simulations in the first and fourth year of the training program allowed for evaluation of training outcomes over time. Results showed that medical residents and OT and PT students demonstrated skills during SP encounters congruent with TI training on addressing ACEs with adults, particularly in explaining ACEs, demonstrating empathy, collaborative treatment planning, and stigma reduction. PC residents showed both positive and negative changes in PATH©-specific skills from year 1 to 4 of the training program. This study supports the PATH© model and simulation-based training in preparing clinicians to address ACEs with adults and provides insight into further curriculum improvement.

An exploratory study of factors associated with social isolation and loneliness in a community sample.

Individuals across a wide variety of demographies find themselves suffering from social isolation or loneliness. Both of these conditions have been associated with a variety of negative outcomes including poor physical, mental and social health. Based on data collected from a sample of 420 individuals from a community in the South Western US, this research reports on conditions associated with social isolation and loneliness. Results of regression analysis indicate sex, stress, loneliness, community health and social cohesion were statistically significantly associated with social isolation. Living alone, depression/anxiety, stress and social isolation were statistically significantly associated with loneliness. The implications of these findings for social work practice and research is discussed.

Using Social Simulation to Teach Rehabilitation Science Students About Adverse Childhood Experiences and Trauma Informed Care.

Recent research has identified the relationships between adverse childhood experiences (ACEs) and adult adoption of health risk behaviors, negative health outcomes, and measures of well-being. Given these findings, it is important to consider training models that educate allied health students about the relevance of ACEs to adult health across a myriad of practice settings and equip them with the skills necessary to help patients with a history of ACEs. Physical therapy (PT) and occupational therapy (OT) are key members of the health care team, well positioned to address ACEs with their patients. This study reports on the evaluation of an innovative simulation-based training program, Professional ACE-Informed Training for Health Professionals (PATH), conducted with 26 second-year PT and OT students. Pre- and post-training measures consisted of the General Self-Efficacy Scale, Adult Hope Scale, and a test of knowledge and familiarity with ACEs and trauma-informed care (TIC). Results indicate that self-efficacy, hope, and knowledge of ACEs and TIC increased from pre- to post-tests for both PT and OT students. Qualitative results demonstrate that PT and OT students appreciated participating in the training model and learned a great deal from their experiences; however, they would like even more information and instruction on how to work effectively with patients who have a history of ACEs. Implications of this study and a discussion of the importance of continuing and expanding such training in rehabilitation sciences education and training are provided.

Adverse Childhood Experiences, Other Psychosocial Sources of Adversity, and Quality of Life in Vulnerable Primary Care Patients.

INTRODUCTION: Adults who had adverse childhood experiences (ACEs) have increased risk of negative health outcomes. Despite the prevalence of ACEs, literature is scarce on quality of life (QOL) and ACEs in disadvantaged primary care populations. OBJECTIVE: To examine the prevalence of ACEs and association with chronic health problems and QOL in disadvantaged primary care patients in Oklahoma. METHODS: During a primary care visit, adults completed a questionnaire measuring demographics, ACEs, current health status and well-being, sources of support and adversity, and QOL. A physician investigator reviewed participants' health records, recording the incidence of 32 diagnoses commonly associated with chronic health problems. RESULTS: The survey was completed by 354 patients. Forty-three percent received disability benefits and 71% were unemployed. More than 37% reported 4 or more ACEs, and 35.5% had 0 or 1 ACE.The amount of health problems ranged from 0 to 11 and increased with the number of reported ACEs. The mean number of health problems for each ACE level was as follows: ACEs 0 to 1 had 3.01 problems (95% confidence interval = 2.96-3.88), ACEs 2 to 3 had 3.42 problems (95% confidence interval = 2.96-3.88), and ACEs 4 and above had 4.18 problems (95% confidence interval = 3.72-4.64). ACEs were significantly related to QOL. CONCLUSION: This disadvantaged primary care population had high numbers of ACEs. ACEs correlated with increasing numbers of health problems and worse QOL. Enhanced awareness and action are needed to reduce health disparities and improve outcomes in similar populations.

A simulation and video-based training program to address adverse childhood experiences.

Adverse childhood experiences (ACEs) are 10 categories of childhood abuse and maltreatment, which have a dose-response relationship with common adult health concerns seen in primary care including health risk behaviors, chronic disease, and mental illness. Many of the ACEs-associated biopsychosocial risk factors are modifiable. However, physicians may not address these issues for fear of opening "Pandora's Box", that is, a source of extensive problems for which they are not sufficiently prepared with training, resources, or time. Residents need training in how to conduct trauma-focused conversations within the limited scope of an office visit. To address this need, a 4-hour simulation and video-based training program was developed for primary care residents about how to conduct brief interventions connecting their patients' current health concerns with their experiences of ACEs. Resident participants have evaluated this program as preparatory for real-life encounters and as being designed to allow for educational mastery. This article describes a workshop presenting this training program which was given at the 37th Annual Behavioral Science Forum in Family Medicine. Five skills targeted in the program were presented and a demonstration was made of the components, that is, didactics, provider and patient videos, simulated patient encounters, trainee feedback, and facilitated discussion that encompasses targeted skills, clinical implementation, and self-care. Companion tools were shared, including the syllabus, evaluation rubric, and provider and patient resources. Participants practiced trainee feedback and discussed the challenges in implementation.

Changing the culture of a medical school by orienting students and faculty toward community medicine.

Oklahoma's health status has been ranked among the worst in the country. In 1972, the University of Oklahoma established the Tulsa branch of its College of Medicine (COM) to expand the physician workforce for northeastern Oklahoma and to provide care for the uninsured patients of the area. In 2008, the Tulsa branch launched a distinct educational track, the University of Oklahoma COM's School of Community Medicine (SCM), to prepare providers equipped and committed to addressing prevalent health disparities.The authors describe the Tulsa branch's Summer Institute (SI), a signature program of the SCM, and how it is part of SCM's process of institutional transformation to align its education, service, and research missions toward improving the health status of the entire region. The SI is a weeklong, prematriculation immersion experience in community medicine. It brings entering medical and physician assistant students together with students and faculty from other disciplines to develop a shared culture of community medicine. The SI uses an unconventional curriculum, based on Scharmer's Theory U, which emphasizes appreciative inquiry, critical thinking, and collaborative problem solving. Also, the curriculum includes Professional Meaning conversations, small-group sessions to facilitate the integration of students' observations into their professional identities and commitments. Development of prototypes of a better health care system enables participants to learn by doing and to bring community medicine to life.The authors describe these and other curricular elements of the SI, present early evaluation data, and discuss the curriculum's incremental evolution. A longitudinal outcomes evaluation is under way.

Violence in the Lives of Rural, Southern, and Poor White Women.

Poor White single mothers and their children in non-urban communities in the American South experience high levels of domestic violence. We report selected findings from a life history study among White, low-income, unmarried mothers in South Carolina. Here, we examine how domestic violence in both childhood and adulthood may inhibit asset development by diminishing low-income single mothers' accumulation of human and social capital, thus compromising their well-being as adults and parents.

An experiential community orientation to improve knowledge and assess resident attitudes toward poor patients.

BACKGROUND: Future physicians may not be prepared for the challenges of caring for the growing population of poor patients in this country. Given the potential for a socioeconomic "gulf" between physicians and patients and the lack of curricula that address the specific needs of poor patients, resident knowledge about caring for this underserved population is low. INTERVENTION: We created a 2-day Resident Academy orientation, before the start of residency training, to improve community knowledge and address resident attitudes toward poor patients through team-based experiential activities. We collected demographic and satisfaction data through anonymous presurvey and postsurvey t tests, and descriptive analysis of the quantitative data were conducted. Qualitative comments from open-ended questions were reviewed, coded, and divided into themes. We also offer information on the cost and replicability of the Academy. RESULTS: Residents rated most components of the Academy as "very good" or "excellent." Satisfaction scores were higher among residents in primary care training programs than among residents in nonprimary care programs for most Academy elements. Qualitative data demonstrated an overall positive effect on resident knowledge and attitudes about community resource availability for underserved patients, and the challenges of poor patients to access high-quality health care. CONCLUSIONS: The Resident Academy orientation improved knowledge and attitudes of new residents before the start of residency, and residents were satisfied with the experience. The commitment of institutional leaders is essential for success.

Kin networks and poverty among African Americans: past and present.

Trends in social welfare policy and programs place increasing expectations on families to provide members with various forms of material and socioemotional support. The historic ability of kin networks of many African Americans to provide such support has been compromised by long-term community and family poverty. The potential mismatch between the expectations of social welfare systems for kin support and the actual functional capacities of kin networks places African Americans living in poverty at great risk of chronic poverty and its long-term multiple consequences. This article reviews historical and contemporary research on the structure and function of African American kin networks. On the basis of evidence of functional decline, the authors argue that social workers must re-examine the a priori assumption of viable kin networks as a reliable source of resilience among African Americans living in poverty. Social workers must focus assessment at all levels of practice on a variety of aspects of kin networks to make accurate judgments about not only the availability of resources, but also the perceived costs and benefits of participation in exchange for resources.

Poverty, race, and the contexts of achievement: Examining educational experiences of children in the U.S. south.

This article considers issues of educational inequality in the U.S. South from a social work/ social justice perspective. After a review of existing literature and discussion of cultural versus structural explanations for race and socioeconomic status gaps in academic achievement, findings are presented from a study examining child-, classroom-, and school-level factors that influence academic achievement among public school children in the South. Although a sizeable minority of southern children attend schools that are segregated along racial and socioeconomic lines, and although these schools are different in various aspects of educational environment, once family structure, parental characteristics, the use of ability grouping, and rural school location were taken into account, no influence of race on achievement remained. Implications for social work policy and practice are discussed.