The Impact of Attachment-Disrupting Adverse Childhood Experiences on Child Behavioral Health.

OBJECTIVES: To describe patterns of overall, within-household, and community adverse childhood experiences (ACEs) among children in vulnerable neighborhoods and to identify which individual ACEs, over and above overall ACE level, predict need for behavioral health services. STUDY DESIGN: This was a cross-sectional study that used a sample of 257 children ages 3-16 years who were seeking primary care services with co-located mental healthcare services at 1 of 2 clinics in Chicago, Illinois. The outcome variable was need for behavioral health services (Pediatric Symptom Checklist score ≥28). The independent variables were ACEs, measured with an adapted, 28-item version of the Traumatic Events Screening Inventory. RESULTS: Six ACE items were individually predictive of a clinical-range Pediatric Symptom Checklist score after adjusting for sociodemographic covariates: emotional abuse or neglect (OR 2.93, 95% CI 1.32-6.52, P < .01), natural disaster (OR 3.89, 95% CI 1.18-12.76, P = .02), forced separation from a parent or caregiver (OR 2.95, 95% CI 1.50-5.83, P < .01), incarceration of a family member (OR 2.43, 95% CI 1.20-4.93, P = .01), physical attack (OR 2.84, 95% CI 1.32-6.11, P < .01), and community violence (OR 2.35, 95% CI 1.18-4.65, P = .01). After adjusting for overall ACE level, only 1 item remained statistically significant: forced separation from a parent or caregiver (OR 2.44, 95% CI 1.19-5.01, P = .02). CONCLUSIONS: ACEs that disrupt attachment relationships between children and their caregivers are a significant predictor of risk for child emotional or behavioral problems.

Development and Evaluation of Two Integrated Care Models for Children Using a Partnered Formative Evaluation Approach.

Objective: To describe the development and evaluation of two integrated care models using a partnered formative evaluation approach across a private foundation, clinic leaders, providers and staff, and a university-based research center. Design: Retrospective cohort study using multiple data sources. Setting: Two federal qualified health care centers serving low-income children and families in Chicago. Participants: Private foundation, clinic and academic partners. Interventions: Development of two integrated care models and partnered evaluation design. Main Outcome Measures: Accomplishments and early lessons learned. Results: Together, the foundation-clinic-academic partners worked to include best practices in two integrated care models for children while developing the evaluation design. A shared data collection approach, which empowered the clinic partners to collect data using a web-based tool for a prospective longitudinal cohort study, was also created. Conclusion: Across three formative evaluation stages, the foundation, clinic, and academic partners continued to reach beyond their respective traditional roles of project oversight, clinical service, and research as adjustments were collectively made to accommodate barriers and unanticipated events. Together, an innovative shared data collection approach was developed that extends partnered research to include data collection being led by the clinic partners and supported by the technical resources of a university-based research center.

Validation of the Traumatic Events Screening Inventory for ACEs.

OBJECTIVES: Our purpose in this study was to adapt and validate the Traumatic Events Screening Inventory (TESI) as a primary-care childhood adversity screening tool for children living in vulnerable neighborhoods using a community-partnered approach. METHODS: In this cross-sectional, descriptive study, we used a sample of 261 children (3-16 years old) who were seeking services at a Federally Qualified Health Center with colocated behavioral health services in Chicago and had a positive Pediatric Symptom Checklist screen result or received a referral for behavioral health evaluation. The TESI was adapted as a screening tool to be sensitive to adverse childhood experiences (ACEs) unique to the clinic communities. ACEs were mapped by zip code with objective neighborhood crime data, and latent class analysis was performed to identify ACE subgroups. RESULTS: The mapping validation suggested face validity for geographic overlap between participant ACEs and objective violent-crime occurrence. With latent class analysis, we identified 3 ACE subgroups: (1) high ACE (18.0% of the sample; polyvictimization and/or maltreatment), (2) moderate ACE (52.1%; violent environments), and (3) low ACE (29.9%; few adverse experiences). Membership in the high-ACE subgroup was associated with higher odds of a clinically significant Pediatric Symptom Checklist score (odds ratio = 3.83) and clinical-level attention problems (odds ratio = 3.58) even after accounting for child resilience and parent depression. CONCLUSIONS: ACEs play a significant role in predicting a need for behavioral health services among children seeking primary-care services. The community-adapted TESI is a valid ACE screening tool.

Trends in prescriptions for oxycodone and other commonly used opioids in the United States, 2000-2010.

BACKGROUND: Little information has been published on opioid prescribing practices in the United States as a whole for any year since 2005, despite increased use and increased overdoses. The objective of this study was to describe trends in prescribing rates and prescription sizes for commonly used opioids over the past decade. METHODS: We used 2 data systems. Vector One: National (VONA; data obtained for the period 2000-2009) is a service that can estimate the number of prescriptions dispensed by retail pharmacies. The Automation of Reports and Consolidated Orders System (ARCOS; data obtained for the period 2000-2010) is a mandatory reporting system that allows the US Drug Enforcement Administration to monitor certain controlled substances from the point of manufacture to the point of sale. ARCOS data represent the amount of controlled substances legitimately distributed at the retail level. We calculated crude prescription rates of various opioids from VONA data, total drug amounts distributed (as milligrams per 100 persons) from ARCOS data and morphine milligram equivalents (MME) per prescription by combining data from these 2 sources. RESULTS: The number of opioid prescriptions per 100 persons increased by 35.2%, from 61.9 to 83.7, during the period 2000-2009. The distribution of opioids to US pharmacies, in milligrams per 100 persons, increased by at least 100% for all selected opioids during the period 2000-2010. The average size of an oxycodone prescription increased by 69.7% (from 923 MME to 1566 MME) during the same period, while the average size of a hydrocodone prescription increased by 69.4% (from 170 MME to 288 MME). The increase for fentanyl was smaller (20.9%) (from 4804 MME to 5809 MME). INTERPRETATION: The rate of opioid prescribing, the amount of opioids distributed and the average prescription size all increased markedly in the United States over the past decade. Rates of death from opioid overdose also have increased steadily through 2008 and have likely continued to increase in subsequent years. Effective measures to prevent prescription drug overdoses have yet to be identified and employed.