Medical Students’ Knowledge, Attitudes Toward, and Identification of Adverse Childhood Experiences and Trauma-Informed Care

Abstract

Introduction

Adverse childhood experiences (ACEs) are traumatic experiences that occur prior to age 18 years and can have a long-term impact on adult physical and mental health. Knowledge of ACEs, including the link between ACEs and health, and trauma-informed care (TIC), is essential for medical professionals to ensure respectful and compassionate care for those with a history of childhood adversity. This study examined medical students’ knowledge, attitudes toward, and identification of ACEs and TIC to inform curricular efforts.

Methods

Using a cross-sectional design, students were recruited from 2 medical schools, one allopathic (medical degree) and one osteopathic (doctor of osteopathic medicine degree) to complete an electronic needs assessment survey. The survey included a patient vignette to assess students’ ability to identify ACEs as contributing factors to patient health. The students were blind to the full purpose of the study to obtain an objective measurement of their ability to identify ACEs as contributors to patient health. Additional questions targeting knowledge and attitudes of ACEs and TIC were devised from previously published surveys with supplemental study-designed questions.

Results

Two hundred forty students completed the survey. Results demonstrated variable ability to identify ACEs; strong general knowledge of ACEs, with less developed practical knowledge; and overall positive attitudes toward ACEs and TIC. No differences were found between the medical degree and doctor of osteopathic medicine degree, or year in program.

Conclusions

Medical students would benefit from curricular efforts that help to increase knowledge of the link between ACEs and health, increase practical application of ACEs and TIC, and improve their ability to identify ACEs in clinical scenarios.

Introduction

Adverse childhood experiences (ACEs) are traumas that occur prior to age 18 years and can have a long-term impact on adult physical and mental health.^1,2 In order to provide respectful, compassionate, and effective care for those with a history of childhood adversity, medical practitioners must possess 1) a solid understanding of how ACEs and trauma impact health outcomes across the lifespan, 2) training and skill in the provision of trauma-informed care (TIC), and 3) familiarity with the range of evidence-based treatment options for this population.³ Although differences exist in how ACEs have been defined, a theme within the literature is the commonality of ACEs within the community. As the Centers for Disease Control and Prevention has reported, 60.9% of adults have experienced at least 1 ACE, but 15.6% have reported ≥ 4.² These data are from the Behavioral Risk Factor Surveillance System, which defines ACEs similarly to the original ACE study, including categories of abuse, neglect, and household dysfunction. Research using the expanded definition of ACEs, which includes the original categories of adversity along with bullying, community violence, neighborhood safety, racism, and living in foster care, have found even higher rates of ACEs.⁴

ACEs have been associated with a variety of conditions, including, but not limited to, depression, posttraumatic stress disorder, chronic obstructive pulmonary disease, heart disease, cancer, and obesity.^1,2,5–7 A dose-dependent relationship has been found between ACEs and health, with a greater chance of adverse health outcomes associated with ≥ 4 ACEs.^1,2,5–7 Despite the impact of ACEs on health, physicians have demonstrated limited knowledge of ACEs. Recently, > 80% of community physicians reported they never heard of the ACEs Questionnaire, and only 3% reported using it in practice.⁸ Improving physician knowledge of ACEs may begin in medical school. In a recent study, 80% of medical students reported having heard of the ACEs Study, and 70% had received information regarding ACEs.⁹ However, knowledge alone may not be sufficient toward improving practice related to ACEs. Research has shown that understanding the link between ACEs and physical health is associated with screening of ACEs, whereas basic knowledge of ACEs was not.¹⁰ Therefore, understanding students’ ability to identify ACEs as contributors to patient health is warranted.

Improving the knowledge and understanding of ACEs and toxic stress is one important component of medical education. Helping students to apply this knowledge toward application of TIC and related interventions is an equally important aim. There has been recent focus on the development and implementation of TIC practices within medicine. TIC involves an understanding of what trauma is, how it impacts health, how to recognize signs of trauma, and how to incorporate sensitivity of trauma into policy, procedures, and practices to avoid retraumatization.^3,11 For TIC to be effectively implemented, ACEs training needs to be incorporated into medical education. Research has shown that facilitators to implementing TIC in practice include more positive attitudes toward TIC and higher levels of TIC skills assessed at the post-training level.¹² However, until recently no guidelines existed on essential elements in a TIC curriculum for medical education programs. The Trauma-Informed Health Care Education and Research (TIHCER) group recently published TIC competencies for medical education, which highlight the importance of addressing trauma, ACEs, and TIC within the medical school curriculum.¹³ The validated trauma-informed competencies for undergraduate medical education (UME) include 43 competencies clustered across 8 domains. The competency domain areas are knowledge for practice, patient care, practice-based learning and improvement, interpersonal and communication skills, professionalism, systems-based practice, interprofessional collaboration, and personal and professional development.¹³

The purpose of this study was to examine students’ ability to identify ACEs as contributors to patient health, as well as their knowledge of, and attitudes toward, ACEs and TIC. Although previous research has established that medical students have some knowledge regarding ACEs and that they hold generally positive attitudes toward ACEs, to date, no known research has attempted to establish if students are able to identify ACEs as contributors to patient health without being primed to the purpose of the study. Therefore, this study sought to understand if students view ACEs as implicated in patient health in a manner that would approximate clinical practice. Specifically, do medical students conceptualize ACEs as contributors to health when presented with a hypothetical patient vs only when being asked about their understanding directly. In addition, this study sought to compare students from different programs and different years in school regarding the outcome variables.

Methods

Design, setting, and participants

Using a cross-sectional design, students were recruited electronically from 2 medical schools to complete a needs assessment survey via REDCap. The medical schools were in neighboring states within the Midwestern Region of the United States. Students were in their first through fourth years, pursuing either a medical degree (MD), or a doctor of osteopathic medicine degree (DO). Neither school had established TIC curricular training. The project was reviewed and approved by both schools’ institutional review boards.

Survey development

The survey included a patient vignette designed to assess students’ ability to identify ACEs as contributing factors to patient health. It was designed as a history and physical, with a social history of ACEs and a medical history of conditions that have been associated with ACEs (eg, cardiovascular disease). Social history included both current (eg, occupation) and past social history (eg, ACEs). The ACEs included were extracted from the original ACEs Study, including parental divorce, parental incarceration, parental drug use, and childhood physical abuse.¹ The number was deemed important given the increased risk to those with ≥ 4 ACEs. To ensure accuracy, the vignette was reviewed by experts in cardiovascular disease and childhood trauma. See Figure 1.

Figure 1:

Patient vignette.

To assess ability to identify, each factor in the vignette (22 factors, 4 ACEs included) were provided as choices for students to identify as contributing to patient health. These included demographic factors, medical factors, health risk factors, current social factors, family medical history, and past social factors. The students could choose as many as they identified as contributing to the patient’s health. See Figure 2. Although there were several technically correct answers (eg, high cholesterol impacts health), only the choice of ACEs was used to calculate the ability to identify score. The score for ability to identify ranged from 0 (no ACEs) up to 4 (all ACEs identified).

Figure 2:

Factors available for choice.

The study also included questions to elicit student knowledge of and attitudes toward ACEs and TIC, hereafter referred to as knowledge and attitudes. The questions were developed through a review of published studies assessing knowledge and attitudes toward ACEs and TIC, with supplemental questions designed for the present study.^14–17 See Supplemental Materials.

Knowledge was assessed using multiple choice, Likert scale, and true/false questions. The questions were designed to assess for general knowledge (eg, what are ACEs?), specific knowledge (eg, understanding what does and what does not constitute an ACE), practical knowledge (eg, how to assess for and intervene), as well as self-reported familiarity with ACEs and TIC. In total, the knowledge questions afforded a range of scores from 0 (no knowledge) up to 24 (highest level of knowledge).

Attitudes was assessed using Likert scale questions, such as, “How important do you think it is for a patient’s medical record to include any history of childhood adversity?” and “To what extent do you think it is your role as a medical professional to screen for history of childhood adversity?” The attitudes questions afforded a range of scores from 11 to 63, with higher scores indicating more positive attitudes. See Supplemental Materials for the survey in full.

Data Analysis

Descriptive statistics were used for the demographic information, including calculation of frequencies of all categorical data. Descriptive statistics were used to calculate the mean and standard deviation (SD) for ability to identify, knowledge, and attitudes. To determine if there was a relationship between the type of program, year in program, and the outcome variables a factorial multivariate analysis of variance was run.

Results

The sample (N) consisted of 240 students (120 MD, 120 DO). The majority identified as female (n = 157, 65.4%) and were second-year students (n = 91, 37.9%) between the ages of 25 and 35 (n = 161, 67.1%). A majority identified as White/Caucasian (n = 182, 75.8%) and not Hispanic or Latino (n = 214, 89.2%). See Table 1.

Table 1:

Student demographics

Demographic	n (%)
Programs of study
MD	120 (50)
DO	120 (50)
Year in program
First	21 (8.8)
Second	91 (37.9)
Third	66 (27.5)
Fourth	62 (25.8)
Age (y)
18–24	78 (32.5)
25–34	161 (67.1)
35–44	1 (0.4)
Gender
Male	82 (34.2)
Female	157 (65.4)
Other	1 (0.4)
Race
White/Caucasian	182 (75.8)
Asian/Asian American	37 (15.4)
Black/African American	7 (2.9)
Other Pacific Islander	2 (0.8)
American Indian	1 (0.4)
Prefer not to answer	11 (4.6)
Ethnicity
Not Hispanic/Latino	214 (89.2)
Hispanic/Latino	7 (2.9)
Other	9 (3.8)
I prefer not to answer	10 (4.2)

DO, doctor of osteopathic medicine degree; MD, medical degree.

For ability to identify, scores ranged from 0 to 4, signifying that some students were unable to identify any ACEs and some students successfully identified all 4. For ability to identify, the mean (SD) score was 2.23 (1.80). See Table 2.

Table 2:

Total group, ability to identify, knowledge, attitudes

Identification		Knowledge		Attitudes
n	Mean (SD)	n	Mean (SD)	n	Mean (SD)
240	2.23 (1.80)	240	11.44 (3.49)	240	50.04 (4.62)

SD, standard deviation.

For knowledge, the range of scores was 2–23, with a mean (SD) score of 11.44 (3.49). See Table 2. Although 97.1% were able to identify that ACEs are generally stressful or traumatic events that occur during childhood, fewer were able to identify some of the links between ACEs and specific medical conditions. For example, 36% of students reported “no” or “I don’t know,” when asked about the link between cancer and ACEs. Practical knowledge related to ACEs was also limited. As an example, 47.9% of students reported that they were “not at all knowledgeable” and 32.9% were “vaguely knowledgeable” about how to assess for ACEs. Even fewer students expressed knowledge regarding management of ACEs. When asked about knowledge related to intervention and provision of resources for a patient’s ACEs history, 55.8% reported that they were “not at all knowledgeable,” 31.3% were “vaguely knowledgeable,” 12.1% were “somewhat knowledgeable,” and only 0.8% were “very knowledgeable” (ie, “I know specific methods for management”). Further, the majority reported they were either “vaguely familiar” (42.5%) or “not at all familiar” (28.8%) with TIC.

For attitudes, the scores ranged from 37 to 62, with a mean (SD) score of 50.04 (4.62). See Table 2. Approximately 60% of students reported it was extremely important for a patient’s medical history to include a record of childhood adversity and that it was extremely important for medical professionals to screen for ACEs, with 74.2% acknowledging that ACEs are a medical problem.

Finally, results from the multivariate analysis of variance suggested that there were no significant relationships found between type of program or year in program for ability to identify, knowledge, and attitudes. A summary of mean scores and SDs for the outcome variables by total group, by year in program (first to fourth years), and by program can be found in Table 2 and Table 3. No significant differences between mean values of the outcome variables were found by race or gender.

Table 3:

Ability to identify, knowledge, and attitudes by year in school and by type of program

Demographic	Identification		Knowledge		Attitudes
	n	Mean score (SD)	n	Mean score (SD)	n	Mean score (SD)
Year in program
First	21	2.43 (1.83)	21	10.33 (3.35)	21	10.42 (4.89)
Second	91	2.43 (1.78)	91	10.91 (3.36)	91	11.29 (4.13)
Third	66	2.18 (1.79)	66	12.09 (3.71)	66	12.50 (5.32)
Fourth	62	1.94 (1.86)	62	11.87 (3.38)	62	50.16 (4.39)
Program type
MD	120	2.50 (1.74)	120	12.10 (3.51)	120	49.97 (4.43)
DO	120	1.97 (1.84)	120	10.79 (3.37)	120	50.10 (4.80)

DO, doctor of osteopathic medicine degree; MD, medical degree; SD, standard deviation.

Discussion

The present study sought to use a novel approach to understand medical students’ ability to identify ACEs as contributors to health, as well as their knowledge and attitudes toward ACEs and TIC. Given that the TIHCER competencies include knowledge for practice,¹³ the use of a patient vignette to assess students’ ability to identify ACEs as contributors to patient health appears timely. The study also sought to compare students from MD and DO programs, as well as to better understand how year in program may contribute to the outcome variables.

The results of the present study suggest that medical students have variable ability to identify ACEs as contributors to patient health. Although this study is the first known attempt at using a blinded sample to assess ability to identify ACEs, previous studies have asked directly about the link between ACEs and health and have yielded similar results. For example, first-year medical students evidenced a mean score of 1.44 (range of 1–5) on a question that asked, “I recognize the link between ACEs and chronic medical problems,” suggesting limited knowledge of this link prior to training.¹⁸ Given that understanding this link appears to drive screening efforts,¹⁰ increasing understanding of this connection should be a focus for medical education. Thus far, efforts to improve student understanding of the link between health and ACEs has been successful, allowing students to increase knowledge related to this concept and resulting in strong student agreement that training can improve understanding of the link between ACEs and health.^18,19

For knowledge, although students appear to know what ACEs are generally (eg, can identify a definition of ACEs from a list), they are less knowledgeable about practice related to ACEs (eg, how to assess for ACEs) and, importantly, do not appear to know what TIC entails (eg, how familiar are you with trauma-informed care). In addition, although attitudes were generally positive toward ACEs and TIC, students’ self-reported lack of knowledge and familiarity of TIC would appear to confound a true understanding of attitudes toward TIC. Educational efforts to improve student knowledge and attitudes toward ACEs and TIC have demonstrated positive impacts, including improvement in knowledge and specifics related to ACEs,¹⁸ along with changes in knowledge and comfort with being able to address a trauma disclosure,^19,20 as well as increased use of TIC concepts and ACE screening.²¹

The present study included limitations. Measures were study-developed and not validated. Attempts to increase face validity of the tools were made (ie, expert review); however, it is not clear if the questions designed truly measured the constructs of interest. In addition, one question devised to assess for knowledge of ACEs relied on the original definition of ACEs¹ and did not account for the more expanded and current definition of ACEs, which includes poverty, bullying, community violence, racism, and living within foster care.⁴ The question was deemed to be poorly written and was removed from the data analysis. In addition, although the questionnaire did ask about knowledge and comfort with practical application, additional questions to clarify what students may know about TIC and trauma-related interventions would be useful to best inform curricular efforts. Further, although there was an even split between MD and DO programs, the study was heavily weighted toward female and White students, limiting the diversity of the study sample and the applicability to medical school populations more broadly. There was also an uneven split between students across years of program, contributing to the limits of powering analyses to best understand the relationship that year in program may have had on outcomes.

Regarding future directions, there are several educational- and research-related considerations. The varied demonstration of students’ ability to identify ACEs, regardless of their year in the program, suggests the need for a developmental approach to education on the science of ACEs and toxic stress across the medical school curriculum. The recent development of the TIHCER TIC¹³ competencies for UME can guide next steps toward curricular change. In the early stages of medical education, patient vignettes may be used to assess and build on students’ foundational knowledge of ACEs and TIC. The competency domain knowledge for practice includes specific areas of competency, such as describing the epidemiology of different types of trauma and their associated adverse health effects.¹³ The use of hypothetical patient scenarios written to display different forms of trauma and different health conditions would allow students to learn about these associations and work toward this area of competency. Vignettes may also be used at later stages of UME to teach medical students practical knowledge and skill, such as how to work with ACEs and apply the principles of TIC. The competency domain of patient care includes the demonstration of students’ ability to apply trauma-informed principles to history gathering, physical examinations, clinical decision making, and treatment.¹³ Patient vignettes may assist with this process in the classroom, allowing students to learn the clinical decision making process. Further, as students advance in their medical education, vignettes may be transitioned to objective structured clinical examinations to assess competency related to the students’ demonstration of their ability to manage ACEs and implementation of TIC using simulated patients.

Given the increased need for TIC within medical educational and clinical practice settings, future studies will benefit from the use of validated tools²² to measure medical students’ competency in recognizing and inquiring about ACEs, in addition to responding to patient disclosures about trauma. Future studies may focus on how well curricular changes, such as those described above, help students to understand how to work with trauma in their practice spaces, make clinical decisions about what they can and should directly address, and what would be important to refer to a mental health trauma-related specialist. Future studies toward these aims may help to articulate if educational efforts increase comfort around management of ACEs and toxic stress for students, and ultimately, whether or not these educational aims help to increase clinical attention to ACEs and health. It will also be important in future directions within the research to strive toward larger and more diverse samples of medical students to provide representation of the diverse landscape of medical education.

Conclusions

Despite limitations, this study provides insight into medical students’ ability to identify ACEs as contributors to patient health without being directly guided to consider ACEs in their conceptualization. This approach mimics what future physicians will be faced with in the field, such as patients with a history of childhood adversity that has likely impacted their health and the need for physicians to utilize a TIC-based approach to care. Incorporating the use of patient vignettes and/or simulated patients to both assess and demonstrate knowledge, attitudes, and skills will likely help to accomplish the aims of competency-based practice and improve patient outcomes in the future.