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. Author manuscript; available in PMC: 2025 Sep 1.
Published in final edited form as: Pediatrics. 2024 Sep 1;154(3):e2023065412. doi: 10.1542/peds.2023-065412

Preventing Adverse Childhood Experiences in a Sample of Largely Indigenous Children

Katie M Edwards a, Emily A Waterman b, Lorey A Wheeler a, Ramona Herrington a, Natira Mullet c, Weiman Xu a, Skyler Hopfauf a, Leon Leader Charge a, Preciouse Trujillo a
PMCID: PMC11616712  NIHMSID: NIHMS2032629  PMID: 39136077

Abstract

Objectives:

The purpose of this study was to develop, pilot, and evaluate a culturally grounded, family-based program to prevent adverse childhood experiences (ACEs) among low-income and/or Indigenous children ages 10 to 14. The Tiwahe Wicagwicayapi program (TWP) is a 7-session program that teaches skills to prevent ACEs and is rooted in Lakota culture, language, and history.

Methods:

124 families (124 caregivers [96% Indigenous; 90% reported yearly income less than $40,000] with 194 children ages 10 to 14 [93% Indigenous]) were randomly assigned to the treatment (N = 66 families and 183 individuals) or waitlist (N = 58 families and 145 individuals) control groups. Caregivers and children completed a baseline, immediate post-test, and 6-month follow-up survey.

Results:

Treatment effects were detected indicating, compared to control participants, reductions in incidence of child ACEs (IRR = .64), bullying victimization (OR = .53), depression (d = –.20), and externalizing behaviors (d = –.23), and increased parent-child communication (g = .27) and child help seeking behaviors (d = .28). For caregivers, effects indicated the program prevented intimate partner violence victimization (IRR = .36) and perpetration (IRR = .45), harsh parenting (g = –.35), and depression (d = –.24), and increased emotion regulation (d = .37), social support (d = .33), and cultural connection (d = .34).

Conclusions:

The TWP holds great promise in preventing ACEs among low-income, Indigenous children, showing potential promise for widespread public health impact. Future rigorous research on the TWP is warranted.

Research documents the alarming rates and deleterious outcomes of adverse childhood experiences (ACEs).1–4 ACEs disproportionally impact children who are low income and/or Indigenous due to systems of oppression.3,5,6 However, we are not aware of any programs to date that have been shown through rigorous research to prevent ACEs among children who are low income and/or Indigenous.

To address this critical gap, we recently developed using participatory methods the Tiwahe Wicagwicayapi program (TWP; Lakota for Strengthening Families).2 The TWP was developed, and subsequently implemented and evaluated, with partners in a small city in South Dakota near several large, rural Indian Reservations. In creating the TWP, we drew heavily from the Strengthening Families Program (SFP), a family-based drug and alcohol prevention program.7–11 The TWP was created through focus groups12, photovoice12,13, an open pilot trial, and ongoing and iterative feedback from an Advisory Board.

The goal of TWP is to prevent ACEs (primary outcome) and child internalizing and externalizing behaviors (secondary outcomes). The hypothesized mechanisms through which these changes are made include: enhancing family resilience, skill development in caregivers and children, and strengthening social support and cultural identity in caregivers and cultural identity children. Taught by Indigenous adults, including Elders, the TWP includes seven, 2.5-hour sessions beginning with a family meal followed by break-out sessions for children and caregivers before families come back together at the end. Each session is named after a Lakota virtue (e.g., love, respect, bravery), and programming is deeply rooted in Lakota culture, history, and language; cultural practices (e.g., smudging, prayer, storytelling, talking circles) are integrated into all program sessions. Indigenous community partners felt that it was important for non-Indigenous children living in the same community and living in poverty to be able to participate with the belief that all individuals can benefit from Lakota culture and virtues.

The purpose of the current study was to examine the efficacy of the TWP on preventing new ACEs and new intimate partner violence (IPV) victimization and perpetration events (primary outcomes). We also examined the TWP’s impact on secondary (e.g., child depression) and intermediary (e.g., family bonding) outcomes.

Methods

Procedures

Recruitment methods included social media ads, fliers, knocking on doors in key neighborhoods, tables at events and store fronts, recruitment events. Families who were eligible to participate and interested then met a project staff to complete consent/assent. All surveys were conducted on paper and administered by trained research staff. Monetary compensation was given for completing surveys ($30 per person) and each session attended ($30 per family). The study was approved by the [masked for review] IRB as well as the Indian Health Service IRB. The publication of this paper was approved by the Indigenous Advisory Board and the Indian Health Services IRB. See Figure 1 for CONSORT Chart.

Figure 1.

Figure 1.

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CONSORT CHART

Randomized Control Trial Design

To be eligible, children had to be aged 10 to 14 and identify as either Indigenous and/or from a family living below the poverty line. Caregivers (e.g., parent, grandparent) had to be the caregiver of a child that met those criteria. While completing the baseline survey, families (N = 124) were randomly assigned to either a wait-list control (n = 58 families) or treatment (n = 66 families) arm. Randomization (at the household level) took place by rolling a dice. Participants in the wait-list control group received information about community resources until they were offered the program. 75.8% of caregivers (n = 50) and 73.8% (n = 79) of children attended at least one session; only three caregivers and four children attended all seven sessions.

Participants

Children.

The mean age of children was 11.80 years (SD = 1.40; range 10–14). Children self-identified as boys (48.86%), girls (43.75%), and another gender (e.g., 7.29%). Most children self-identified as Indigenous (92.67%), followed by White (9.95%), Black or African American (7.33%), Native Hawaiian or Pacific Islander (2.09%). Twenty-five children also self-identified as being of Latin origin (14.04%).

Caregivers.

The mean age of caregivers was 40.32 years (SD = 10.08; range 21–74). Most caregivers self-identified as women (90.32%). Most caregivers self-identified as heterosexual/straight (91.75%), and 8.26% identified as gay, bisexual, lesbian, or something else. Most caregivers self-identified as Indigenous (95.97%), followed by White (8.87%) and Black or African American (5.65%). Fifteen also self-identified as being of Latin origin (12.10%). Regarding yearly income, 48.4% reported less than $10,000; 41.1% reported $10,001 to $40,000, and 9.6% reported greater than $40,000.

Measures

Primary Outcomes.

Adverse Childhood Experiences (Child).

This measure was created for the current study, adapted after reviewing previous ACEs measures.14 Children responded to questions regarding ACEs in the past 6 months with the response options yes (1) or no (0).

Intimate Partner Violence (Caregiver).

The Conflict Tactics Scale (CTS)15 measured intimate partner violence perpetration and victimization in the past 6 months with response options yes (1) and no (0); there were four subscales, negotiation, psychological, physical, and sexual coercion.

Secondary Outcomes.

Depression (Past 30 days; Caregiver and Child).

Caregivers answered the Center for Epidemiologic Studies Depression Scale.16 Response options ranged from: rarely or none of the time (0) to most or all of the time (3). Children answered the Children’s Depression Screener.17 Response options ranged from strongly disagree (0) to strongly agree (3).

Social Support Survey Instrument (Caregiver only).

Caregivers responded to the emotional/informational support subscale of the Social Support Survey Instrument.18 The scale included eight items such as, “Someone you can count on to listen to you when you need to talk” and response options ranged from none of the time (0) to all of the time (4).

Externalizing Symptoms (Caregiver Report).

Caregivers responded to the Pediatric Symptom Checklist-17 (PSC-17)19 about how often they see behaviors in their children. Response options ranged from never (0) to often (2).

Peer Violence (Child).

Adapted from the Youth Risk Behavior Survey20, children responded to the items measuring bullying, with the response options yes (1) and no (0).

Intermediary Outcomes.

Knowledge of Sexual Abuse (Child).

Children responded (true/false) to items that aligned with program content.

Cultural Connection (Caregiver and Child).

Items were adapted from Orthogonal Cultural Identification Measure21 and previous research on a nearby Indian Reservation.22 Response options ranged from not at all (0) to a lot (3). Factor analyses indicated a two-factor solution for both caregiver (instrumental connection and psychological connection) and child (family-facilitated and personal connection).

Help-seeking (Caregiver and Child).

Caregivers responded to questions about how likely they would be to respond in a certain way to another person trying to hurt their child on a scale from not at all likely (0) to extremely likely (4). Children responded to questions about how likely they would be to respond in a certain way to another person trying to hurt them on a scale from not at all likely (0) to very likely (2).

Future Orientation (Caregiver and Child).

Items from the Future Mindedness scale23 and the Life Paths measure24 measured future orientation on a scale from strongly disagree (0) to strongly agree (3).

Emotion Regulation (Caregiver).

The Emotion Regulation Scale-Short Form (DERS-SF)25 measured emotion regulation in six domains: awareness, clarity, acceptance of emotional responses, access to strategies, controlling emotion, and engagement in goals (goal-directed behaviors). For caregivers, response options ranged from almost never (0) to almost always (4). For children, response options ranged from not at all (0) to a lot (3).

Parent-child Communication (Caregiver and Child).

Items from the Revised Parent-Youth Communication Form26 measured communication between the family members participating in the project. Caregivers responded to questions on a scale from almost never (0) to almost always (4). Children responded to questions on a scale from not at all (0) to a lot (3).

Harsh Parenting, Parental Monitoring, and Positive Reinforcement (Caregiver and Child).

Caregivers and children responded to questions about their relationship with the family member participating in the project over the past 6 months. Eight questions related to harsh parenting27, 10 questions related to parental monitoring28, and 12 questions related to positive reinforcement29. Scale for caregivers ranged from never (0) to always (4) and scale for children ranged from not at all (0) to a lot (3).

Family Cohesion (Caregiver and Child).

An adapted version of the Family Adaptability and Cohesion Evaluation Scales II.30 assessed family cohesion. Caregivers responded to questions on a scale from almost never or never (0) to almost always or always (4). Children responded to mirrored items on a scale from not at all (0) to a lot (3).

Data Analytic Plan

To test the efficacy of TWP on outcomes, we used several analytic approaches. First, we used the intent-to-treat (ITT) approach, which includes all participants enrolled and randomized to the study. The treatment effect was operationalized as the difference between the control and treatment groups at the immediate post-test (T2) and 6-month follow-up (T3), controlling for baseline (T1) levels of outcomes. Analysis of covariance (ANCOVA) was conducted for continuous outcomes. Poisson regression was used for count outcomes. Logistic regression was used for categorical outcomes. Second, we conducted two sets of supplemental analyses that examined: a) the effect of time within arm (i.e., repeated measures) and b) the effect of TWP dosage. The repeated measure analyses captured within group change from T1 to T2 and from T1 to T3 and examined differences in magnitude of effect size (standardized difference between timepoints) between groups. The dosage analyses divided the treatment group into two dosage groups (i.e., “0–1 attendance” group and “2 or more attendance” group). Then differences between the control and each dosage group were examined at three time points.

For all approaches, we used Mplus 8.8 (Muthén & Muthén, 1998–2022) and full information maximum likelihood-robust to reduce bias from missing data. Tables 1–2 include child and caregivers reported outcome variables and descriptive statistics. In all analyses, cohort was included as a covariate. Baseline equivalence analyses suggested that caregiver’s romantic relationship status was necessary to include for caregiver outcomes. Effect sizes used include the Cohen’s d, Hedge’s g, incidence rate ratio (IRR), and odds ratio (OR).

Table 1.

Descriptive Statistics of Primary, Secondary, Intermediary Child Outcomes Compared by Condition

Baseline Posttest 6-Month Follow-Up
TWP Control TWP Control TWP Control
Outcomes M SD M SD M SD M SD M SD M SD
Primary
 ACEs (count) 4.12 4.15 4.52 3.97 2.72 3.56 3.4 3.7 2.48 2.94 3.80 3.56
Secondary
 Depression 9.55 5.05 9.30 4.69 8.56 4.83 9.2 4.3 8.25 4.34 9.12 5.50
 Externalizing symptoms (PR) (count) 5.35 2.76 4.75 2.98 4.71 2.75 4.81 2.91 4.80 3.15 4.48 2.80
 Bullying victimization (categorical) .39 .49 .32 .47 .25 .44 .28 .45 .23 .42 .24 .43
 Bullying perpetration (categorical) .10 .30 .22 .42 .12 .33 .16 .37 .05 .22 .07 .26
Intermediary
 Knowledge of child sexual abuse (categorical)
  Scream no .91 .29 .92 .27 .91 .29 .86 .35 .90 .31 .91 .29
  Run away .91 .28 .91 .29 .94 .25 .85 .36 .96 .20 .91 .29
  Tell adult .95 .23 .93 .26 .91 .28 .89 .32 .94 .25 .93 .26
 Cultural connection
  Family-facilitated 1.96 .70 1.67 .71 1.90 .65 1.78 .73 1.94 .63 1.68 .82
  Personal connection 2.28 .50 2.14 .64 2.20 .49 2.13 .55 2.17 .54 2.20 .61
 Help seeking
  Self 1.59 .64 1.64 .68 1.59 .72 1.64 .72 1.68 .61 1.76 .58
  Others 1.56 .74 1.70 .60 1.60 .75 1.65 .73 1.74 .55 1.82 .49
 Future orientation 2.08 .69 2.12 .61 2.20 .57 2.22 .66 2.20 .70 2.17 .69
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Note. At baseline, N ranged from 93 to 105 for treatment group and 77 to 84 for control group. At immediate post-test, N ranged from 77 to 91 for treatment group and 72 to 80 for control group. At 6-month follow-up, N ranged from 76 to 85 for treatment group and 65 to 69 for control group. PR = caregiver report.

Table 2.

Descriptive Statistics of Primary, Secondary, Intermediary Caregiver and Family Outcomes by Condition

Baseline Immediate Post-Test 6-Month Follow-Up
TWP Control TWP Control TWP Control
Outcomes M SD M SD M SD M SD M SD M SD
Primary
 IPV victimization - overall (count) 4.36 5.71 3.00 4.18 1.56 3.21 1.24 2.22 3.20 5.10 2.21 3.92
 IPV perpetration - overall (count) 2.25 3.26 1.90 3.08 1.03 2.68 .52 1.19 1.22 1.60 1.26 2.27
Secondary
 Depression 15.35 4.80 14.81 4.30 14.16 5.28 14.30 4.81 13.76 4.83 13.83 4.75
 Social support 2.60 1.04 2.69 1.06 2.72 1.14 2.81 1.05 2.93 .95 2.98 .99
Intermediary
 Emotion regulation
  Strategies 4.09 .72 4.17 .86 4.07 .81 4.25 .84 4.34 .61 4.33 .79
  Acceptance 3.80 .97 4.06 .84 3.90 .94 4.07 .85 3.96 .80 3.85 1.02
  Emotion control 4.51 .60 4.48 .85 4.47 .64 4.54 .77 4.59 .56 4.59 .56
  Engagement in goals 3.72 .92 3.66 1.09 3.79 .93 3.74 1.10 3.93 .85 3.52 1.28
  Clarity 4.15 .68 4.17 .92 4.20 .76 4.20 .78 4.13 .92 4.33 .74
  Awareness 3.69 .93 3.75 1.09 3.61 1.12 3.71 1.04 3.75 1.03 3.86 .94
 Cultural connection
  Instrumental 1.86 .66 1.98 .70 1.97 .67 1.87 .69 2.07 .63 1.97 .64
  Psychological 2.75 .44 2.81 .29 2.76 .48 2.58 .62 2.67 .50 2.72 .36
 Help seeking 2.98 .90 3.07 1.00 2.78 .94 2.75 1.09 2.94 .73 3.07 .77
 Future orientation 2.69 .65 2.71 .58 2.73 .69 2.81 .36 2.65 .71 2.64 .71
 Parent-child communication (PR) 3.91 .55 3.95 .55 3.93 .66 3.91 .66 4.01 .72 3.97 .55
 Parent-child communication (CR) 1.92 .69 2.03 .65 2.07 .63 1.91 .72 2.08 .71 1.99 .72
 Parenting skills (PR)
  Harsh parenting .64 .54 .61 .48 .51 .51 .54 .55 .54 .52 .58 .54
  Parental monitoring 3.39 .76 3.35 .72 3.36 .97 3.29 .82 3.46 .88 3.39 .63
  Positive reinforcement 3.51 .58 3.46 .74 3.51 .77 3.36 .80 3.40 .84 3.50 .59
 Parenting skills (CR)
  Harsh parenting .54 .59 .72 .61 .46 .51 .64 .64 .46 .54 .64 .63
  Parental monitoring 2.04 .75 2.00 .80 2.09 .83 1.98 .80 2.17 .82 2.16 .77
  Positive reinforcement 2.24 .73 2.21 .68 2.14 .73 1.99 .84 2.22 .76 2.21 .76
 Family cohesion (PR) 3.69 .63 3.71 .83 3.75 .68 3.71 .77 3.75 .77 3.76 .74
 Family cohesion (CR) 1.96 .64 1.94 .66 1.94 .62 1.80 .66 2.08 .52 1.92 .60
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Note. At baseline, N ranged from 55 to 66 for treatment group and 49 to 58 for control group. At immediate post-test, N ranged from 38 to 58 for treatment group and 45 to 53 for control group. At 6-month follow-up, N ranged from 36 to 56 for treatment group and 38 to 48 for control group. PR = caregiver report. CR = child report.

Results

Primary Outcomes

Child outcomes.

The ITT analyses revealed that at the 6-month follow-up, the incidence rate of ACEs in the TWP group was .64 times lower than that of the control group (Table 3). This indicated that the TWP group, compared to control, had a 36% lower incidence rate of ACEs. Supplemental repeated measures analyses revealed for the TWP group when compared to T1, there was a reduction in ACEs incidence immediately (T2) (IRR = .66) and 6-months later (T3) (IRR = .60) (Table 4). For the control group, there was also a reduction in incidence of ACEs, IRR= .76, but only at T2 and at a lower magnitude than the TWP group. Moreover, dosage analyses revealed that only children attending TWP at a higher rate (2 or more times), compared with the control group, had a lower ACEs incidence rate both immediately, IRR = .66, and at the 6-month follow-up, IRR = .52 (Table 5).

Table 3.

Analysis of Covariance (Intent to Treat) Results for Child Outcomes

Posttest1 6-month Follow-up1
Outcomes b p IRR/OR2 95% CI b p IRR/OR2 95% CI
Primary
 ACEs (count) –.22 .150 .80 [.59, 1.08] –.45 .001 .64 [.49, .84]
Secondary
 Bullying victimization (categorical) –.28 .464 .76 [.36, 1.6] –.17 .668 .84 [.38, 1.86]
 Bullying perpetration (categorical) .18 .734 1.20 [.43, 3.36] .00 .997 1.00 [.23, 4.29]
Intermediary
 Knowledge of child sexual abuse (categorical)
  Scream no .56 .311 1.75 [.59, 5.18] –.15 .799 .86 [.28, 2.67]
  Run away .95 .118 2.57 [.79, 8.43] .88 .230 2.41 [.57, 10.1]
  Tell adult .20 .727 1.22 [.4, 3.71] .15 .826 1.16 [.30, 4.48]
b S.E. p g b S.E. p g
Secondary
 Depression –.85 .58 .145 –.18 –.89 .75 .236 –.18
 Externalizing symptoms (PR) –.69 .45 .128 –.24 .00 .53 .998 .00
Intermediary
 Cultural connection
  Family-facilitated –.01 .10 .892 –.02 .15 .11 .199 .20
  Personal connection –.02 .06 .746 –.04 –.08 .08 .357 –.13
 Help seeking
  Self –.05 .11 .662 –.07 –.07 .10 .497 –.11
  Others –.05 .12 .651 –.07 –.08 .09 .375 –.15
 Future orientation –.02 .09 .810 –.03 .03 .11 .788 .04
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Note. PR = caregiver report. IRR = incidence rate ratio. OR = odds ratio.

1

Reference group is the baseline measurement.

2

IRR for count variables and OR for categorical variables. Bold = p < .05. IRR and OR, closer to 1 represent smaller effects. Hedge’s g, small = .15, medium = .38, large = .69 (Lavakov & Agadullina, 2017).

Table 4.

Supplemental Results from Repeated Measures Analysis for Child Outcomes

TWP Control
Outcome Wald Test (df) p IRR/OR2 95% CI IRR/OR2 95% CI
Primary
 ACEs (count) 28.88 (4) <.001
  Posttest .66 [.53, .84] .76 [.61, .94]
  6-month Follow-up .60 [.48, .76] .84 [.68, 1.03]
Secondary
 Bullying victimization (categorical) 7.94 (4) .094
  Posttest .53 [.29, .97] .85 [.50, 1.45]
  6-month Follow-up .47 [.24, .89] .67 [.36, 1.25]
 Bullying perpetration (categorical) 10.13 (4) .038
  Posttest 1.20 [.55, 2.64] .68 [.34, 1.35]
  6-month Follow-up .48 [.15, 1.48] .28 [.11, .72]
Intermediary
Knowledge of child sexual abuse (categorical)
  Scream no 3.38 (4) .497
   Posttest .99 [.37, 2.67] .52 [.21, 1.24]
   6-month Follow-up .91 [.32, 2.59] .82 [.28, 2.42]
  Run away 4.34 (4) .362
   Posttest 1.34 [.45, 3.99] .55 [.24, 1.31]
   6-month Follow-up 2.32 [.58, 9.32] .97 [.33, 2.88]
  Tell adult 2.58 (4) .631
   Posttest .58 [.17, 1.99] .63 [.26, 1.51]
   6-month Follow-up .84 [.26, 2.74] 1.03 [.38, 2.79]
Wald Test (df) p d p d p
Secondary
 Depression 6.29 (4) .178
  Posttest –.20 .021 –.03 .670
  6-month Follow-up –.28 .885 –.04 .807
 Externalizing symptoms (PR) 7.90 (4) .095
  Posttest –.23 .018 .02 .871
  6-month Follow-up –.19 .185 –.09 .204
Intermediary
 Cultural connection
  Family-facilitated 4.69 (4) .320
   Posttest –.10 .433 .16 .069
   6-month Follow-up –.03 .708 .02 .715
  Personal connection 5.19 (4) .269
   Posttest –.15 .116 –.01 .895
   6-month Follow-up –.21 .067 .10 .734
 Help seeking
  Self 2.93 (4) .569
   Posttest .00 .680 .00 .972
   6-month Follow-up .14 .176 .19 .288
  Others 8.18 (4) .085
   Posttest .05 .690 –.07 .654
   6-month Follow-up .28 .030 .22 .093
 Future orientation 5.36 (4) .253
  Posttest .20 .059 .16 .145
  6-month Follow-up .18 .143 .07 .691
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Note. PR = caregiver report. IRR = incidence rate ratio. OR = odds ratio.

1

Reference group is the baseline measurement.

2

IRR for count variables and OR for categorical variables. Bold = p < .05. IRR and OR, closer to 1 represent smaller effects. Cohen’s d, small = .20, medium = .50, large = .80 (Cohen, 1992).

Table 5.

Supplemental Dosage Analyses Results for Child Outcomes

Posttest1 6-month Follow-up1
Outcome b p IRR/OR2 95% CI b p IRR/OR2 95% CI
Primary
 ACEs (count)
  0–1 sessions3 –.03 .898 .98 [.67, 1.43] –.27 .114 .76 [.54, 1.07]
  2 or more sessions3 –.41 .026 .66 [.46, .95] –.64 <.001 .52 [.37, .75]
Secondary
 Bullying victimization (categorical)
  0–1 sessions3 .24 .581 1.27 [.54, 3.00] .20 .670 1.22 [.49, 3.09]
  2 or more sessions3 –.97 .069 .38 [.14, 1.08] –.62 .249 .54 [.19, 1.54]
 Bullying perpetration (categorical)
  0–1 sessions3 .64 .287 1.89 [.58, 6.13] –.67 .560 .51 [.05, 4.88]
  2 or more sessions3 –.43 .552 .65 [.16, 2.71] .38 .636 1.47 [.30, 7.18]
Intermediary
 Knowledge of child sexual abuse (categorical)
  Scream no
   0–1 sessions3 .02 .970 1.02 [.32, 3.32] –.46 .488 .63 [.18, 2.30]
   2 or more sessions3 1.69 .116 5.44 [.66, 45.04] .21 .775 1.24 [.29, 5.30]
  Run away
   0–1 sessions3 .45 .505 1.57 [.42, 5.85] .13 .860 1.14 [.27, 4.89]
   2 or more sessions3 1.87 .091 6.47 [.74, 56.39] NA NA NA NA
  Tell adult
   0–1 sessions3 –.49 .423 .61 [.18, 2.04] –.62 .381 .54 [.13, 2.15]
   2 or more sessions3 1.55 .156 4.69 [.55, 39.83] NA NA NA NA
b S.E. p g b S.E. p g
Secondary
 Depression
  0–1 sessions3 –.78 .72 .280 –.17 –1.26 .95 .183 –.24
  2 or more sessions3 –.92 .70 .192 –.21 –.59 .88 .503 –.12
 Externalizing symptoms (PR)
  0–1 sessions3 –.80 .59 .178 –.28 .28 .67 .674 .09
  2 or more sessions3 –.62 .51 .224 –.22 –.19 .60 .755 –.06
Intermediary
 Cultural connection
  Family-facilitated
   0–1 sessions3 –.03 .12 .782 –.05 .12 .14 .390 .15
   2 or more sessions3 .00 .12 .977 –.02 .17 .13 .200 .23
  Personal connection
   0–1 sessions3 –.05 .08 .506 –.10 –.10 .10 .339 –.17
   2 or more sessions3 .01 .07 .938 –.05 –.06 .10 .558 –.09
 Help seeking
  Self
   0–1 sessions3 –.13 .14 .351 –.17 –.02 .12 .838 –.04
   2 or more sessions3 .03 .14 .842 .19 –.10 .12 .370 –.18
  Others
   0–1 sessions3 –.14 .14 .349 –.17 –.12 .11 .253 –.22
   2 or more sessions3 .03 .14 .860 .20 –.04 .10 .715 –.08
 Future Orientation
  0–1 sessions3 –.05 .11 .687 –.07 –.09 .14 .531 –.12
  2 or more sessions3 .00 .11 .997 .17 .13 .13 .323 .19
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Note. PR = caregiver report. IRR = incidence rate ratio. OR = odds ratio. Bold = p < .05.

1

Reference group is the baseline measurement.

2

IRR for count variables and OR for categorical variables.

3

Reference group is the control condition. IRR and OR, closer to 1 represent smaller effects. Hedge’s g, small = .15, medium = .38, large = .69 (Lavakov & Agadullina, 2017). We were not able to conduct dosage analyses of “2 or more sessions” group with the control condition as the reference group for two variables (i.e., run away and tell adult in knowledge of child sexual abuse measure) at 6-month follow-up. Because for these two variables, the majority of respondents (97.5% and 97.7%) gave the correct answers in the “2 or more sessions” group.

Caregiver outcomes.

Regarding IPV victimization, no significant findings emerged from ITT analyses (Table 6). Repeated measures analyses revealed that, for the TWP group, compared to baseline, IPV victimization at T2 decreased, IRR = .36 (Table 7). For the control group, the decrease was at a lower magnitude, IRR = .41 (Table 7). Results from the dosage analyses indicated that caregivers attending TWP 2 or more times, compared to control, had lower rates of victimization at T2, IRR = .37 (Table 8). But caregivers in the treatment group attending TWP 0 or 1 times, compared with those in the control group, had higher rates of victimization, IRR = 2.70 (Table 8).

Table 6.

Analysis of Covariance (Intent to Treat) Results for Caregiver and Family Outcomes

Posttest1 6-month Follow-up1
Outcome b p IRR 95% CI b p IRR 95% CI
Primary
 IPV victimization - overall (count) .08 .840 1.09 [.50, 2.39] .39 .298 1.48 [.71, 3.07]
 IPV perpetration - overall (count) .23 .631 1.25 [.50, 3.13] .06 .849 1.06 [.59, 1.89]
b S.E. p g b S.E. p g
Secondary
 Depression –.53 .88 .547 –.10 –.17 .92 .851 –.04
 Social support .05 .18 .772 .05 .07 .16 .653 .07
Intermediary
 Emotion regulation
  Strategies –.18 .14 .216 –.21 .01 .13 .942 .01
  Acceptance –.04 .15 .766 –.05 .20 .18 .257 .22
  Emotion control –.16 .13 .230 –.22 –.03 .11 .771 –.05
  Engagement in goals –.04 .15 .781 –.04 .33 .19 .078 .30
  Clarity –.03 .14 .827 –.04 –.17 .17 .311 –.20
  Awareness –.13 .17 .444 –.12 –.07 .17 .697 –.07
 Cultural connection
  Instrumental .14 .10 .150 .21 .18 .08 .036 .28
  Psychological .17 .09 .076 .30 –.01 .07 .902 –.02
 Help seeking .02 .16 .905 .02 –.12 .13 .354 –.16
 Future orientation –.10 .11 .337 –.18 .01 .15 .960 .01
 Parent-child communication (PR) .05 .10 .614 .08 .07 .11 .512 .11
 Parent-child communication (CR) .18 .09 .045 .27 .16 .12 .183 .22
 Parenting skills (PR)
  Harsh parenting –.09 .09 .298 –.17 –.04 .09 .692 –.07
  Parental monitoring .05 .14 .720 .05 .11 .12 .362 .14
  Positive reinforcement .13 .11 .254 .16 –.04 .11 .693 –.06
 Parenting skills (CR)
  Harsh parenting –.09 .09 .291 –.16 –.11 .09 .252 –.18
  Parental monitoring .10 .10 .322 .12 .07 .12 .585 .08
  Positive reinforcement .09 .11 .411 .11 .00 .12 .982 .00
 Family cohesion (PR) .00 .12 .976 .00 .04 .15 .795 .05
 Family cohesion (CR) .11 .10 .269 .17 .15 .09 .073 .27
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Note. IPV = intimate partner violence. PR = caregiver report. CR = child report. IRR = incidence rate ratio. Bold p < .05.

1

Reference group is the baseline measurement. IRR, closer to 1 represent smaller effects. Hedge’s g, small = .15, medium = .38, large = .69 (Lavakov & Agadullina, 2017).

Table 7.

Supplemental Results from Repeated Measures Analysis Caregiver and Family Outcomes

TWP Control
Outcome Wald Test (df) p IRR 95% CI IRR 95% CI
Primary
 IPV victimization - overall (count) 2.70 (4) .0004
  Posttest .36 [.19, .69] .41 [.25, .70]
  6-month Follow-up .73 [.41, 1.31] .72 [.41, 1.27]
 IPV perpetration - overall (count) 26.03 (4) <.001
  Posttest .45 [.24, .87] .28 [.14, .55]
  6-month Follow-up .54 [.33, .87] .66 [.38, 1.13]
Wald Test (df) p d p d p
Secondary
 Depression 8.20 (4) .085
  Posttest –.24 .036 –.11 .353
  6-month Follow-up –.33 .061 –.22 .496
 Social support 8.22 (4) .084
  Posttest .11 .229 .11 .482
  6-month Follow-up .33 .013 .28 .722
Intermediary
 Emotion Regulation
  Strategies 13.34 (4) .010
   Posttest –.03 .894 .10 .474
   6-month Follow-up .37 .009 .19 .257
  Acceptance 4.89 (4) .299
   Posttest .10 .265 .01 .900
   6-month Follow-up .17 .121 –.23 .192
  Emotion control 4.63 (4) .328
   Posttest –.05 .576 .08 .551
   6-month Follow-up .15 .345 .15 .318
  Engagement in goals 4.56 (4) .335
   Posttest .07 .420 .08 .366
   6-month Follow-up .23 .070 –.11 .735
  Clarity 2.32 (4) .677
   Posttest .08 .512 .04 .807
   6-month Follow-up –.02 .908 .19 .261
  Awareness 2.81 (4) .591
   Posttest –.08 .294 –.04 .667
   6-month Follow-up .06 .847 .11 .542
 Cultural connection
  Instrumental 11.80 (4) .019
   Posttest .16 .099 –.16 .271
   6-month Follow-up .34 .002 –.01 .911
  Psychological 1.72 (4) .030
   Posttest .04 .496 –.49 .013
   6-month Follow-up –.16 .314 –.29 .028
 Help seeking 14.33 (4) .006
  Posttest –.22 .012 –.31 .028
  6-month Follow-up –.05 .707 .00 .914
 Future orientation 4.22 (4) .377
  Posttest .06 .545 .19 .284
  6-month Follow-up –.05 .837 –.12 .269
 Parent-child communication (PR) 1.27 (4) .866
  Posttest .03 .632 –.06 .600
  6-month Follow-up .15 .373 .04 .861
 Parent-child communication (CR) 5.97 (4) .201
  Posttest .23 .096 –.17 .111
  6-month Follow-up .22 .155 –.05 .494
 Parenting skills (PR)
  Harsh parenting 7.42 (4) .115
   Posttest –.24 .048 –.15 .094
   6-month Follow-up –.18 .310 –.07 .229
  Parental monitoring 1.32 (4) .858
   Posttest –.03 .846 –.07 .653
   6-month Follow-up .08 .777 .06 .730
  Positive reinforcement 2.07 (4) .722
   Posttest .00 .725 –.14 .448
   6-month Follow-up –.15 .231 .06 .814
 Parenting skills (CR)
  Harsh parenting 3.05 (4) .550
   Posttest –.15 .168 –.13 .319
   6-month Follow-up –.15 .182 –.14 .512
  Parental monitoring 3.48 (4) .481
   Posttest .06 .404 –.03 .929
   6-month Follow-up .17 .095 .20 .360
  Positive reinforcement 9.38 (4) .052
   Posttest –.14 .082 –.28 .033
   6-month Follow-up –.03 .742 .00 .930
 Family cohesion (PR) .72 (4) .950
  Posttest .08 .439 .00 .829
  6-month Follow-up .08 .750 .06 .919
 Family cohesion (CR) 7.49 (4) .112
  Posttest –.03 .836 –.20 .141
  6-month Follow-up .20 .128 –.02 .561
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Note. IPV = intimate partner violence. PR = caregiver report. CR = child report. IRR = incidence rate ratio.

1

Reference group is the baseline measurement. Bold = p < .05. IRR, closer to 1 represent smaller effects. Cohen’s d, small = .20, medium = .50, large = .80 (Cohen, 1992).

Table 8.

Supplemental Dosage Analyses Results for Caregiver and Family Outcomes

Posttest1 6-month Follow-up1
Outcome b p IRR 95% CI b p IRR 95% CI
Primary
 IPV victimization - overall (count)
  0–1 sessions3 .99 .008 2.70 [1.29, 5.66] .49 .266 1.63 [.69, 3.84]
  2 or more sessions3 –1.00 .035 .37 [.14, .93] .32 .500 1.37 [.55, 3.42]
 IPV perpetration - overall (count)
  0–1 sessions3 .96 .030 2.62 [1.10, 6.24] –.28 .629 .76 [.24, 2.34]
  2 or more sessions3 –.51 .476 .60 [.15, 2.46] .19 .520 1.21 [.67, 2.18]
b S.E. p g b S.E. p g
Secondary
 Depression
  0–1 sessions3 .45 1.14 .693 .09 1.03 1.17 .378 .21
  2 or more sessions3 –1.18 1.00 .238 –.23 –.98 1.03 .344 –.20
 Social support
  0–1 sessions3 .11 .24 .657 .10 .23 .21 .274 .23
  2 or more sessions3 .02 .21 .928 .02 –.03 .18 .881 –.03
Intermediary
 Emotion regulation
  Strategies
   0–1 sessions3 –.36 .18 .049 –.44 –.04 .17 .803 –.07
   2 or more sessions3 –.06 .16 .725 –.06 .05 .15 .765 .06
  Acceptance
   0–1 sessions3 –.25 .19 .186 –.28 .17 .23 .463 .09
   2 or more sessions3 .09 .16 .602 .18 .22 .20 .267 .24
  Emotion control
   0–1 sessions3 –.14 .18 .434 –.19 –.06 .14 .689 –.24
   2 or more sessions3 –.17 .15 .253 –.10 –.02 .12 .899 –.03
  Engagement in goals
   0–1 sessions3 –.21 .20 .293 –.21 .33 .24 .160 .06
   2 or more sessions3 .06 .17 .714 .31 .32 .21 .134 .29
  Clarity
   0–1 sessions3 –.09 .19 .631 –.12 –.34 .21 .106 .01
   2 or more sessions3 .01 .16 .972 –.40 –.05 .19 .793 –.06
  Awareness
   0–1 sessions3 –.26 .22 .235 –.24 –.24 .21 .257 –.04
   2 or more sessions3 –.04 .19 .816 –.24 .06 .19 .773 .06
 Cultural connection
  Instrumental
   0–1 sessions3 .16 .13 .233 .23 .35 .10 .001 .20
   2 or more sessions3 .13 .11 .232 .54 .05 .09 .574 .08
  Psychological
   0–1 sessions3 .20 .12 .113 .36 .08 .09 .403 .26
   2 or more sessions3 .15 .11 .166 .17 –.07 .08 .397 –.15
 Help seeking
  0–1 sessions3 .13 .21 .516 .13 –.17 .17 .322 –.05
  2 or more sessions3 –.06 .18 .757 –.23 –.09 .15 .552 –.12
 Future orientation
  0–1 sessions3 –.17 .14 .238 –.29 .10 .19 .577 –.11
  2 or more sessions3 –.06 .12 .606 .14 –.06 .17 .712 –.08
 Parent-child communication (PR)
  0–1 sessions3 –.04 .13 .729 –.07 .00 .15 .988 .16
  2 or more sessions3 .11 .12 .348 .00 .12 .12 .325 .18
 Parent-child communication (CR)
  0–1 sessions3 .27 .12 .030 .37 .21 .15 .158 .27
  2 or more sessions3 .11 .10 .269 .17 .12 .14 .382 .17
 Parenting skills (PR)
  Harsh parenting
   0–1 sessions3 .07 .10 .488 .14 .18 .13 .176 .33
   2 or more sessions3 –.19 .10 .049 –.35 –.18 .10 .053 –.34
  Parental monitoring
   0–1 sessions3 .20 .13 .130 .22 .34 .13 .011 .42
   2 or more sessions3 –.04 .19 .824 –.05 –.04 .18 .816 –.05
  Positive reinforcement
   0–1 sessions3 .07 .13 .573 .09 .17 .11 .141 .21
   2 or more sessions3 .16 .13 .220 .22 –.18 .15 .247 –.24
 Parenting skills (CR)
  Harsh parenting
   0–1 sessions3 –.08 .11 .487 –.13 –.03 .11 .821 –.04
   2 or more sessions3 –.10 .10 .287 –.17 –.17 .10 .088 –.30
  Parental monitoring
   0–1 sessions3 .06 .15 .711 .07 .09 .16 .587 .11
   2 or more sessions3 .14 .11 .200 .17 .05 .14 .745 .06
  Positive reinforcement
   0–1 sessions3 .14 .13 .274 .18 .13 .14 .326 .18
   2 or more sessions3 .04 .12 .758 .05 –.11 .15 .475 –.14
 Family cohesion (PR)
  0–1 sessions3 .01 .16 .952 .01 –.03 .20 .891 –.01
  2 or more sessions3 –.01 .13 .935 –.04 .08 .16 .601 .11
 Family cohesion (CR)
  0–1 sessions3 .12 .13 .326 .19 .19 .11 .085 .32
  2 or more sessions3 .09 .10 .361 .14 .12 .11 .212 .22
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Note. IPV = intimate partner violence. PR = caregiver report. CR = child report. IRR = incidence rate ratio. Bold = p ≤ .05.

1

Reference group is the baseline measurement.

2

IRR for count variables and OR for categorical variables.

3

Reference group is the control condition. IRR, closer to 1 represent smaller effects. Hedge’s g, small = .15, medium = .38, large = .69 (Lavakov & Agadullina, 2017).

Turning to perpetration, for TWP, as compared to baseline, there were decreases perpetration at both T2, IRR = .45, and T3, IRR = .54 (Table 7). Perpetration for the control group, compared to baseline, also decreased, but only at T2, IRR = .28 (Table 7). But caregivers in the treatment group attending TWP 0 or 1 times, compared with caregivers in the control group, had higher rates of perpetration, IRR = 2.62 immediately (Table 8).

Secondary Outcomes

Child outcomes.

For the control group, most outcomes did not change over time. The one exception, children in the control group were less likely to show bullying perpetration at T3 compared to baseline, OR = .28 (Table 4). For the TWP Group, repeated measures analyses revealed that when compared to baseline, children in the TWP group were less likely to show bullying victimization at T2, OR = .53 (Table 4), and at T3, OR = .47 (Table 4). Compared to baseline, in the TWP group, depression decreased at T2 (d = –.20, p = .02; Table 4). Children in the TWP group had decreased externalizing symptoms at T2, compared with baseline (d = –.23, p = .02; Table 4).

Caregiver and family outcomes.

For caregiver secondary outcomes, compared with baseline, caregivers in the TWP group, compared with caregivers in the control group, reported decreased depression at T2 (d = –.24, p = .04; Table 7), and increased social support at T3 (d = .33, p = .01; Table 7).

Intermediary Outcomes

Child outcomes.

For child intermediary outcomes, help seeking behaviors for others increased from T1 to T3 (d = .28, p = .03; Table 4) for the TWP group, but not the control group.

Caregiver and family outcomes.

For the caregiver intermediary outcomes, the ITT analyses revealed that the TWP group, compared to control group, showed higher levels of cultural connection-instrumental (g = .28, p = .04; Table 6), at follow-up (T3). Repeated measures analyses revealed that caregivers in the TWP group at T3, compared with T1, had increased cultural connection-instrumental (d = .34, p = .002; Table 7). Conversely, caregivers in the control group had decreased levels of cultural connection-psychological at both T2 (d = –.49, p = .01) and T3 (d = –.29, p = .03; Table 7) compared to baseline. Dosage analyses indicated that caregivers attending TWP 0 or 1 times, compared with caregivers in the control group, had increased cultural connection-instrumental (g = .20, p = .001; Table 8).

For emotion regulation, repeated measures analyses revealed that caregivers in the TWP group at T3 compared with T1 had increased emotion regulation strategies (d = .37, p = .01; Table 7). Dosage analyses indicated that caregivers attending TWP 0 or 1 times, compared with caregivers in the control group, had lower levels of emotion regulation strategies at T2 compared with T1 (g = –.44, p = .049; Table 8).

For help seeking, repeated measures analyses indicated that caregivers in the control group had decreased help seeking at T2 compared to baseline (d = –.31, p = .03; Table 7). Caregivers in the TWP group also had decreased help seeking at T2 compared to baseline (d = –.22, p = .01; Table 7) but at a smaller magnitude compared to the control group.

For parenting behaviors, child reports of positive reinforcement parenting skills decreased from T1 to T2 among the control group (d = –.28, p = .03) but not the TWP group (d = –.14, p = .08; Table 7). Parent reports of harsh parenting decreased from T1 to T2 among the TWP group (d = –.24, p = .048; Table 7). Dosage analyses indicated that caregivers attending TWP 2 or more times, compared to the control group, had decreased harsh parenting skills at both T2 (g = –.35, p = .049) and T3 (g = –.34, p = .053; Table 8). Caregivers attending TWP 0–1 times, compared to the control group, had higher levels of parental monitoring at T3 (g = .42, p = .01; Table 8).

For parent-child communication, children in the TWP group reported increased levels of parent-child communication compared with the control group at T2 (g = .27, p = .045; Table 6). Dosage analyses further indicated that children attending 0–1 TWP sessions reported increased parent-child communication, compared to the control group (g = .37, p = .03; Table 8).

Discussion

This is the first ever evaluation of a program to prevent ACEs among children who are low-income and/or Indigenous. Results families who participated in the program had decreases in ACE incidence as well as reductions in caregiver depression, caregiver use of harsh parenting, and caregiver IPV. Results also indicated that the TWP reduced bullying among children, and children’s depression and externalizing behaviors, suggesting that the TWP may provide additional benefits beyond ACEs prevention.

Although we were not able to formally test mediation due to the small sample size in this initial evaluation, findings regarding the intermediary outcomes point to the mechanisms through the TWP may have prevented ACEs. Treatment effects were found for caregiver cultural connection, social support, and increased emotion regulation which may point to potential mechanisms through which the TWP prevented ACEs among children. These factors may be especially salient to Indigenous populations given the important role of culture, connection to others (e.g., Mitákuye Oyás’iŋ [All Are Related]), and focus on the whole person including mind, body, emotion and spirit, which is congruent with emotion regulation.31,32 These culturally relevant factors could help explain the enduring impacts at the 6-month post-test and hopefully longer, which future research can assess.

It is interesting that none of the parenting or family process variables were impacted by the TWP. It is possible that the TWP may not have moved the needle on these outcomes and that ACEs prevention was driven by other factors (e.g., cultural connection). Alternatively, it is possible that these findings were due to measurement issues, such that the measures used in this study may not have accurately captured Indigenous parenting and family process.33,34

Several limitations should be noted. First, although the 6-month follow-up is appropriate for the first ever pilot evaluation of the TWP, the extent to which the TWP led to positive impacts past this time point is unknown. Second, there were challenges with uptake (i.e., only 64% of families in the treatment group attended the program). Thus, effect sizes may be underestimated and are considered conservative estimates of intervention effects given the context of low to moderate attendance. Third, 6-month incidence rates on many of the ACEs were low and thus we were not able to conduct item-level analyses. Fourth, given our sample size, we were also unable to conduct mediation and demographic moderation analyses. Future research using larger samples, longer follow-ups are needed. Research is also needed to examine barriers to update and address them.

In conclusion, the TWP holds great promise to prevent ACEs among low-income, Indigenous children. The program also moved the needle on a number of other outcomes, showing potential promise for widespread public health impact among a highly structurally minoritized population. Future rigorous research on the long-term impact of the TWP and its applicability to other Indigenous communities and settings is warranted. More specially, the TWP could be adapted to include inter-tribal values (e.g., circulatory, kinship) so that it can be delivered to diverse groups of Indigenous peoples with varied tribal affiliations. The TWP may also be impactful for other cultural groups if adapted to be inclusive of culturally specific concepts and values. Future research on the utility of the TWP for other cultural groups is warranted given the promise of the TWP documented in this study.

Article Summary

A culturally grounded, family-based program prevented adverse childhood experiences and other adversities (e.g., child depression) and increased resilience (e.g., child help-seeking, caregiver cultural connection).

What’s Known on This Subject

Research documents high rates of ACEs among low-income, Indigenous children as well as a number of risk and protective factors for ACEs among this population. However, to date few programs have demonstrated efficacy to prevent ACEs among low-income, Indigenous children.

What This Study Adds

This study is the first ever evaluation of a culturally grounded, family-based program prevented ACEs among low-income, Indigenous children. Results highlight the promise of the TWP in preventing a public health crisis among a structurally minoritized group.

Funding/Support:

Funding for this project was provided by Centers for Disease Control and Prevention (CDC), R01CE003190. The findings and conclusions in this presentation are those of the authors and do not necessarily represent the official position of the CDC.

Role of Funder/Sponsor (if any):

CDC had no role in designing or conducting the study.

Abbreviations:

ACEs

adverse childhood experiences

TWP

Tiwahe Wicagwicayapi program

IPV

intimate partner violence

Footnotes

Clinical Trial Registration (if any): NCT05129501

Conflict of Interest Disclosures (includes financial disclosures): The authors have no example conflicts of interest to disclose.

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