Abstract
Objective
The stress associated with adverse childhood experiences (ACEs) has immediate and long-lasting effects. The objectives of this study were to examine (1) how often pediatricians ask patients’ families about ACEs, (2) how familiar pediatricians are with the original ACE study, and (3) physician/practice characteristics, physicians’ mental health (MH) training, and physicians’ attitudes/beliefs that are associated with asking about ACEs.
Methods
Data were collected from 302 non-trainee pediatricians exclusively practicing general pediatrics who completed the 2013 American Academy of Pediatrics Periodic Survey. Pediatricians indicated whether they usually, sometimes, or never inquired about or screened for 7 ACEs. Sample weights were used to reduce non-response bias. Weighted descriptive and logistic regression analyses were conducted.
Results
Only 4% of pediatricians usually asked about all 7 ACEs; 32% did not usually ask about any. Fewer than 11% of pediatricians reported being very or somewhat familiar with the ACE study. Pediatricians who screened/inquired about ACEs usually asked about maternal depression (46%) and parental separation/divorce (42%). Multivariable analyses showed that pediatricians had more than twice the odds of usually asking about ACEs if they disagreed that they have little effect on influencing positive parenting skills, disagreed that screening for social emotional risk factors within the family were beyond the scope of pediatricians, or were very interested in receiving further education on managing/treating MH problems in children and adolescents.
Conclusion
Few pediatricians ask about all ACEs. Pediatric training that emphasizes the importance of social/emotional risk factors may increase the identification of ACEs in pediatric primary care.
Keywords: ACE, adverse childhood experiences, screening, pediatric primary care
Introduction
The stress associated with cumulative adverse experiences in early childhood has immediate and long-lasting effects, as it can disrupt developing brain circuits and increase levels of stress hormones, leading to adult health and mental health problems.1 Adverse experiences in early childhood have been linked to developmental delays and injuries in 4- and 5-year olds, learning and behavioral disorders and high body mass index among children and adolescents, and poor mental health (MH) in young children.2, 3, 4 The Adverse Childhood Experiences (ACE) study retrospectively examined the long-term impact of adverse experiences, such as childhood abuse, neglect and household dysfunction, and demonstrated that greater numbers of stressors experienced early in life were associated with later-in-life risk-taking and unhealthy lifestyles, as well as with disease.5
Identifying ACEs in young children who are not yet in school can be difficult. However, most infants do receive well-child visits,6 and the American Academy of Pediatrics (AAP) recommends 7 well-child visits for children during the 1st year of life, and frequent visits throughout early childhood.7 Given the frequency of contact with pediatricians, and the impact that ACEs can have on children’s health, pediatric offices may be a promising venue for identifying and managing adverse experiences in early childhood.
The AAP recognizes that early life experiences can impact long-term health outcomes, and has consequently made significant efforts to raise the awareness of ACEs and their effects on early brain and child development among pediatricians.8, 9 For example to identify children at risk, it has encouraged pediatricians to implement routine screening to identify family- or community-level factors that may adversely affect children.9, 10 However, we know little about which pediatricians do and do not regularly identify adverse childhood experiences among their patients.
In 2013, the AAP included questions about identifying adverse experiences among children in its Periodic Survey (PS). Given these unique data, the goals of this study were to: (1) examine how often pediatricians ask patients’ families about ACEs; (2) examine pediatricians’ familiarity with the original ACE study; (3) assess pediatricians’ attitudes and beliefs about the impact of stress/adversity on child development, and the role that parents and pediatricians have in mitigating their effects; and (4) examine the associations of physician and practice characteristics, MH training, and physician attitudes and beliefs with asking about ACEs.
Methods
PS 85 Survey Administration
The AAP has conducted a PS of pediatricians 3 or 4 times each year since 1987 to inform policy, to develop new initiatives, and/or to evaluate current projects. Data collection for the PS 85 occurred between July and December 2013. The survey contained largely closed-ended questions, asking about sociodemographic and practice characteristics, and included questions about attitudes, training, and behaviors about child/adolescent and maternal MH. The questionnaire was pretested and approved by the AAP institutional review board before the mailings. Information about the survey is available at www.aap.org/en-us/professional-resources/Research/pediatrician-surveys/Pages/Periodic-Survey-of-Fellows.aspx.
Of the 54,491 US non-retired AAP members, 1617 were randomly selected and asked to complete the PS 85. While the sample represents the AAP membership on age, sex, and region (data not shown), the response rate was suboptimal (n=594, 37%). Comparisons of responders and non-responders showed that the former group was significantly older (46.6 vs. 43.7 years, p<.001). Additional analyses examined differences between early and late responders, using late responders as a proxy for non-responders. The groups were similar with respect to how often pediatricians ask patients’ families about ACEs, familiarity with the original ACE study, and pediatricians’ attitudes and beliefs about the impact of stress/adversity on child development (results not shown). Nonetheless, sample weights were created to reduce potential non-response bias and ensure that the respondents were representative of the AAP membership. Logistic regression was used to estimate response propensity scores. The final model included the three-way interaction of age, sex, and region, as well as their two-way interactions and main effects. Ten groups were created using deciles of the response propensity score distribution. The sample weights were the inverse of the average propensity score for each group. The sample weights were rescaled such that the mean was unity and the sum was equal to the analytic sample size.
Exposure and outcome variables
Sociodemographic factors included physician characteristics (e.g., race/ethnicity, sex and age) and practice characteristics (years in practice, type of practice, patient insurance, etc.). Physicians were asked about their past child MH-related residency and fellowship training (in Developmental/Behavioral Pediatrics (DBP), Child Psychiatry, Adolescent Medicine, and Behavioral Sciences), and their interest in future MH-related education, which was rated on a three-point ordinal scale (very, somewhat, not at all). Physicians were also asked how familiar they were with the original ACE study (very, somewhat, vaguely, or not at all familiar). Their beliefs and attitudes about adverse experiences, their impact on children, and the role that parents and providers play in mitigating their effects, were assessed using a 5-point Likert scale, ranging from strongly agree to strongly disagree. Responses were dichotomized such that strongly agree and agree were compared to the other 3 categories for positively worded questions, and strongly disagree and disagree were compared to the other 3 categories for negatively worded questions.
Using a three-point ordinal scale (usually, sometimes, never), pediatricians were asked how often they inquired about or routinely screened for 7 ACEs: maternal depression, parental separation/divorce, physical or sexual abuse, hostile/rejecting parenting by mothers, domestic violence exposure, parental alcohol/drug use, and incarcerated relative. Although hostile/rejecting parenting by mothers was not included in the original ACE study, it is conceptually similar to emotional abuse, which was in the original study; emotional abuse was not included in the PS 85. Pediatricians who reported usually inquiring about or routinely screening for one or more ACEs (asking about any ACEs), were compared to those who reported sometimes or never asking about any ACEs.
Statistical Analysis
Univariate and bivariate analyses were summarized using weighted percentages for categorical measures and weighted means and standard errors for continuous measures. Bivariate comparisons were assessed using the Rao-Scott Chi-square test and weighted linear regression. Weighted multivariable logistic regression was used to examine associations of physician characteristics, practice characteristics, and beliefs/attitudes with usually asking about any ACEs. The results are summarized using odds ratios (OR) and 95% confidence intervals, and statistical significance was set at p<.01. All analyses were performed in SAS 9.3 (SAS Institute, Cary, NC).
Results
Examination of the 321 non-trainee pediatricians who exclusively practiced general pediatrics showed that 302 answered the majority of the ACEs questions and therefore were included in the analytic sample. Pediatricians were 46 years old on average and 68% were female (Table 1). About half (51%) practiced in suburban settings, 53% worked in pediatric group practices, and 21% were in practice for less than 5 years. Almost two-thirds saw fewer than 100 ambulatory visits per week (65%), and the majority of the patients served were Caucasian and did not have private insurance. About half of pediatricians completed 4 or more weeks of a DBP rotation in residency, and 70% completed 4 or more weeks of a residency rotation in some child MH area; very few (2%) completed a fellowship in child MH. Approximately 50% attended a child MH lecture/conference in the past 2 years, and were very interested in further education on child and adolescent MH (Table 2).
Table 1.
Physician and Practice Characteristics For the Analytic Sample and Bivariate Associations with Pediatricians Usually Asking About One or More ACEs (Weighted % Shown)
| Analytic Sample (n=302) |
Pediatrician Usually Asks About One or More ACEs |
|||
|---|---|---|---|---|
| No (n=96) |
Yes (n=206) |
p-value | ||
| Physician Characteristics | ||||
| Sex | ||||
| Female | 68.1 | 30.8 | 69.2 | .5648 |
| Male | 31.9 | 34.2 | 65.8 | |
| Age, y; weighted mean (SE) Years in practice | 46.0 (0.6) | 47.1 (1.3) | 45.5 (0.7) | .2597 |
| <5 | 21.3 | 34.3 | 65.7 | .0518 |
| 5–9 | 16.5 | 18.1 | 81.9 | |
| 10–19 | 29.6 | 27.0 | 73.1 | |
| ≥20 | 32.6 | 41.4 | 58.6 | |
| Race/Ethnicity | ||||
| Caucasian | 74.5 | 31.2 | 68.8 | .0107 |
| Asian | 11.5 | 51.6 | 48.4 | |
| Other | 13.9 | 19.3 | 80.7 | |
| Location of practice | ||||
| Urban | 39.1 | 29.7 | 70.3 | .5484 |
| Suburban | 50.7 | 34.5 | 65.5 | |
| Rural | 10.2 | 26.1 | 73.9 | |
| Practice Characteristics | ||||
| Type of practice | ||||
| 1 or 2 physician | 8.7 | 38.5 | 61.5 | .7505 |
| Pediatric group practice | 52.7 | 33.9 | 66.1 | |
| Multispecialty group | 12.1 | 29.5 | 70.5 | |
| Medical school/parent university | 7.2 | 28.4 | 71.6 | |
| Other/unknown | 19.3 | 26.1 | 73.9 | |
| Ambulatory visits per week | ||||
| < 100 | 65.2 | 28.4 | 71.6 | .0694 |
| ≥ 100 | 34.8 | 38.8 | 61.2 | |
| Practice Characteristics | ||||
| Patient insurance | ||||
| <80% have Medicaid/public insurance | 70.1 | 31.0 | 69.0 | .8051 |
| ≥80% have Medicaid/public insurance | 15.8 | 31.7 | 68.3 | |
| Unknown | 14.1 | 36.2 | 63.8 | |
| Caucasian patients, % | ||||
| ≤49% | 41.4 | 28.5 | 71.5 | .4829 |
| 50–74% | 35.7 | 33.9 | 66.1 | |
| ≥75% | 22.9 | 36.5 | 63.5 | |
Table 2.
Mental health training and bivariate associations with pediatricians usually asking about one or more ACEs (Weighted % Shown)
| Analytic Sample (n=302) |
Pediatrician Usually Asks About One or More ACEs |
|||
|---|---|---|---|---|
| No (n=96) |
Yes (n=206) |
p-value | ||
| Child/Adolescent MH training | ||||
| Completed ≥4 week residency rotation in DBP | ||||
| No | 45.0 | 33.9 | 66.1 | .4879 |
| Yes | 55.0 | 30.2 | 69.8 | |
| Completed ≥4 week residency rotation in child MH area | ||||
| No | 30.4 | 35.3 | 64.7 | .3952 |
| Yes | 69.6 | 30.4 | 69.6 | |
| Completed fellowship in child MH area | ||||
| No | 97.7 | 33.1 | 66.9 | .2450 |
| Yes | 2.3 | 13.0 | 87.0 | |
| Attended child MH lecture/conference in past 2 years | ||||
| No | 55.7 | 33.8 | 66.2 | .4884 |
| Yes | 44.3 | 30.0 | 70.0 | |
| Very interested in further education on identifying child and adolescent MH problems | ||||
| No | 47.6 | 39.1 | 60.9 | .0097 |
| Yes | 52.4 | 25.0 | 75.0 | |
| Very interested in further education on managing/treating child and adolescent MH problems | ||||
| No | 55.6 | 40.0 | 60.0 | .0009 |
| Yes | 44.4 | 21.9 | 78.1 | |
Only 2% of pediatricians reported that they were very familiar with the ACEs study, 9% were somewhat familiar, 13% were vaguely familiar, and 76% were not at all familiar (results not shown). Approximately one-third (32%) of pediatricians reported that they did not usually ask about any ACEs, while 4% reported usually asking about all 7 ACEs (Figure 1). The ACEs pediatricians usually asked about most often were maternal depression (46%) and parental separation/divorce (42%) (Figure 2). The least commonly asked about ACEs were hostile/rejecting parenting by mothers (10%) and incarcerated relatives (9%). A greater percentage of physicians who were very or somewhat familiar with the ACEs study usually asked about ACEs compared to physicians who were vaguely or not at all familiar with the ACEs study (83.2% vs. 66.2%, p=.04) (results not shown). Only 2% reported routinely using a screening tool for child ACEs, 4% reported using the tool at times, 46% reported never using the screening tool, and 49% reported that they had never heard of the screening tool (results not shown).
Figure 1.
Number of ACEs pediatricians reported usually asking about (Weighted % Shown)
Figure 2.
Frequency with which pediatricians reported asking about each child ACE (Weighted % Shown)
Hostile/rejecting parenting by mothers is a proxy for the original ACE, emotional abuse.
Unadjusted bivariate analyses showed that the only physician characteristic associated with usually asking about ACEs was race/ethnicity: significantly fewer Asian pediatricians usually asked about ACEs compared to Caucasian pediatricians or pediatricians of other race/ethnicity (Table 1). No practice characteristics were associated with asking about ACEs. Physicians who were very interested in further education on 1) identifying child and adolescent MH problems, and 2) managing/treating child and adolescent MH problems were significantly more likely to usually ask about ACEs compared to those who were somewhat or not at all interested in further education on these topics (Table 2).
Pediatricians’ attitudes and beliefs are reported in Table 3. Most notably, only one-third of physicians (34%) agreed that prolonged or excessive physiologic stress in childhood can result in epigenetic modification of the DNA, but almost all agreed that persistent physiologic stress in childhood can make children less capable of coping with future stress (92%) and disrupt brain development an impair educational achievement (96%). A great majority also indicated that stable and supportive adult relationships can mitigate the negative effects of persistent childhood stress (84%). Most pediatricians disagreed that positive parenting has little influence on a child’s life-course trajectory (96%), that advice from pediatricians has little effect on influencing positive parenting skills (79%), and that screening for social emotional risk factors within the family are beyond the scope of the pediatric medical home (81%).
Table 3.
Beliefs about the effect of stress/adversity on children and bivariate associations with pediatricians usually asking about one or more ACEs (Weighted % Shown)
| Analytic Sample (n=302) |
Pediatrician Usually Asks About One or More ACEs |
|||
|---|---|---|---|---|
| No (n=96) |
Yes (n=206) |
p-value | ||
| Prolonged or excessive physiologic stress in childhood can result in epigenetic modification of the DNA | ||||
| Neutral / Disagree / Strongly Disagree | 66.3 | 35.4 | 64.6 | .0393 |
| Agree / Strongly Agree | 33.7 | 23.7 | 76.3 | |
| Persistent physiologic stress in childhood can make children less capable of coping with future stress | ||||
| Neutral / Disagree / Strongly Disagree | 8.3 | 27.8 | 72.2 | .6660 |
| Agree / Strongly Agree | 91.7 | 32.0 | 68.0 | |
| Prolonged or excessive physiologic stress in childhood can disrupt brain development and impair educational achievement | ||||
| Neutral / Disagree / Strongly Disagree | 3.7 | 44.4 | 55.6 | .3554 |
| Agree / Strongly Agree | 96.3 | 31.2 | 68.8 | |
| Brief periods of stress can have a positive effect on a child by serving to motivate and build resilience | ||||
| Neutral / Disagree / Strongly Disagree | 42.8 | 30.6 | 69.4 | .6880 |
| Agree / Strongly Agree | 57.2 | 32.8 | 67.2 | |
| Parents who have experienced significant adversity in childhood have a harder time forming stable and supportive relationships with their children | ||||
| Neutral / Disagree / Strongly Disagree | 41.7 | 34.6 | 65.4 | .3951 |
| Agree / Strongly Agree | 58.3 | 29.9 | 70.1 | |
| Stable and supportive adult relationships can mitigate the negative effects of persistent childhood stress | ||||
| Neutral / Disagree / Strongly Disagree | 16.4 | 37.5 | 62.5 | .3809 |
| Agree / Strongly Agree | 83.6 | 31.0 | 69.0 | |
| Positive parenting has little influence on a child’s life-course trajectory | ||||
| Neutral / Agree / Strongly Agree | 4.4 | 53.4 | 46.6 | .0921 |
| Disagree / Strongly Disagree | 95.6 | 30.9 | 69.1 | |
| Advice from pediatricians has little effect on influencing positive parenting skills among patients’ parents | ||||
| Neutral / Agree / Strongly Agree | 21.2 | 49.9 | 50.1 | .0005 |
| Disagree / Strongly Disagree | 78.8 | 26.7 | 73.3 | |
| Screening for social emotional risk factors within the family are beyond the scope of the pediatric medical home | ||||
| Neutral / Agree / Strongly Agree | 18.9 | 53.6 | 46.4 | .0001 |
| Disagree / Strongly Disagree | 81.1 | 26.8 | 73.2 | |
Unadjusted bivariate associations of these attitudes and beliefs with usually asking about ACEs are also shown in Table 3. Agreeing that prolonged or excessive physiologic stress in childhood can result in epigenetic modification of the DNA was positively associated with usually asking about ACEs (p=.04). Disagreeing that advice from pediatricians has little effect on influencing positive parenting skills among patients’ parents and that screening for social emotional risk factors within the family are beyond the scope of the pediatric medical home were also positively associated with usually asking about ACEs (p-values <.001).
Results from the multivariable logistic regression analyses showed that those who disagreed that pediatricians have little effect on influencing positive parenting skills among patients’ parents had a 2.2-fold increased odds of usually asking about ACEs (Table 4). Similarly, pediatricians who disagreed that screening for social emotional risk factors within the family are beyond the scope of the pediatric medical home had a 2.4-fold increased odds of usually asking about ACEs. Pediatricians who were very interested in receiving further education on managing/treating MH problems in children and adolescents had a 2.1-fold increased odds of usually asking about ACEs.
Table 4.
Odds of pediatricians usually asking about one or more ACEs
| OR | 95% CI | P-val | |
|---|---|---|---|
| Advice from pediatricians has little effect on influencing positive parenting skills among patients’ parents | |||
| Disagree vs. Agree* | 2.19 | 1.21, 3.97 | .0095 |
| Screening for social emotional risk factors within the family are beyond the scope of the pediatric medical home | |||
| Disagree vs. Agree* | 2.42 | 1.29, 4.56 | .0061 |
| Interested in receiving further education on managing/treating MH problems in children and adolescents | |||
| Very vs. somewhat or not at all | 2.13 | 1.25, 3.65 | .0058 |
Disagree includes disagree and strongly disagree; agree (reference group) includes neutral, agree and strongly agree
Discussion
Our data suggest that most pediatricians surveyed have never heard of the original ACE study and do not understand the epigenetic effects of adverse childhood experiences. Nevertheless, most believe that childhood stressors can have a negative impact on children, that pediatricians can help influence parenting, and that positive parenting can influence children’s trajectories. Even so, almost one-third of pediatricians in our sample do not usually ask about any ACEs, and only 4% ask about all of them, representing a missed opportunity to address familial issues that may have a large impact on children’s development, as well as both physical and mental health. Additional training on the importance of identifying ACEs in pediatric practices is essential to ensuring high-level care for all children.
The adverse experience most commonly asked about was maternal depression, yet fewer than half of pediatricians reported usually asking about this condition. It is not surprising that maternal depression is asked about most often, given the focus of the AAP on this issue.11, 12 Studies of the impact of maternal depression on children have consistently demonstrated both short- and long-term negative effects.13–16 However, only 1 in 10 pediatricians usually asked about hostile/rejecting parenting, our study’s proxy for the original ACE study’s “emotional abuse.” Although asking about this sensitive issue is certainly challenging, it seems critical that pediatricians gather information about parenting practices, given research suggesting that supportive parenting is associated with positive changes in brain structure and fewer mental health symptoms.17, 18, 19, 20 The distribution of ACEs usually asked about suggests that while individual adverse experiences may be salient with some pediatricians, as a whole they have not embraced the concept of comprehensively identifying the social and emotional factors that can impact children
The factors that were most strongly associated with usually asking about ACEs were pediatricians’ attitudes and beliefs. Although most pediatricians believed that they can influence parenting, this attitude doubled the odds of pediatricians asking about ACEs, suggesting that training that emphasizes pediatricians’ ability to impact the lives of their young patients, as well as strategies that pediatricians can use to help parents mitigate the impacts of stressful situations at home, might increase identification. The majority of pediatricians believed that addressing social emotional issues is within the scope of pediatric practice, and those with this attitude also had twice the odds of asking about ACEs. These findings suggest that learning how social and environmental factors can influence health may be an important, yet missing, component of pediatric training. Further, pediatricians who were very interested in further mental health education were twice as likely to ask about ACEs as those who were not, suggesting that training is particularly important for pediatricians who are not interested in mental health issues.
Our data also indicate that almost no pediatricians use a screening tool to assess adverse experiences in families, and almost half had never heard of such a tool. This is not surprising, given the lack of validated ACEs screening tools available to pediatricians, although there are some promising screening models available to gather data on individual adverse events (e.g.: http://umm.edu/programs/childrens/services/child-protection/seek-project). Nonetheless, the field should invest in the development of validated comprehensive, easy to use tools to help pediatricians better assess their patients’ needs.
Identifying ACEs among young children may lead to concrete steps to address family situations and mitigate the consequences of the event; additionally, conversations about ACEs with parents might encourage them to seek help either due to an increased understanding of the importance of adverse events to their children’s health, or as a result of someone expressing interest in their difficulties and validating their experiences. One reason pediatricians do not ask about ACEs more often may be that they lack the training to do so. We did not have data on pediatricians’ feelings of competence in this area, but research in other areas suggests that if physicians do not feel competent in a topic, they do not address it with their patients or their families.21–23 Pediatric training programs should consider including practical approaches to not only asking about, but also discussing, ACEs with families. Providers would likely be more comfortable using screening tools if they had training on how to talk with parents about sensitive subjects such as adverse experiences and what to do with the information they collect. Further, it would be helpful for training to stress the importance of incorporating screening tools and anticipatory guidance into practice. Future research should examine more fully the barriers to having discussions about adverse childhood experiences in pediatric practice.
These data are not without limitations. The survey had a suboptimal response rate which is typical for surveys of physicians.24,25 However, extensive analysis of response bias in AAP surveys, including periodic surveys, has shown little non-response bias.26 Further, we found little difference among AAP members, providers who were randomly selected for the survey and survey participants. Additionally, early and late responders were similar with respect to the primary outcomes of this study. Nonetheless, even though the results were weighted to reduce potential non-response bias, there may have been differences in unmeasured variables. For example, pediatricians who were very interested in the topic may have been more likely to respond.27 There is also the possibility of response bias for professionally desirable behaviors. If non-response or social desirability bias were present, we anticipate that our findings would overestimate the prevalence of physicians who usually ask about ACEs. Also, the 7 questions about ACEs were conceptually similar to those used in the original ACEs study, although the wording was not exactly the same, and 2 of the original ACE questions were not included in the AAP survey (physical neglect and emotional neglect). An additional ACE, emotional abuse, was examined with a proxy, hostile/rejecting parenting. Further, the original study separated out physical and sexual abuse. If anything, we believe that these differences would overestimate the number of ACEs that pediatricians usually ask about. Finally, these data are cross sectional and therefore the reported associations do not imply causality.
This national survey of pediatricians suggests that although pediatricians seem to understand the importance of childhood stressors to children’s health and development, most are not asking about all ACEs in their practice. Educating pediatricians about toxic stress became an AAP educational goal around the same time that this survey was administered, so it would be beneficial to repeat this survey to see if recent efforts have made a difference in asking about ACEs. The 2013 survey showed that those who believe that pediatricians can influence parenting practices and those who believe that asking about social emotional issues is within the scope of pediatric practice are more likely to ask about ACEs compared to those who do not hold such beliefs. These findings emphasize the need to include the importance of social and emotional risk factors, and the role that pediatricians can play in addressing these factors, in pediatric training. This may require a change in the focus of pediatric well-child visits to emphasize the importance of children’s families and social and emotional health. Without increased attention to adverse experiences in pediatric training, pediatric care will remain a missed opportunity to ensure that all aspects of children’s health and development receive the attention they deserve.
What’s New.
Few pediatricians usually ask patients about all ACEs. Pediatricians’ attitudes and beliefs about ACEs are related to asking about them; physician/practice/training factors are not. Pediatric training that emphasizes the importance of social/emotional risk factors may increase identification in pediatric practices.
Acknowledgments
Funding Source: American Academy of Pediatrics supported this research. NIMH P30 MH09 0322 (PI K. Hoagwood) supported Dr. Storfer-Isser, Dr. Hoagwood and Dr. Horwitz’s participation in this research.
Abbreviations
- ACE
adverse childhood experience
- MH
mental health
- AAP
American Academy of Pediatrics
Footnotes
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Financial Disclosure: None
Conflict of Interest: None
Contributors’ Statement:
Bonnie D. Kerker, Ph.D.: Dr. Kerker conceptualized the analyses, conducted the analyses, drafted the initial manuscript, and approved the final manuscript as submitted.
Amy Storfer-Isser, Ph.D.: Dr. Storfer-Isser conducted the analyses, drafted sections of the manuscript, critically reviewed all drafts, and approved the final manuscript as submitted.
Moira Szilagyi, M.D.: Dr. Szilagyi participated in the development of the survey, critically reviewed all drafts, and approved the final manuscript as submitted.
Ruth EK Stein, M.D.: Dr. Stein participated in the development of the survey, critically reviewed all drafts, and approved the final manuscript as submitted.
Andrew Garner, M.D., Ph.D.: Dr. Garner participated in the development of the survey, critically reviewed all drafts, and approved the final manuscript as submitted.
Karen G. O’Connor, B.S.: Ms. O’Connor designed and conducted the survey, critically reviewed all drafts, and approved the final manuscript as submitted.
Kimberly E. Hoagwood, Ph.D.: Dr. Hoagwood critically reviewed all drafts and approved the final manuscript as submitted.
Sarah M. Horwitz, Ph.D.: Dr. Horwitz participated in the development of the survey, critically reviewed all drafts, and approved the final manuscript as submitted.
Contributor Information
Bonnie D. Kerker, Email: Bonnie.Kerker@nyumc.org.
Amy Storfer-Isser, Email: Amisi@stats@gmail.com.
Moira Szilagyi, Email: Drmoira777@gmail.com.
Ruth E.K. Stein, Email: Ruth.Stein@einstein.yu.edu.
Andrew Garner, Email: Andrew.Garner@uhhospitals.org.
Karen G. O’Connor, Email: KOConnor@aap.org.
Kimberly E. Hoagwood, Email: Kimberly.Hoagwood@nyumc.org.
Sarah M. Horwitz, Email: Sarah.Horwitz@nyumc.org.
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