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Empower Your Career with the DMH + UCLA Early Childhood Fellowship

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Empower Your Career with the DMH + UCLA Early Childhood Fellowship

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DMH + UCLA Early Childhood Fellowship Flyer_Final

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Supporting our Kids in Crisis- A Response to the LA Wildfires with Dr. Connie Lillas

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Supporting our Kids in Crisis- A Response to the LA Wildfires with Dr. Connie Lillas

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Supporting our Kids in Crisis- A Response to the LA Wildfires with Dr. Connie Lillas

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IntroDUCKtion to Big Feelings (Bilingual version) 

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IntroDUCKtion to Big Feelings (Bilingual version) 

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App Store link for webpage

1. On the website, upload the image (black or white version) of the Download from Apple – see below images

2. Link the Url (either long version or short)

3. And here is the app icon (Duck art) as an option for inclusion as well

Short or long version of the clickable url link to

https://apps.apple.com/us/app/introducktion-to-big-feelings/id553721733?itscg=30200&itsct=apps_box_link&mttnsubad=553721733

https://apple.co/4gIj5kL

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App Store link for webpage

1. On the website, upload the image (black or white version) of the Download from Apple – see below images

2. Link the Url (either long version or short)

3. And here is the app icon (Duck art) as an option for inclusion as well

Short or long version of the clickable url link to

https://apps.apple.com/us/app/introducktion-to-big-feelings/id553721733?itscg=30200&itsct=apps_box_link&mttnsubad=553721733

https://apple.co/4gIj5kL

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Applications for the 2024–2025 California Infant and Early Childhood Mental Health Consultant Training Program

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Applications for the 2024–2025 California Infant and Early Childhood Mental Health Consultant Training Program

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n collaboration with the California Department of Social Services (CDSS), Child Care and Development Division (CCDD), the California Infant and Early Childhood Mental Health Consultation (IECMHC) Network at WestEd is launching the second cohort of the California Infant and Early Childhood Mental Health (IECMH) Consultant Training Program to build California’s workforce of consultants who provide high-quality, diversity-informed infant and early childhood mental health consultation services in center-and home-based child care and early education settings.

Infant and early childhood mental health consultation is an evidence-based service in which infant and early childhood mental health professionals partner with the adults in young children’s lives to build their capacity to foster healthy social and emotional development and relational health.

The CTP is a nine-month program offering fundamental training in the specialized role of mental health consultation in child care and early education settings. Faculty meet monthly with participants in a highly interactive learning experience. Upon completion of the program, participants will receive a Certificate of Completion in Infant and Early Childhood Mental Health Consultation. Licensed participants may also secure continuing education hours. The California Infant and Early Childhood Mental Health (IECMH) Consultant Training Program (CTP) is offered at no cost to accepted participants.

Who Should Apply?

With the goal of increasing California’s capacity to respond to the mental health needs of young children, their families, and the child care and early education providers who serve them, we invite racially, culturally, and linguistically diverse applicants serving various communities to apply. We are specifically seeking:

·      Practitioners in California currently employed or seeking employment as Infant and Early Childhood Mental Health Consultants serving  child care and early education programs

·      Practitioners who are endorsed through the California Center for Infant-Family and Early Childhood Mental Health

·       Practitioners working in geographically remote and/or traditionally under-served communities

·      Practitioners with specific experience working with tribal communities and family child care home providers

Note: If you are not currently practicing as an Infant and Early Childhood Mental Health Consultant, please contact us to discuss how the CTP Training Program may or may not align with your current or future work/practice before applying.

Applications for the CTP will be accepted June 3 – 21, 2024. View the IECMH Consultant Training Program page for more information, including course objectives, requirements, and timelines. You can also contact us at 1-877-524-2422, extension 6.

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2024 - 2025 IECMH Consultant Training Program Cohort - IECMHC

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Infant and early childhood mental health consultation is an evidence-based service in which early childhood mental health professionals partner with the adults in young children’s lives to build their capacity to foster healthy social and emotional development and relational health. The California Infant and Early Childhood Mental Health (IECMH) Consultant Training Program is designed to ... Read more

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Understanding New Milestones for Infants & Toddlers: Connecting All Kids to Services - Recorded Webinar from the Children's Partnership

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Understanding New Milestones for Infants & Toddlers: Connecting All Kids to Services - Recorded Webinar from the Children's Partnership

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Understanding New Milestones for Infants and Toddlers: Connecting All Kids to Services

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Developmental screenings are an important tool for promoting early childhood development. For many children of color, however, they, too often, fail to receive the evaluations and services for which they are eligible.

Learn about the recent update to CDC developmental milestones and how we can work together to ensure equitable access to child development and early childhood mental health services.

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Racial Disparity in Infant Mental Health: Interview with Dr. Marva Lewis

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Racial Disparity in Infant Mental Health: Interview with Dr. Marva Lewis

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Racial Disparity in Infant Mental Health: Interview with Dr. Marva Lewis

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Play in Early Childhood: The Role of Play in Any Setting

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Play in Early Childhood: The Role of Play in Any Setting

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Center on the Developing Child at Harvard University

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Play in Early Childhood: The Role of Play in Any Setting

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I Am Somebody (Giant Song) | #ComingTogether

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Young, Proud, and Sung-jee: A Children's Book on Fighting Anti-Asian Racism During COVID-10

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Young, Proud, and Sung-jee: A Children's Book on Fighting Anti-Asian Racism During COVID-10

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Young, Proud, and Sung-jee: A Children’s Book on Fighting Anti-Asian Racism During COVID-19

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Tips for Virtual Learning for Young Children

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Tips for Virtual Learning for Young Children

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Equity in Infant and Early Childhood Mental Health Consultation Webinar Series

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Equity in Infant and Early Childhood Mental Health Consultation Webinar Series

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Equity in IECMHC Webinar 1 - How did we get here? ...

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Apr 30, 2020
https://www.iecmhc.org

Equity in IECMHC Webinar 1 - How did we get here?: An overview of the root causes of disparities in child outcomes, and the role of child serving systems.

Explores the historical and societal institution of racism and other forms of bias on the early care and education experiences of children and families from marginalized communities, and identifies ways to address equity, bias, and disparities through an IECMHC framework.


The purpose of the Equity in IECMHC Webinar Series is to promote equity through IECMHC by building awareness of the impact of institutional racism and other forms of bias on the experiences of children and families from marginalized communities and identifying policies and strengthening culturally responsive practices that reduce disparities and improve child outcomes.

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It's never too early to talk with children about race

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It's never too early to talk with children about race

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Infants as young as six months old can recognize differences in skin color. By age two and a half, research has shown, children prefer playmates who are similar in race and gender. And as early as age three, they are forming judgments about people based on racial differences.

What children learn, hear, and witness from family members, friends, and others in their communities about race plays a major role in how they view people who are different from them, according to Yale experts.

Children "identify all kinds of differences quite readily," said Yarrow Dunham, assistant professor of psychology at Yale and director of the Social Cognitive Development Lab. "The critical question is: Which of those differences do they come to think of as important determinants of social identity and social outcomes? They make those decisions by observing the world around them. And here - unfortunately - the world presents them with abundant evidence that race matters."

As a result, it's imperative that parents recognize and talk about racial differences with kids from an early age to prevent racism from taking root, said Yale experts.

"It's important that we tell children about their environment and what's going on in the world," said Dr. Wanjiku Njoroge, a board-certified child psychiatrist and adjunct professor of psychiatry at Yale, whose research focuses on the impact of culture on early infant and childhood development. "Or they will make up their own stories."

This requires that parents who are uncomfortable talking about race confront and overcome that feeling, Dunham said.

"Many white parents are very uncomfortable talking about race," Dunham said. "As a consequence, they do not put in the work to support the emergence of a structural or justice-minded understanding of racial disparities and of racism more generally. As white parents, we have an obligation to put in this work."

Silence is a message

Avoiding conversations about race sends a message that there's something off-limits, and even bad, about racial differences, said Njoroge, who completed four fellowships at Yale and is also an assistant professor at the University of Pennsylvania's Perelman School of Medicine and program director of the Department of Child and Adolescent Psychiatry and Behavioral Sciences at Children's Hospital of Philadelphia.

She recalls a young patient who asked if her skin was so dark because she didn't take baths.

"If you are in communities that are not diverse, you can introduce race through books and through play," she said. "Talk about how there are different genders, different races, languages, and cultures. Tie their questions to education - get out the globe or the map and tell stories."

In the absence of these conversations, she said, silence is powerful: "If they hear nothing about race, they figure out that there's something different about that topic. And that difference can become imbued with negativity."

Start with self-reflection

The words are important, but what's more important is that you are open to talk about this. It's not one conversation, it is many conversations.

Dr. Amalia Londono Tobon

Dr. Amalia Londono Tobon, a board-certified psychiatrist and clinical fellow in the Yale Child Study Center, who collaborates with Njoroge on projects related to race, culture and young children, said different conversations are possible at every stage of a child's development. "Be comfortable with the fact that you don't know everything," she said. "The words are important, but what's more important is that you are open to talk about this. It's not one conversation, it is many conversations. And as kids grow, they have more complex questions."

White parents need to critically examine their own upbringing, she said, to think about how they learned about race, and how they may have acted in ways that revealed bias against black people - crossing the street to avoid a black person, or treating them with distrust. "Think about where you are right now," she said. "What are you reading? What TV shows are you watching? Who are your friends?" All of that, she said, affects the way a child perceives the world.

Avoiding race conversations is privilege

The ability to avoid talking about race is a form of white privilege, the researchers said.

In black families, racial differences, and the history of race relations in America, are conversations that happen organically, at all ages, said Njoroge. "For many African-American families, there is that history of segregation, of 'separate but equal,' woven into the fabric of our experiences."

Njoroge, whose father is Kenyan and mother is African American, recalls growing up in Missouri and taking trips in the summer to visit her maternal grandparents' house in the tiny town of Glenmora, Louisiana. The town had one main road, one movie theater, and two gas stations. At the local movie theater, she said, black people had to sit in a balcony, use a separate entrance, and had separate access to concessions. For children growing up in black families, she said, this experience "leads to questions: Why couldn't you go to the movies? Why couldn't you go to the school in town?"

Njoroge was taught by her mother to always get a receipt when she bought something from a store, no matter how small, in case she was questioned. It's something she does to this day.

The ongoing nationwide protests in the aftermath of the police killing of George Floyd is an opportunity to have conversations with kids about racial differences, white privilege, and systemic racism, Njoroge said.

"This is a moment where you can't ignore the history of the U.S.," she said.

She recommends that parents talk honestly with their children about their own moments of racism - and how they have learned to be better.

"Describe the inequities built into our country," she said.

Recommended resources for talking to kids about race

The following resources were recommended by Dr. Amalia Londono Tobon, clinical fellow of the Yale Child Study Center, and Dr. Wanjiku Njoroge, an adjunct professor at Yale and program director of the Department of Child and Adolescent Psychiatry and Behavioral Sciences at Children's Hospital of Philadelphia, for parents who want to have conversations with their kids about race and racism.

VIDEO

How to talk to kids about racism, protests & injustice: article and video with journalist Sheinelle Jones from the "Today" show.

AUDIO

How white parents can talk about race: NPR's Michel Martin talks to Jennifer Harvey, author of "Raising White Kids: Bringing Up Children in a Racially Unjust America," about how to talk with white kids about racially charged events.

ARTICLES

Racism and violence: how to help kids handle the news: A guide on supporting your kids during scary times from the Child Mind Institute, a nonprofit focused on children's mental health.

Talking to children about racial bias: steps parents can take to confront their own racial bias and talk about racial differences from the American Academy of Pediatrics.

How to talk to kids about race and racism: a comprehensive Parent Toolkit on talking to kids about race and racism from NBC News.

Discussing race with white children, part one: This article from the Yale School of Medicine offers white parents advice for self-reflection as well as media recommendations and other resources to help guide discussion.

BOOKS

Where to find diverse children's books: a guide to blogs and sites where parents can find books featuring diverse characters and highlighting social justice from EmbraceRace, a parent-founded organization to fight systemic racism.

Anti-racism books for kids: books for kids of different ages that celebrate racial diversity and explain how diversity makes us stronger from Books for Littles, an organization that uses picture books to help parents have important conversations about social issues.

Social justice books for teens: a compilation of books for teens exploring how race, class, gender, size, and sexuality affect our lives from the Chicago Public Library.

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It's never too early to talk with children about race

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Infants as young as six months old can recognize differences in skin color. By age two and a half, research has shown, children prefer playmates who are similar in race and gender. And as early as age three, they are forming judgments about people based on racial differences.

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The Black Mamas Matter toolkit is a resource for advocates who are concerned about the health and well-being of black women and girls. It takes a human rights based approach to maternal health, identifying the rights of pregnant and birthing parents and the corresponding role of government to ensure safe and respectful maternal health care for all. First released in June 2016, the toolkit was produced by the Center for Reproductive Rights in partnership with members of the Black Mamas Matter Alliance.

Download the Toolkit Now

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The Black Mamas Matter toolkit is a resource for advocates who are concerned about the health and well-being of black women and girls. It takes a human rights based approach to maternal health, identifying the rights of pregnant and birthing parents and the corresponding role of government to ensure safe and respectful maternal health care [...]

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California Maternal Quality Care Collaborative

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California Maternal Quality Care Collaborative

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Improving Care, Experiences and Outcomes for Black Mothers

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California Birth Equity Collaborative
Improving Care, Experiences and Outcomes for Black Mothers

The California Birth Equity Collaborative is a CMQCC quality improvement initiative to improve birth care, experiences and outcomes for Black mothers and birthing people in California. Our team is comprised of partnerships between CMQCC and participating hospitals and their local communities.

Since 1999, the reported maternal mortality data in California show a persistent 3-4x gap between Black mothers and mothers from all other racial groups. Between 1999 and 2006, maternal mortality rates nearly doubled in California, and CMQCC was founded in 2006 at Stanford University School of Medicine together with the State of California. Since CMQCC's inception, California's maternal mortality rate has declined by 55 percent while the national maternal mortality rate continued to rise. The expectation was that widespread adoption of CMQCC's clinical safety bundles would reduce the gap in the number of maternal deaths among Black women. However, despite the reduction in Black maternal mortality rates, the difference in outcomes for Black mothers compared with all other racial groups has persisted.

Thus, CMQCC's Birth Equity Collaborative presents an opportunity to develop QI tools to promptly evaluate and transform birth care, experiences, and outcomes through the integration of clinical and sociocultural interventions.

Data shows that even in the absence of risk factors such as maternal age over 35 years, lack of health insurance, inadequate or no prenatal care, and less than high school education, the U.S. system of health care is not protecting Black mothers and birthing people from experiencing higher numbers of deaths or life-threatening complications during pregnancy and childbirth.

Increasing evidence points to racism within and across multiple levels, and not race, as a key cause of these birth disparities.

Data also show variations in the maternal outcomes by race across hospitals in California, highlighting opportunities for advancing equity in quality improvement.

With our California Birth Equity Collaborative pilot, CMQCC aims to transform birth care for Black mothers and birthing people in California in partnership with participating pilot hospitals.

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California Birth Equity CollaborativeImproving Care, Experiences and Outcomes for Black MothersThe California Birth Equity Collaborative is a CMQCC quality improvement initiative to improve birth care, experiences and outcomes for Black mothers and birthing people in California. Our team is comprised of partnerships between CMQCC and participating hospitals and their local

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Infographic from the Harvard University Center for the Developing Child

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Center on the Developing Child at Harvard University

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What could our society look like if racial disparities in health and learning outcomes didn't exist? According to extensive studies, the U.S. would save billions in health care costs alone. The value of realizing the potential contributions of so many people around the world who are impaired by-or die from-preventable chronic illnesses is enormous, and the human costs are incalculable.

Advances in science are presenting an increasingly clear picture of how significant adversity in the lives of young children can disrupt the development of the brain and other biological systems. These early disruptions can undermine young children's opportunities to achieve their full potential. And, while they may be invisible to those who do not experience them, there is no doubt that both systemic racism and interpersonal discrimination can lead to chronic stress activation that imposes significant hardships on families raising young children.

It's time to connect these dots. This infographic explains in basic terms how racism in particular gets "under the skin" and affects learning, behavior, and lifelong health. There is much more to say, but by starting with a shared understanding, we can work together toward creative strategies to address these long-standing inequities.

Sources
Panel 1
Forde, A.T., Crookes, D.M., Suglia, S.F., & Demmer, R.T. (2019). The weathering hypothesis as an explanation for racial disparities in health: a systematic review. Annals of Epidemiology, 33, 1-18.e3
Panel 2
Geronimus, A.T., Hicken, M., Keene, D., & Bound, J. (2006). "Weathering" and age patterns of allostatic load scores among blacks and whites in the United States. American Journal of Public Health, 96(5), 826-833.

McEwen, B.S. (1998.) Protective and damaging effects of stress mediators. New England Journal of Medicine, 338(3), 171-9.
Panel 3
Williams, D.R., & Wyatt, R. (2015). Racial Bias in Health Care and Health: Challenges and Opportunities. JAMA 314(6): 555-556.

Williams, D.R., Mohammed, S.A., Leavell, J., & Collins, C. (2010). Race, socioeconomic status and health: Complexities, ongoing challenges and research opportunities. Annals of the New York Academy of Sciences, 1186, 69.

Panel 4
Agency for Healthcare Research and Quality (2019). 2018 National Healthcare Quality and Disparities Report. Rockville, MD. AHRQ Pub. No. 19-0070-EF https://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2018qdr-final-es.pdf

Manuel J. I. (2018). Racial/Ethnic and Gender Disparities in Health Care Use and Access. Health Services Research, 53(3), 1407-1429.
Panel 5
Heard-Garris, N.J., Cale, M., Camaj, L., Hamati, M.C., & Dominguez, T.P. (2018). Transmitting trauma: A systematic review of vicarious racism and child health. Social Science & Medicine, 199, 230-240.

Pachter, L.M., & Coll, C.G. (2009). Racism and child health: a review of the literature and future directions. Journal of Developmental and Behavioral Pediatrics, 30(3), 255-263.

Clark, R., Anderson, N.B., Clark, V.R., & Williams, D.R. (1999). Racism as a stressor for African Americans: A biopsychosocial model. American Psychologist, 54(10), 805- 816.
Panel 6
Trent, M., Dooley, D.G., & Dougé, J. (2019). The impact of racism on child and adolescent health. Pediatrics, 144(2), e20191765.

Williams, D. R., & Cooper, L. A. (2019). Reducing Racial Inequities in Health: Using What We Already Know to Take Action. International Journal of Environmental Research and Public Health, 16(4), 606.
Panel 7
Collins, C., Asante-Muhammed, D., Hoxie, J., & Nieves, E. (2017). The road to zero wealth: How the racial wealth divide is hollowing out America's middle class. Washington, DC: Prosperity Now and Institute for Policy Studies.

Weir, K. (2016). Policing in Black & White. Monitor on Psychology, 47(11). Retrieved from http://www.apa.org/monitor/2016/12/cover-policing
Panel 8
National Scientific Council on the Developing Child. (2020). Connecting the Brain to the Rest of the Body: Early Childhood Development and Lifelong Health Are Deeply Intertwined: Working Paper No. 15. Retrieved from www.developingchild.harvard.edu

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How Racism Can Affect Child Development - Center on the Developing Child at Harvard University

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What could our society look like if racial disparities in health and learning outcomes didn't exist? According to extensive studies, the U.S. would save billions in health care costs alone. The value of realizing the potential contributions of so many people around the world who are impaired by-or die from-preventable chronic illnesses is enormous, and [...]

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What the research says about the impact of media on children under the age of 3

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Babies today are born into a world full of rich human interaction and engaging screen media experiences. This leaves parents with a lot of questions! Are you curious about the role that screen media should play in your child's life? Wondering if screen time is damaging, or if it is just another form of media (like books) that can be used to help children learn?

Screen Sense-our resource series that summarizes the research on screens and children under age three-helps to answer those questions (and more!). If you choose to make screen media a part of your child's life, use tips and recommendations from Screen Sense as a way to harness the potential of technology to enhance learning and development.

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Babies today are born into a world full of rich human interaction and engaging screen media experiences. This leaves parents with a lot of questions! Are you curious about the role that screen media should play in your child's life?

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Eva Marie Shivers -Racial Inequity Interview

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Greater father involvement in infant parenting is beneficial for paternal mental health

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By Anna Sigurdsson, science writer
Fathers who are more involved in the parenting of an infant are less likely to experience depressive symptoms during the first year of parenthood. Time spent with the infant, parenting self-efficacy and material support predict depressive symptoms, and parenting self-efficacy predict risk of clinical depression. These results have important implications for development of interventions to assist fathers in parenting and improve paternal mental health, as well and for the implementation of policies like paid paternal leave.
A father's involvement in the parenting of an infant is associated to a lower risk of experiencing paternal depressive symptoms during the first year of the child's life, according to a study published in the open-access journal Frontiers in Psychiatry. The investigators in the larger study conducted home interviews with 881 low-income ethnically and racially diverse fathers from 5 different sites in the US, one month after the birth of a child and controlling for social and demographic variables, they examined the three parenting indicators: father time spent with the infant, parenting self-efficacy and material support for the infant. They also assessed paternal depressive symptoms at regular intervals (1, 6 and 12 months after birth) using the Edinburgh Postpartum Depression Scale.

The authors found that all three indicators - greater amount of time fathers spent with their new born, parenting self-efficacy and ability to provide material support - predicted lower rates of depressive symptoms in the fathers during the following year. The authors also found that only parenting self-efficacy was associated to a higher risk of clinical depression, with the percentage of fathers with symptoms indicating clinical depression being 10% after 1 month, 15% after 6 months and 12% after 12 months.

"We found that fathers who were more involved with their infants shortly after their birth were less likely to be depressed a year later," says Dr Olajide N. Bamishigbin Jr., Assistant Professor of Psychology at California State University, Long Beach, USA, and first author of the paper. "In our paper, we suggest a few reasons that greater father involvement in parenting would lead to less depression in fathers. For example, fathers who are more involved during infancy may feel more competent as parents and be more satisfied in their role as parents over time, and this could contribute to lower depressive symptoms."

Father Involvement in Infant Parenting in an Ethnically Diverse Community Sample: Predicting Paternal Depressive Symptoms
► Read original article
► Download original article (pdf)

The present study is one of the first to focus on a larger community sample of low-income fathers from diverse racial/ethnic backgrounds and is paving the way for more research into specifically paternal well-being after the birth of a child. While previous research has focused on paternal involvement as an outcome or a predictor of mother- and child focused outcomes, this is the first study to examine the link between early paternal involvement with the infant and later paternal depressive symptoms during the first year after a child is born.

"Family researchers are recognizing, more and more, the vital roles fathers play in the lives of their children and the functioning of the entire family unit," said Bamishigbin. "As researchers who care deeply about paternal health, we are excited to be a part of this growing field."

The findings of this study have important implications for future research on the contributors to father involvement, the effects of early involvement, the link between parental self-efficacy and depression and the relationship between paternal and maternal depression. The authors emphasise that a deeper understanding of these and related variables might be helpful in designing interventions for expecting fathers and shaping public policies.

"In our study, greater early involvement was related to less depression later on. This is very important because, it suggests that, if fathers are involved with their infants early and often, their mental health, and the health of the entire family unit, may fare better," said Bamishigbin. "This is why we suggest that paid paternal leave policies which can allow fathers the opportunity to be more involved with their kids and gain confidence as a parent early on in their lives, without having to worry about their economic security, and may help allow fathers more opportunities to be involved with their kids and be part of shaping healthier and thriving future generations. In turn, this may improve the well-being of the entire family."

Image: Shutterstock

Original article: Father Involvement in Infant Parenting in an Ethnically Diverse Community Sample: Predicting Paternal Depressive Symptoms

REPUBLISHING GUIDELINES: Open access and sharing research is part of Frontiers' mission. Unless otherwise noted, you can republish articles posted in the Frontiers news blog - as long as you include a link back to the original research. Selling the articles is not allowed.

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Greater father involvement in infant parenting is beneficial for paternal mental health

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By Anna Sigurdsson, science writer Fathers who are more involved in the parenting of an infant are less likely to experience depressive symptoms during the first year of parenthood. Time spent with the infant, parenting self-efficacy and material support predict depressive symptoms, and parenting self-efficacy predict risk of clinical depression.

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Dr. Gilkerson speaks about she has adapted the FAN Model to address social justice issues

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Addressing Bias in Infant and Toddler Programs

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Addressing Bias in Infant and Toddler Programs

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The First Step for Addressing Bias in Infant and Toddler Programs

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Awareness of beliefs and biases is important for growing as intentional teachers

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Internalized Racism

Internalized racism is the situation that occurs in a racist system when a racial group oppressed by racism supports the supremacy and dominance of the dominating group by maintaining or participating in the set of attitudes, behaviors, social structures and ideologies that undergird the dominating group's power. It involves four essential and interconnected elements:

D ec isi on-m ak i ng - Due to racism, people of color do not have the ultimate decision-making power over the decisions that control our lives and resources. As a result, on a personal level, we may think white people know more about what needs to be done for us than we do. On an interpersonal level, we may not support each other's authority and power - especially if it is in opposition to the dominating racial group. Structurally, there is a system in place that rewards people of color who support white supremacy and power and coerces or punishes those who do not.

Re s ou r ces - Resources, broadly defined (e.g., money, time, etc.), are unequally in the hands and under the control of white people. Internalized racism is the system in place that makes it difficult for people of color to get access to resources for our own communities and to control the resources of our community. We learn to believe that serving and using resources for ourselves and our particular community is not serving "everybody."

S t anda r d s - With internalized racism, the standards for what is appropriate or "normal" that people of color accept are white people's or Eurocentric standards. We have difficulty naming, communicating and living up to our deepest standards and values, and holding ourselves and each other accountable to them.

Na m i n g the problem - There is a system in place that misnames the problem of racism as a problem of or caused by people of color and blames the disease - emotional, economic, political, etc., on people of color. With internalized racism, people of color might, for example, believe we are more violent than white people and not consider state-sanctioned political violence or the hidden or privatized violence of white people and the systems they put in place and support.

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In talking about issues of race, a common vocabulary is essential to avoid misunderstandings and misinterpretations. Words often have different meanings to different people, based on their experiences. The purpose of this glossary, which is a work in progress, is to help avoid such misunderstandings.

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Racial Equity Tools offers tools, research, tips, curricula, and ideas for people who want to increase their own understanding and to help those working for racial justice at every level -in systems, organizations, communities, and the culture at large.

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Using Your Power as a Parent to Support Children Aged Two to Five

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Television and radio news, social media and neighborhood conversations are sometimes dominated by violence and conflict stemming from racism. Many adults across our nation continue to try to make sense what is happening in our world today, and parents face the added struggle of thinking through how to talk about racism and violence with children. These stories, and adults' reactions to them, are being seen and felt by children, including babies and toddlers. While we hope that they don't know what's going on, even young babies pick up on and react to the emotions of those they depend on.

This resource provides thoughts and guidelines for talking about these complex issues of racism and equity in age-appropriate ways with children aged two to five years of age. These are difficult and uncomfortable discussions for which there is no recipe. You will know how to adapt these ideas in a way that reflects your unique situation and the individual needs of your child. You might also find it helpful to seek input from your family and trusted sources like religious and other community leaders.

Guidelines for Talking about Racism and Violence

1) Limit access to media images and discussions about frightening events. Young children are taking in everything they see and hear, and are working to understand what it all means. They are careful observers, closely attuned to and affected by the events happening around them. But, between ages two and five, children lack the reasoning skills to make sense of complex issues. Parents have an important role in helping young children understand, manage and process what they have seen and feel. By limiting your child's access to screens and keeping her away from adult conversations (including your own very natural worries about your child's safety), you can protect her from scary events that she has no way of understanding yet.

2) Stay calm when answering, as hard as that may be. This can lessen children's fear and help them to feel safe. There will naturally be times when you just can't be totally calm. If you are upset, you can explain in simple language why: "I'm crying because I see that man is hurt. I feel so sad for him and his family. I'm sad and that's why I'm crying."

Children are very sensitive and know when there are topics mommy or daddy don't want to discuss. Even babies as young as 3-5 months old can sense if you are upset or sad! So, as much as you can, try not to expose young children (even babies) to your anxiety.

3) Answer your child's questions using simple language that they understand. Let your child know that he can come to you with any questions he has and that you are not afraid of talking about difficult issues. This makes it more likely children will turn to you as a resource, and not struggle alone with their questions.

If children ask questions about events they have seen or heard adults talk about, parents can provide short answers responding to the child's specific question. For example, a child might ask: "Why is he hitting that man?" You can answer: "He is afraid of him and angry, and has lost control. He is hurting the man and that is not ok." Then pause and wait to see if your child has another question.

If your child stops asking questions, then stop providing details-even if you haven't fully explained the situation. Children decide what and how much they can take in at a given time.

Following your child's lead is a good strategy since it gives you information about what your child is thinking about, worried about, and what he is trying to understand.

4) Tailor how you talk with your child based on his age and stage of development. When young children witness events that involve people that "look like me", these events command great attention and are meaningful to young children. It is natural for them to have questions. Depending on what your child asks and her level of understanding, she may be ready to talk about differences, equality and racism in simple, age-appropriate ways. For example, between ages four and five, children understand the concept of fairness more than ever before. For preschoolers, this means that discussions about racism can be framed as unfair behavior because people see differences in skin color as better or worse. Explaining this word and idea to your child is a starting point. Sharing storybooks on the topic is a good idea as well.

Ideas for Answering Difficult Questions

Here are some ideas for how to approach challenging and complex topics about racism, safety, and police violence are below-although it's important to modify messages for your individual child's age and stage.

Are police officers good guys or bad guys?
The job of police officers is to protect people. Police officers are just people. And there are some people who are good and kind, and some people who are not. Some police officers are good, helpful men and women. And some are not. But I believe that most police officers want to keep us safe (if you do believe this).

Why are people being mean and hurting others?
These people don't like anyone who is different from them. They only like people who look like them. And they want everyone to think the same way they do. It can feel sad and scary to see them being so mean. I'm glad that so many kind and caring people are saying, "Hey, it's not ok to be mean and hurtful to others."
If your child has seen footage of people being injured and asks about it: Sometimes people get so stressed that they do things they should not do. It is never okay to hurt people because we disagree with them. The person who was hurt has gone to the doctor for help.

What is going to happen?
Many good people are really upset about this. I don't know what is going to happen, but we're together. I love you and I will keep you safe.

Is Daddy safe? Is Mommy safe?
Grown-ups can take care of themselves and keep themselves safe. You don't have to worry. Mommy/Daddy always try to be safe in everything we do. Remember how we always look both ways before we cross the street? That is one way we stay safe. And there are many other ways that grown-ups stay safe too.

Am I safe?
Mommy/Daddy will keep you safe. That is our job. Your job is to be a kid and have fun. We love you and we will keep you safe. There are many people-black people, white people, and kind police officers-who are also working to make sure you are safe.

Police Violence:
Some police officers see an African-American person and think they are going to make trouble because of their skin color. That is wrong and there are many people trying to change that. The job of a police officer is to keep all people safe, no matter what their skin color is.

[If your child is looking for additional information:] Sometimes people get so stressed that they do things they should not do. [Consider giving an example that your child might be able to relate to: Remember how I yelled when I lost my wallet?] That happens to police officers too and sometimes it means they act badly and are too rough and hurt people.

If you don't know the answer to your child's question, that's okay. These are complex issues. It builds your child's trust in you when you are open about not always knowing the answer.

Your child may be upset or confused following these challenging discussions. Watch for these signs and respond with extra support, hugs, and time together so that your child feels secure. Point out positive, supportive members of her community (family members, religious leaders, teachers, home visitors, physicians and others) who also care for and nurture your child. Let children know they have a network of people who are there for them.

How to Help Your Child Respond to Traumatic or Scary Experiences

If your young child is a witness to violence or has seen his/her caregiver in tense or frightening interactions with the police or others, watch for behaviors like:

Increased clinginess, crying, and whining

Greater fear of separation from parents or primary guardian

Increase in aggressive behavior

More withdrawn and harder to engage

Play that acts out scary events

Changes in sleeping and eating patterns

More easily frustrated and harder to comfort

A return to earlier behaviors, like frequent night-time wakings, toileting accidents, or thumb sucking

These are signs that a child is struggling with making sense of a scary or traumatic experience and needs additional support. Reach out to your child's health care provider or to a counselor with experience with young children to plan how to move forward.

What You Can Do

Create an environment of safety and consistency. Children who have been exposed to traumatic images or experiences benefit from an environment that is safe and predictable. Regular daily routines (like at mealtime, bath-time, hair-combing, and bed-time) help children trust and anticipate what will come next. Remember that these routines are as important to babies as they are for older children for feeling safe and secure. Maintaining a child's school or child care attendance is also helpful, since this is a familiar routine that offers a sense of consistency and normalcy. If you can, try to limit changes (like switching preschool/child care providers) during this time. For children having a hard time with transitions, offer a comfort object like a special blanket or stuffed animal, or even a favorite action figure to hold.

Harness the power of positive touch. If your child is having a hard time, offer extra cuddles or add a massage to your child's daily bedtime routine. Deep pressure touch can help some children feel more 'together' and regulated.

Build children up. Point out your child's strengths and abilities. Give him opportunities to experience successes and achievements. Celebrate these milestones together. A strong sense of self and family begins with your child's relationship with you.

Use the daily routine of combing hair to connect with your young child. As a parent you can make this routine a relaxed, predictable time to talk, touch, and listen to your child. Sitting on your lap or snugly between your legs allows your baby or young child to be physically connected to you as you carry out this routine. The soothing and repetitive gentle hair-brushing of a boy or girl communicates warmth, caring, and a sense of security. Allowing your child to participate in the task (choosing bows or the number of braids) also reinforces a sense of control.

Tell the story of your family. Use stories to communicate the strength, resilience, courage, humor, and intelligence of your family members. You can also highlight different themes like safety, courage, and adults providing protection. Storytelling is an ideal way to communicate your values, rich heritage, and traditions, and build a sense of family and cultural identity and pride.

Make time for laughter and fun. Let your child see you laugh out loud while telling a story or going about your daily routines. Laugh together as a family. At the same time, be honest with your emotions. If the current tragedies are triggering memories of your own losses, be mindful of your feelings and seek support for yourself.

Protecting Children While We Work for Social Justice

As our country grapples with the complex issues of race and violence, you have the ability to build a safe haven of love, joy, hope and protection within the relationship you develop with your child. Children dream, children play, and children have hope-because of all you do.

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Racism and Violence: Using Your Power as a Parent to Support Children Aged Two to Five

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Television and radio news, social media and neighborhood conversations are sometimes dominated by violence and conflict stemming from racism. Many adults across our nation continue to try to make sense what is happening in our world today, and parents face the added struggle of thinking through how to talk about racism and violence with children.

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Teaching Children About Race- Conversation with Dr. Wanjiku Njoroge

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Teaching Children About Race Wanjiku Njoroge

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Author, Manuela Molina created this book for children under the age of 7 years to learn about the COVID-19 virus. The book is offered in several languages, including English, Spanish, Italiano, Portugûes, French, Polish, German, Turkish, Russian, Arabic and more.

The Mind Heart

Brazelton Touchpoints Center

Family Connections

Breastfeeding

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Centers for Disease Control and Prevention

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TTAC Webinar: Supporting Families and Caregivers of Infants and Young Children Affected by the COVID-19 Pandemic

Educational Resources for Students with Sensory Processing Disorders

The Sensory Projects

Educational Resources for Students with Learning Challenges:

Resources for the Smart Kids Community

Handwashing

Sensory considerations for washing hands

Healthy Children:  American Academy of Pediatrics

Information for families

Tips-for-Coping-with-a-New-Baby During COVID-19

Caring-for-Children-in-Foster-Care-During-COVID-19

Co-Parenting Through COVID-19: Putting Your Children First

Informed Immigrant

California Based Resources for Immigrants during the coronavirus crisis

National Alliance on Mental Illness

NAMI Family Support Group

National Association of School Psychologists

Countering COVID-19 (Coronavirus) Stigma and Racism: Tips for Parents and Caregivers

National Autism Association

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National Child Traumatic Stress Network

Supporting Children During Coronavirus (COVID19)

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8 expert tips to help families stay regulated

Sesame Street

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Together: St. Jude Children’s Research Hospital

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World Association of Infant Mental Health

COVID-19 Resources

ZERO TO THREE resources: Parenting during the COVID-19 shelter in place

Young Children at Home during the COVID-19 Outbreak: The Importance of Self-Care

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ACES Connection

10 Ways to Avoid ACEs (During the Pandemic)

Alliance for the Advancement of Infant Mental Health

Resources for Professionals and Parents during COVID-19 Crisis

Telehealth Service in Infant Mental Health Home Visiting

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During a Global Health Pandemic, It's More Important Than Ever to Protect Black Mothers

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During the COVID-19 pandemic, telehealth can help connect home visiting services to families

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Screening for Adverse Childhood Experiences (ACEs) is proliferating in California. In this article from the newsletter of the World Association for Infant Mental Health, the authors review the available studies on the use of such screeners by prenatal and primary care medical professionals. They provide summaries of the perspectives of both providers and patients and outline perceived benefits and concerns around screening.

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The negative consequences of adverse childhood experiences (ACEs) on the physical and mental health of infants and young children has been well-established. In order to reduce the potential effects of these stressful events, inquiring about ACEs in pregnant women, infants, and young children has been identified as an important avenue for prevention. As such, there has been an impetus to use questionnaires asking about ACEs in both the prenatal and pediatric primary care settings. Although the assessment and identification of childhood adversity may be a first step in mitigating poor health outcomes associated with exposure to ACEs, concerns about the potential for discomfort in being asked to report ACEs, lack of trauma-informed training available to healthcare providers, low availability of resources for individuals with high ACEs, and feasibility of asking such questions, have been raised with regard to obtaining ACE histories in primary care settings. The overarching goal of this narrative review was to summarize the existing literature on ACEs history taking in the healthcare setting for pregnant women and children under the age of 6 years. The current review had three main research objectives: 1) to summarize research on parent perspectives on the use of an ACEs-related questionnaire in the prenatal and primary care setting, 2) to summarize research on the perspectives of healthcare providers using an ACEs related questionnaire with patients in pregnancy and under the age of 6, and 3) to identify gaps in the current literature and provide recommendations for future research.

Over the last two decades, there has been a fundamental shift in the understanding of the origins of health and disease across the lifespan: adverse childhood experiences (ACEs) can initiate a cascade of events that may lead to negative consequences for an individual's physical and mental health. Adverse childhood experiences (ACEs) include stressful or traumatic events such as abuse, neglect, and household dysfunction, that occur before the age of 18. The initial ACE study found that exposure to adversity is common with 65% of adults having experienced at least one ACE in childhood and 12% of adults experiencing 4 or more ACEs. They also found a dose-response association between ACEs and health difficulties: as ACEs increase, so too does the consequential effect on health (Felitti et al., 1998).

Although the medical field was revolutionized by this conceptualization of determinants of health and disease in adulthood, research in the fields of infant mental health and developmental psychopathology have long demonstrated the detrimental effect of early adversity (Cicchetti & Toth, 2015; Rutter, 1977). Specifically, exposure to adversity in early childhood has been linked to alterations in the developing brain that have consequences across domains of cognitive, behavioural, social, and emotional functioning (Shonkoff et al., 2012). More recently, the intergenerational transmission of adversity has been demonstrated, whereby parents with high levels of childhood adversity are more likely to have children who also experience adversity (Madigan et al., 2019), as well as developmental difficulties, child mental health disorders, and poor physical health (Choi et al., 2017; Folger et al., 2018; Madigan, Wade, Plamondon, Maguire, & Jenkins, 2017; Racine, Plamondon, Madigan, McDonald, & Tough, 2018). This transmission is hypothesized to occur via biological embedding as well as through environment experiences and exposures (Buss et al., 2017; Racine, Plamondon, et al., 2018). Given that pregnancy and early childhood are sensitive periods for experiencing adversity and its intergenerational transmission, identifying ACEs during these periods has been highlighted as a potential step in preventing the cascade of developmental issues characterized by high ACE scores (Garner et al., 2012; Hudziak, 2018).

In response to this research evidence, prenatal and pediatric clinics across North America and abroad have started to implement routine ACE history-taking to identify both children and their parents who may be at risk of poor health outcomes. Despite the adoption of ACEs history taking as a preventative measure, concerns related to this widespread implementation exist, most notably in relation to potential distress or discomfort for families, the lack of evidence-based treatments specifically tailored for families with high ACE scores, and the availability of resources and trauma training (Finkelhor, 2018; McLennan et al., 2019). Furthermore, there remains a lack of consensus on what adverse experiences should be included as items within the questionnaire (Lacey & Minnis, 2019). Lastly, little is known about whether asking parents about their child's ACEs as well as their own leads to any tangible benefits or adverse events such as distress and discomfort. A summary of the perspectives of parents and healthcare providers in studies that have implemented ACE history taking is needed to inform practice and future research directions.

To our knowledge, there is no overview of how ACEs questionnaires are used in the prenatal and pediatric setting, and how feasible and acceptable this practice is to families and care providers. Therefore, the purpose of this narrative review was to understand the implications of asking about ACEs within these primary care settings. The three main objectives that guided this review were as follows: 1) to summarize research on parent perspectives on the use of the ACEs questionnaire in the prenatal and primary care setting, 2) to summarize research on the perspectives of healthcare providers using the ACEs questionnaire with patients in pregnancy and under the age of 6, and 3) to identify gaps in the current literature and provide recommendations for future research. The synthesis of information surrounding ACE history taking will provide tangible recommendations to practitioners who use the ACEs questionnaire, and inform clinical practice guidelines related to identifying child and parent ACEs in primary care.

A narrative review, as defined by Bryman (2012), served as the methodological guiding tool for this review. A narrative review was selected as outcomes were not consistently reported across studies and could not be easily extracted or analysed through a meta-analysis. A systematic approach to the literature search was conducted to allow for a comprehensive search and to increase the validity of findings (Bryman, 2012; Haddaway, Woodcock, Macura, & Collins, 2015).

To identify relevant articles, searches were conducted in January-February 2019 in the databases MEDLINE, PsycINFO, and CINAHL with no restrictions or filters enabled in the search. The search strategy was developed in collaboration with a Health Sciences librarian and included a combination of MeSH headings and search terms. ACEs were searched as Adverse childhood* and combined with terms related to "healthcare setting" and "screening". A cited reference search was also conducted of key articles that were previously identified.

A total of 1,447 studies were initially identified, and primary studies were included if they: 1) asked parents about two or more categories of ACEs as defined by Felitti et al. (1998); and 2) reported on one of the following outcomes: provider outcomes, parent/child outcomes, and feasibility. Studies were excluded if they were conference abstracts and review articles, and if the topic was unrelated (i.e., not in a pediatric or prenatal setting). Furthermore, studies were only included if parents were asked about their own ACEs or the ACEs of a child who was under the age of 6. After abstract reviews and full-text article review of 77 studies, 9 articles were deemed to meet inclusion criteria for the narrative review (see Figure 1 for a detailed flow diagram of the review process).

Study Characteristics

Of the 9 studies that met inclusion criteria, one study examined healthcare provider perspectives of ACE history taking, three studies provided parent perspectives, and the remaining 5 studies provided perspectives from both healthcare providers and parents. The majority of the studies provided outcomes on ACE history taking in pediatric care facilities (n=6), while the others provided perspectives in either a prenatal care setting (n=1), a primary care setting (n=1), or a mixture of both primary and pediatric care (n=1). With regards to the types of ACE history obtained, 4 studies obtained a parental report of their child's ACEs, 3 studies obtained a report of parental ACEs only, and 2 studies obtained both child and parent ACEs. The majority of studies were conducted in the USA (n=8), while 1 was conducted in Australia. A description of the study characteristics can be found in Table 1.

Outcomes of obtaining an ACE history were identified from the included studies and were divided into two main categories: parent perspectives and healthcare provider perspectives. A summary of the results can be found in Table 2. Parent outcomes included parent comfort and perceived benefits of providing an ACE history. Healthcare provider outcomes included healthcare provider comfort, perceived benefits of history-taking practices, concerns, resource use and availability, and trauma-informed training. Healthcare providers also provided information on the feasibility of ACE history-taking such as the time required and the type of questionnaire used. Descriptive data were reported when provided by the study authors.

Parent Perspectives

Parent Comfort

Six studies provide information on parent comfort with being asked about their child's ACEs or their own ACE history (Conn et al., 2018; Eismann, Theuerling, Maguire, Hente, & Shapiro, 2019; Feigelman, Dubowitz, Lane, Grube, & Kim, 2011; Flanagan et al., 2018; Koita et al., 2018; Nguyen et al., 2019; Selvaraj et al., 2019). One study reported that "only a small handful of caregivers" refused to complete the questionnaire or discuss results, although an exact percentage was not provided (Eismann et al., 2019), while another study reported that 5% of parents (35 out of 660) declined to complete the ACEs questionnaire when asked (Nguyen et al., 2019). Two other studies reported that the majority of patients (85-86%) wanted ACE history taking to continue (Flanagan et al., 2018; Selvaraj et al., 2019). In contrast, Koita et al. (2018) reported that 50% of parents who were asked about their children's ACEs experienced discomfort, as items generated emotional responses of parents' past experiences as children. However, patients still reported gratitude about being asked about adversity, and recognized the importance of being asked (Koita et al., 2018).

Of the four studies that asked about parental ACEs, there were mixed findings regarding parent comfort with reporting on their own ACEs (Conn et al., 2018; Flanagan et al., 2018; Gillespie & Folger, 2017; Selvaraj et al., 2019). Two studies found that parents were more comfortable reporting on their children's ACEs than their own (Conn et al., 2018; Selvaraj et al., 2019). However, two other studies reported that the majority of parents (e.g., 62.6% in Gillespie & Folger, 2017) were comfortable with being asked about their own ACEs (Flanagan et al., 2018; Gillespie & Folger, 2017), were grateful to have been asked about adversity (Gillespie & Folger, 2017), and gave little resistance to providers (Gillespie & Folger, 2017). One study found that parent comfort with being asked about ACEs was moderated by patient ACE scores, with a greater majority of parents with low ACE scores (76.3%) reporting being comfortable with answering questions about ACEs, compared to parents with high ACE scores (34.9%) (Flanagan et al., 2018).

Although not a direct measure of parent comfort, one study reported that parent completion of ACE questionnaires differed by location within the facility, and timepoint when the ACEs history was obtained (Nguyen et al., 2019). The aforementioned study reported that 9.3% more parents completed ACEs questionnaires when asked in an examination room, in comparison to an outpatient waiting room. Furthermore, the study also reported that parents asked in the prenatal period may have been more comfortable answering questions regarding their ACE history in an outpatient setting, in comparison to parents in the postpartum period who were asked in an inpatient setting. Whether the time period or location impacted the comfort in reporting is unknown.

Perceived Benefits

Of the five studies that asked about parental ACEs, one study reported that obtaining an ACE history contributed to mothers feeling better understood by healthcare providers (Flanagan et al., 2018), and in another, improved satisfaction by parents was reported (Feigelman et al., 2011). Two studies reported that ACE history taking resulted in patients viewing their care provider as a resource (Conn et al., 2018; Selvaraj et al., 2019). Two studies also reported that patients recognized the importance of ACE history taking as it made them want to learn more about ACEs, resilience, and parenting (Conn et al., 2018; Gillespie & Folger, 2017).

Healthcare Provider Perspectives

Healthcare Provider Comfort

All four studies that reported on healthcare provider comfort asking about ACEs found that the majority of healthcare providers were comfortable asking about and discussing ACEs with patients (Eismann et al., 2019; Flanagan et al., 2018; Koita et al., 2018). One study reported that provider comfort increased with practice (Flanagan et al., 2018), while two others reported provider comfort increased with training (Eismann et al., 2019; Feigelman et al., 2011). Overall, the majority of healthcare providers were comfortable with asking about ACEs.

Perceived Benefits

Five studies reported on healthcare provider perceived benefits to ACE history taking (Eismann et al., 2019; Feigelman et al., 2011; Flanagan et al., 2018; Gillespie & Folger, 2017; Wickramasinghe, Raman, Garg, Jain, & Hurwitz, 2019). Providers found that asking about ACEs led to more understanding and trusting relationships with patients, and new conversations that allowed providers to support patients in new ways (Eismann et al., 2019; Gillespie & Folger, 2017). Providers saw patient ACEs history as valuable (Gillespie & Folger, 2017; Wickramasinghe et al., 2019) and wanted to continue the practice of asking about them (Feigelman et al., 2011; Flanagan et al., 2018; Wickramasinghe et al., 2019).

History-Taking Practices

Four studies reported on current history taking practices for asking parents about child ACEs (Eismann et al., 2019; Feigelman et al., 2011; Gillespie & Folger, 2017; Wickramasinghe et al., 2019). Three studies (Eismann et al., 2019; Gillespie & Folger, 2017; Koita et al., 2018) that undertook history taking with underprivileged populations asked about additional factors outside the original ACEs questionnaire such as food insecurity (Eismann et al., 2019) or neighbourhood violence (Eismann et al., 2019; Gillespie & Folger, 2017; Koita et al., 2018). One study reported high rates of ACE history taking (all 8 providers in the practice) because of the high instances of trauma in the population (Wickramasinghe et al., 2019). Overall, few providers asked about household dysfunction such as exposure to caregiver mental illness, caregiver substance use, or exposure to domestic violence, and providers were more likely to ask about ACEs if they worked with high-risk populations or had prior knowledge about the effect of ACEs on health.

Healthcare Provider Concerns

Four studies reported on healthcare provider concerns about ACE history taking (Eismann et al., 2019; Flanagan et al., 2018; Gillespie & Folger, 2017; Koita et al., 2018). Overall, the three major provider concerns about asking about ACEs were resource availability, lack of trauma training, and the increased time asking about ACEs would add to patient visits.

Three studies reported that providers were concerned that there were limited resources available to support patients with elevated ACEs (Eismann et al., 2019; Gillespie & Folger, 2017; Koita et al., 2018). Providers from Eismann et al. (2019) also reported being concerned about not knowing enough about resources in the community to assist caregivers. Providers from Flanagan et al. (2018) suggested that resources should be in place prior to implementing routinely asking about ACEs. Three studies identified a lack of knowledge on how to deal with trauma as a major concern, particularly with not knowing how to respond to patients with high ACE scores (Eismann et al., 2019; Flanagan et al., 2018; Gillespie & Folger, 2017). Gillespie and Folger (2017) reported that providers were particularly concerned about triggering an emotional response when asking about parental ACEs. Providers from Eismann et al. (2019) were concerned about offending parents when asking about their child's exposure to parental mental health, substance abuse, or domestic violence.

Three studies reported concerns about the extra time asking about ACEs would add to patient visits (Eismann et al., 2019; Gillespie & Folger, 2017; Koita et al., 2018). Providers from Eismann et al. (2019) reported that they thought asking about ACEs was worth the extra time, but already had pre-existing time pressures to consider. Gillespie and Folger (2017) reported an initial concern about timing prior to when they started asking about ACEs, and this remained a concern in the post-study interview.

Resource Use and Availability

Five studies reported on resources available in the primary care setting. Four of these five studies reported that social workers or counselling services were available within the medical practices, which were either provided by the study authors or were existing beforehand (Eismann et al., 2019; Feigelman et al., 2011; Flanagan et al., 2018; Selvaraj et al., 2019). All four studies reported using their available resources when needed. One study that had social workers and community health workers on site reported that having these personnel onsite as resources was helpful (Eismann et al., 2019). Resources were not provided or available in one study as they were not reported to be needed (Gillespie & Folger, 2017). Overall, most practices had an integration of social services in preparation for ACE history taking and resources were typically used for children's ACEs rather than parent ACEs.

Trauma-Informed Training

Three studies reported that providers received training before they started asking about ACEs (Eismann et al., 2019; Feigelman et al., 2011; Flanagan et al., 2018). Training ranged from 2-8 hours (mean=6 hours), and training procedures included an introduction to trauma-informed care, information on resources in the community, and the health effects of ACEs (Eismann et al., 2019; Feigelman et al., 2011; Flanagan et al., 2018). Two studies reported that training increased provider comfort with asking about ACEs and confidence in their ability to help patients (Eismann et al., 2019; Feigelman et al., 2011; Flanagan et al., 2018). One study found that after receiving training, physicians were more inclined to ask their patients about ACEs (Feigelman et al., 2011). In sum, more training was associated with higher comfort of healthcare providers and increased likelihood of asking about ACEs.

Timing

Three studies reported on the time it took to ask about ACEs (Eismann et al., 2019; Gillespie & Folger, 2017; Wickramasinghe et al., 2019). All studies used different tools to ask about ACEs, each with varied questions of varying lengths. For the two studies that asked about child ACEs, the 15-item Safe Environment for Every Child (SEEK) was used in one, and in the other the 14-item ACE questionnaire was used (Wickramasinghe et al., 2019). The third study asked about ACEs in parents, and used both the 10-item and the 14-item ACE questionnaire (Gillespie & Folger, 2017). However, all three studies found that asking about ACEs only added 1-5 minutes to the visit with each parent. One study that did not report timing did however report that interviews with high ACE patients were longer than interviews with low ACE patients (Flanagan et al., 2018). Providers from Eismann et al. (2019) reported that they thought the extra time added to the visit due to ACE interviews were worth it.

Questionnaire Type

Studies varied in the way they asked about ACEs. In addition to the 15-item SEEK questionnaire (Eismann et al., 2019), the 10-item ACE questionnaire (Gillespie & Folger, 2017) and the 14-item ACE questionnaire (Gillespie & Folger, 2017; Wickramasinghe et al., 2019), one study used the 11-item Behavioural Risk Factor Surveillance System Questionnaire (Flanagan et al., 2018) to screen for ACEs, and two studies (Koita et al., 2018; Selvaraj et al., 2019) created their own tool to identify ACEs by combining aspects from the original ACE questionnaire (Felitti et al., 1998) and other social factors. Furthermore, studies differed in the way they used their questionnaire. For instance, one study paired identified ACEs along with resilience factors, which providers found beneficial (Flanagan et al., 2018). Another study trialled both an item-level response questionnaire and an aggregate-level response questionnaire, and found that an aggregate-level response led to higher ACE identification (Gillespie & Folger, 2017).

With the goal of mitigating the effect of ACEs on infant and maternal mental health and well-being there has been a rapid implementation of ACE history taking in prenatal and pediatric primary care settings. However, there are concerns that this practice may be premature due to the lack of evaluation of potential harms, the lack of targeted interventions for individuals with high ACEs, and challenges with regards to what ACE items should be asked about (Finkelhor, 2018; McLennan et al., 2019). Thus, we conducted a narrative review to summarize the existing literature on parent and healthcare provider perspectives on ACE history-taking within the primary care setting as well as identify implications for clinical practice and directions for future research. Three important findings emerged from the current review: 1) a large proportion of parents (up to 50%) experienced discomfort from being asked about ACEs, particularly parents with high ACEs, 2) trauma-informed training and adopting a trauma-informed approach is needed prior to implementing an ACE history-taking strategy within a clinic or organization (Racine, Killam, & Madigan, 2019), and 3) the availability of resources for patients and families who are asked about ACEs and need additional support is critical. Clinical implications of these findings for the practice of infant mental health as well as areas where more work and evidence are needed are discussed below.

Across the reviewed studies there was variability in the level of comfort parents experienced when reporting on ACEs in the primary care setting. While some parents reported feeling comfortable providing a report, other studies demonstrated that half of parents experienced discomfort when reporting on their family history of adversity (Koita et al., 2018). Furthermore, comfort for providing a report was influenced by the parent's ACE score and the location the questionnaire was given, as parents generally felt more comfortable reporting on their child's ACEs than their own, and were more likely to report their ACEs history in a private examination room in comparison to clinic waiting rooms. These findings suggest that healthcare providers should be mindful of the potential discomfort parents may experience when reporting on their histories of child adversity and use trauma-informed approaches that minimize re-traumatization (SAMHSA, 2014). For example, ensuring a safe and private clinic environment, as well as ensuring staff are aware of the wide impact of trauma are needed. There are also several strategies that could be used within primary care practice that could help reduce parent discomfort and distress. For example, using an aggregate-level ACEs score rather than asking about specific adversity experiences may help reduce discomfort and increase privacy (Gillespie & Folger, 2017). Finally, health organizations and clinics should consider whether asking about ACEs is appropriate in their setting and whether the information is needed or has the potential to improve the outcomes of infants and young children in their practice. For example, will obtaining this information change the approach to care or have the potential to improve outcomes? The potential benefits of ACEs history taking in clinical practice should be weighed against the potential harms, such as parent discomfort.

Healthcare providers identified that trauma-informed training was integral to knowing how to ask and respond when obtaining an ACE history. Across studies in the current review, healthcare providers varied in the training they received on ACEs, however, a consistent concern that was identified was how to respond to patients with high ACE scores. Training in trauma-informed approaches to patient-care was found to improve healthcare provider comfort in asking about ACE. Thus, trauma-informed training should be required by all staff to successfully meet the needs of complex families. Components of a trauma-informed training program should provide information on the impacts of ACEs on health, instructions on how to sensitively respond to individuals who have experienced trauma, and guidance on how to use and incorporate community resources (SAMHSA, 2014). Future research is needed to evaluate how using trauma-informed training approaches may be associated with parent-child health outcomes.

A third important finding identified by the current review is the importance of having resources available for patients to access if they are identified as needing support following an ACE history taking. Studies in our review demonstrated that the presence of mental health personnel, such as social workers, was not only feasible but also already present in several studies. Healthcare providers generally reported that these additional resources were helpful for addressing ACEs. Pediatricians interviewed in a study conducted by Bright, Thompson, Esernio-Jenssen, Alford, and Shenkman (2015) suggested that the use of a multidisciplinary team integrated with community supports such as social workers, teachers, and psychologists was beneficial when asking about past histories of trauma. For organizations where these resources are not readily available, the development of community partnerships can help to fill these service gaps and connect families with the resources they need such as treatment programs, food vouchers, and housing aid (Hall, Porter, Longhi, Becker-Green, & Dreyfus, 2012; Jichlinski, 2017; Plax, Donnelly, Federico, Brock, & Kaczorowski, 2016). Future research needs to identify which resources are beneficial for families with high ACE scores as well as guidance for healthcare professionals on how to acquire and develop community partnerships to meet their patients' needs.

There remain several important future directions to consider with regards to ACE-history taking. First, there was no standardized measure for obtaining an ACEs history across studies. As can be seen in the current review, studies used different questionnaires of different lengths, resulting in a variation in the length of time added to the interview, and the items asked. Currently, there remains no consensus on which adverse childhood experiences are most important to ask about in primary care (Finkelhor, 2018; McLennan et al., 2019). While all studies in this review generally asked about abuse, neglect, or household dysfunction as specified by the original ACE study (Felitti et al., 1998), some studies also asked about factors outside the scope of ACEs such as food insecurity (Eismann et al., 2019; Koita et al., 2018), neighbourhood violence (Eismann et al., 2019; Gillespie & Folger, 2017; Koita et al., 2018), or refugee trauma (Wickramasinghe et al., 2019). These factors have been argued to produce similar effects on long-term health, which suggest that a rigorous evaluation of which childhood adversities should be asked about is needed (Finkelhor, 2018; Finkelhor, Shattuck, Turner, & Hamby, 2013; Lee, Larkin, & Esaki, 2017; Purewal et al., 2016). Indeed, the types of questions that are relevant may vary and differ across clinical populations. However, as noted by Lacey and Minnis (2019), there remains a lack of evidence-based justification as to why even the original 10 ACEs ought to be included in an ACEs questionnaire, let alone other adversities as well. Thus, future research should identify which ACEs are most pertinent to infant mental health outcomes, and how they can be applied across a variety of populations.

A second, future direction is to identify the potential benefits of considering past and current resilience factors that may be present in the lives of infants and young children. One study found that the use of a resilience questionnaire in pregnancy in addition to asking about adversity was beneficial (Flanagan et al., 2018) as identification of resilience factors helped providers better understand patients current coping abilities and availability of support resources. Furthermore, research has demonstrated that resilience factors, such as social support, can attenuate the association between ACEs and relationship difficulties (Madigan, Wade, Plamondon, & Jenkins, 2016), as well as ACEs and difficulties in pregnancy (Narayan, Rivera, Bernstein, Harris, & Lieberman, 2018; Racine, Madigan, et al., 2018). For instance, Madigan et al. (2016) found that the associations between ACEs and marital conflict in the postnatal period was moderated by neighborhood social support: higher ACEs was not associated with marital conflict when neighborhood social support was identified as being high. In addition, a study conducted by Narayan et al. (2018) found that the identification of resilience factors, or benevolent childhood experiences, accounted for the reduced impact of high ACE scores on prenatal health. Thus, social support can act as an important buffer of the effect of ACEs on maternal health and functioning. As such, an understanding of the supports and coping skills that are present for families may be important indicators of overall health and functioning.

A third future direction is to identify when it may be most appropriate to take an ACEs history. As one study reported, the prenatal period may be a more opportune time than the postpartum period as to prevent the likely influence of stress and postpartum hormones from influencing patient comfort with completing the questionnaires (Nguyen et al., 2019). Parents may also have a more well-established relationship with a provider seen routinely in pregnancy than with inpatient staff immediately following birth. Overall, more research is needed to determine appropriate developmental timing for ACEs history taking.

Clinical Implications

The studies included in the current review suggest that asking about ACEs as a preventative measure to improve maternal and infant mental health provides some benefits such as an increased communication and identification of trauma, as well as increased interest in the relationships between trauma and parenting. However, there are major cautions to obtaining an ACE history in the healthcare setting as limited research is available on adverse events related to asking about ACEs. Although parents across studies included in the current review reported varying levels of discomfort with completing the questionnaire, no research to date has identified the extent to which the practice of asking about ACEs in primary care may lead to re-traumatization, particularly for individuals with substantial trauma histories, and how to mitigate these negative outcomes. Research is needed to identify both short and long-term adverse outcomes of asking about ACEs. Furthermore, a randomized control trial conducted by MacMillan et al. (2009) found that asking about interpersonal violence had little impact in reducing rates of interpersonal violence. As such in the context of ACEs, consideration as to whether the benefits of asking about ACEs is worth the risk of parent discomfort, or whether universal implementation of trauma-informed approaches (e.g., fostering trust, transparency, and empathy with families) may be sufficient, is critical. For organizations wishing to implement ACEs history-taking practices, it is important to ensure adequate resources to support caregivers and young children with high ACE scores are available. These resources may include partnerships with social services within the community such as but not limited to, counseling services or housing aid services. Having additional personnel on staff such as social workers may aid in the creation of these partnerships. Lastly, as one of the major concerns reported by providers was how they should deal with patients who've experienced trauma, healthcare providers considering adopting ACE-taking practices should ensure adequate trauma training is obtained prior to implementation.

Limitations

There are limitations to the current narrative review. The summaries generated in the current review were limited by the available evidence. Specifically, few studies reported on adverse outcomes related to ACE-history taking. This could be due to multiple reasons, such as publication bias, the low ACE prevalence across study samples, as well as the failure to collect data on adverse outcomes. For instance, most studies asked participants whether they were comfortable with being asked about ACEs, but not if patients experienced any discomfort or distress related to being asked. Future research should identify potential adverse outcomes of asking about ACEs in order to more accurately inform whether its implementation is appropriate. Another limitation of this review is that different questionnaires that asked about ACEs were used across studies. Therefore, comfort and other outcomes cannot be directly compared as they would be influenced by the type and format of the questionnaire (i.e. wording of questions), as well as the population being asked about ACEs. Research in this area would benefit from the development and use of an evidence-based standardized questionnaire. Furthermore, another limitation is because of the nature of the literature, our results were limited to the data that was available. Many studies reported the results in terms of "majority" and "minority", which limited the specificity of our results.

Conclusions

While the results of this narrative review suggest that there are some benefits to asking about ACEs in the prenatal and pediatric primary care settings, such as parents feeling more understood by health care providers and healthcare provider perceptions of improved relationships with families, these benefits were contingent on trauma-informed training and the availability of resources and interventions for families. There remains a large need to evaluate whether asking about ACEs in the primary context improves patient outcomes. Organizations or practitioners who are considering implementing a system to identify the trauma experiences of the young children and parents they work with should consider whether specifically asking families about these experiences is necessary and whether other trauma-informed approaches, such as universal training for staff and the availability for resources for families presenting with difficulty, would be sufficient (Racine et al., 2019). The implementation and inclusion of an ACEs questionnaire in primary care should be carefully considered in the context of both the potential benefits and limitations.

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Funding

Research support was provided to Dr. Madigan by the Alberta Children's Hospital Foundation and the Canada Research Chairs program. Dr. Racine was supported by a Postdoctoral Trainee Award from the Alberta Children's Hospital Research Institute (ACHRI), the Cumming School of Medicine, and the Social Sciences and Humanities Research Council.

Authors

Whitney Ereyi-Osas, Nicole Racine PhD, Sheri Madigan PhD
Department of Psychology, University of Calgary, Calgary, AB, Canada
Alberta Children's Hospital Research Institute, Calgary, AB, Canada

Address correspondence to: Sheri Madigan, Department of Psychology, University of Calgary, 2500 University Ave., Calgary, AB, T2N 1N4, Canada, Phone: (403) 220-5561; Fax: (403) 282-8249; email: sheri.madigan@ucalgary.ca

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Asking about Adverse Childhood Experiences (ACEs) in Prenatal and Pediatric Primary Care: A Narrative Review and Critique - Perspectives

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Summary The negative consequences of adverse childhood experiences (ACEs) on the physical and mental health of infants and young children has been well-established. In order to reduce the potential effects of these stressful events, inquiring about ACEs in pregnant women, infants, and young children has been identified as an important avenue for prevention.

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Integration of the DC: 0-5  (Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood) into State Policy Related to Early Childhood Mental Health

ZERO TO THREE

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A compelling and evidence-based article about the benefits of breastfeeding

Congratulations to Dr. Zohreh Zarnegar on her Zero to Three Professional Resource article, “Why Should We Support Breastfeeding?” from the CALAIMH Policy Committee.

Why Should We Support Breastfeeding?

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Helping Children Separated at the Border

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Helping Children Separated at the Border

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Fact Sheet: The Trauma of Childhood Separation
Review of short-term and long-term effects of childhood separation

How to Help Children and Families Separated at the Border

The Traumatizing Effects of the Immigration Policy Separating Children from Their Parents.

AACAP: Separating Immigrant Children From Their Families