Abstract
Introduction: Early recognition of adverse childhood experiences (ACEs) and adequate interventions are required to prevent negative effects on the child’s mental and physical health later in life caused by toxic stress. This study aimed to assess how familiar the concepts of ACEs and toxic stress are among Dutch pediatric health care providers (PHCPs) and whether screening for ACEs is standard practice in the Netherlands.
Methods: From October 2018 until March 2019, a nation-wide questionnaire survey was held.
Results: Of 548 participating PHCPs, 29% were familiar with toxic stress, 67% were familiar with ACEs, and 63% knew of the relationship between multiple ACEs and somatic diseases. Routine inquiries about ACEs were done always by 17% of the participants and sometimes by 65%. The ACEs which PHCPs asked about the most included divorce (n=288; 76.8%), bullying (n=265; 70.7%), physical domestic violence (n=184; 49.1%), parental psychiatric diseases (n=205; 54.7%) and sexual abuse (n=164; 43.7%). The ACEs asked about the least included deportation of a family member (n=22; 5.9%), gender discrimination (n=9; 2.4%) and racism (n=17; 4.5%).
Conclusion: Even in 2019, there is limited awareness among Dutch PHCPs of ACEs and toxic stress. While most acknowledged to be aware of the role that toxic stress plays in the physical and mental health consequences of ACEs later in life, only 17% of the respondents performed standard ACE screening. Our findings underscore the need for standard ACE screening guidelines to support early recognition and adequate treatment of children suffering with toxic stress.
Worldwide, adverse childhood experiences (ACEs) are a well-known risk for adverse physical and mental health outcomes later in life. In 1998, the pioneering study on ACEs by Felitti and Anda et al1 showed that ACEs such as sexual and physical abuse, neglect, and extreme household dysfunction had a dose-response relationship with risky health behavior and long-term adverse health outcomes. The ACE Study also showed that ACEs were very common in the study population of 17,337 middle-class participants in the United States, 64% of whom had at least one ACE, and 12.4% had four or more ACEs 1. Observations of great importance to health care were the strong associations between ACEs and long-term adverse health outcomes, such as ischemic heart disease, cancer, asthma, and diabetes. Besides, in participants with an ACE score of six or more, life expectancy was reduced by up to 20 years.1,2 The complicating relationship between the community and social contexts with child development and long-term health outcomes is of growing interest in healthcare. In recent years the original 10-item ACE questionnaire has been modified to larger questionnaires.3,4
According to more recent studies on the observed associations between ACEs and poor health, frequent, prolonged, or intensely negative experiences in childhood disrupt the body’s adaptive stress system and can eventually lead to a toxic stress response. This response can affect the neuroendocrine-immune circuitry, and this can cause modifications of the epigenome, which explains the association between ACEs and disruptions in mental and physical health, learning, and behavior.5-8 While little is known so far about the exact biological mechanisms underlying the toxic stress response in the individual, various studies have reported the important role of resilience and positive parenting skills, which constitute important buffers for the biological impact of the toxic stress response.9-13 Toxic stress can, therefore, be defined as the prolonged activation of the stress response system in the absence of protective relationships.14,15 Due to this toxic stress response, childhood adversity has led to a chronic public health crisis, which underscores the need to start implementing best practices for early recognition and adequate mitigation of toxic stress in daily health care practices.5,6,14,16,17
In 2012, the American Academy of Pediatrics (AAP) released a Technical Report and Policy Statement on Childhood Toxic Stress.14 It was a call to action for the pediatric community to implement the knowledge and science of toxic stress into clinical practice. A 2016 survey by the AAP showed that <11% of pediatricians in the United States reported being very or somewhat familiar with ACEs, and that only 4% of pediatricians asked about all ACEs based on the 10-item ACE categories of the ACE study.18 Almost two-thirds of pediatricians (61%) did not inquire about any ACEs experienced by parents in their youth. Therefore, one of the recommendations in the report was that all health care physicians should utilize the knowledge of childhood toxic stress to understand and explain the disruptions of neuroendocrine-immunological and metabolic systems when the brain and body adapt to chronic and pervasive stressful experiences early in childhood in the absence of adequate buffering.14,19
While timely and effective interventions to identify ACEs and to prevent or mitigate the consequences of early childhood stress would be of benefit to general public health, widespread screening of ACEs is still in its infancy in many countries, and chronic life stressors are routinely missed. Hence, it is unknown, for example, if the rate of screening for ACEs in Dutch children differs from the screening rate among children in the US health system. Although many continue discussing possible pitfalls of standard screening, results of parental acceptance and feasibility in a health care setting show positive results.17,19-24
Currently, there is a paucity of detailed information about the extent of screening for ACEs and about the prevalence of ACEs in the Netherlands. In addition, little is known about the awareness of ACEs and toxic stress among Dutch pediatric health care providers (PHCPs), who might play an important role in providing parents with the knowledge to increase their positive parenting skills and to foster child resilience.
The aim of this study was to assess the awareness of ACEs and toxic stress among PHCPs in the Netherlands and to determine whether and to what extent ACE screenings are performed in the Netherlands. We aimed to answer the following research questions:
How familiar are pediatric health care providers (PHCPs) in the Netherlands with ACEs
How familiar are pediatric health care providers (PHCPs) in the Netherlands with toxic stress?
Do PHCPs screen their patients for ACEs? If so, which ACEs do they ask about?
Methods
This national survey was conducted between October 2018 and March 2019 in Zuyderland Medical Center, a large teaching hospital situated in the southeastern part of the Netherlands. The study data were collected using an online explorative questionnaire. To approach our target population for this survey, we consulted the Dutch pediatric association and youth health care physician association. Both were unable to provide us with participants’ direct email contact details due to new privacy regulations following the implementation of a recent EU and governmental directive, i.e., General Data Protection Regulation (GDPR) that took effect in May 2018. Hence, it was not possible to actively approach members to participate in the survey directly. Since all registered members of both professional associations received a bi-weekly newsletter, we decided to invite them through this medium by including a link to our questionnaire in the newsletter. The same approach was used to invite general practitioners to participate in the survey, by sending them a link to the questionnaire through the regional newsletter from the Zuyderland Medical Center. The newsletter invitations with the links to the questionnaire were sent twice; first in October 2018 and a reminder in November 2018. Social media (LinkedIn, Twitter) and direct mouth-to-mouth communication were also used to remind members of the invitation to the survey. No direct link was shared through social media to ensure that others were not able to complete this questionnaire.
Ethical review permission was obtained from the Institutional Review Board (METC-Z) and from the hospital board (RvB) in September 2018, METCZ20180097.
For this survey, a 13-item questionnaire was designed using Survey Monkey. The questionnaire was designed using expert input and revised before implementation based on the feedback received. Being the first study of its nature there was no prior validated instrument to use or test the validity of our questionnaire. However, face and content validity were obtained from the respective professional bodies and research advisors from our institutional research review board.
Informed consent was sought and obtained from all participants in the first section of the questionnaire, followed by six questions about ACEs, two about toxic stress, three about the participant’s characteristics, and two about their work environment (Table 1). Participants could respond to all items in the questionnaire with ‘yes,’ ‘no,’ or ‘no, but heard of this occasionally,’ and each question had an open field for responding with ‘other’ and adding personal comments. Question 6, “Which ACEs do you enquire about?”, could be answered by ticking multiple responses or ‘all the above,’ which referred to a list of ACEs that comprised the ten items of the ACE questionnaire from the original ACE Study and eight additional items related to adverse community and social experiences from the revised two-part ACE questionnaire of the Center for Youth Wellness (CYW) in California.25
Participant Demographics
Results
The questionnaire (Table 2) was sent to a total of 3,668 registered members of the newsletters, 2,204 of whom were pediatricians, 1,230 youth physicians, and 234 general practitioners. The informed consent page was the first question of the online questionnaire and rejecting to give consent automatically ended their participation in the survey. A total number of 548 respondents agreed to participate (14.9%) in the survey, and eventually, 444 completed the entire questionnaire (12.1%) as shown in Table 1.
Survey Questions
This study population comprised of 264 pediatricians, 154 youth physicians, and 26 general practitioners. Of the pediatricians, 81 worked in an academic medical center and 169 in a general hospital, 111 of whom worked in a teaching hospital. The work environments of the youth physicians varied widely, ranging from settings in which they worked with age groups of 0-4 years, 0-12 years, or 0-18 years to school settings with the age group 4-18 years and other settings (e.g., education, asylum center).
Of the 548 PHCPs who agreed to participate, 504 answered the questions on ACEs and toxic stress, shown in Figure 1; a total of 66.9% were familiar with the term Adverse Childhood Experiences (ACEs) (n=337), 25.8% were not (n=130), and 7.3% answered ‘no, but heard of this occasionally’ (n=37). A total of 29.6% were familiar with the term toxic stress (n=149), 64.9% were not (n=327) and 5.5% answered ‘no, but heard of this occasionally’ (n=28). The remarks of the participants who had only heard of ACEs and of toxic stress occasionally are clustered in Table 3.
Graphical display of Dutch pediatric healthcare provider familiarity with (A) adverse childhood events (ACEs) and (B) toxic stress.
Summary of comments of participants on Q2, Q3 and Q6
Of the 548 PHCPs who agreed to participate, 453 answered the question about being familiar with the relationship between multiple ACEs in the period from 0 to 18 years and psychosocial problems later in life, such as behavior problems, attention-deficit/hyperactivity disorder (ADHD), suicide, and depression. Of these participants, 91.6% answered ‘yes’ (n=415), 5.7% answered ‘no’ (n=26), and 2.7% had ‘heard about this occasionally’ (n=12).
Also, 453 respondents answered the question about being familiar with the relationship between multiple ACEs in the period from 0 to 18 years and physical problems later in life, such as asthma, obesity, diabetes, auto-immune diseases, and cardiovascular diseases. Of these, 63.6% answered ‘yes’ (n=288), 30.4% answered ‘no’ (n=138), and 6% had ‘heard of this occasionally’ (n=27).
A total of 488 participants answered the question whether asking about adverse childhood experiences was standard procedure in the contact with their patients. Of these participants 17% answered ‘yes’ (n=83) while 18% reported that they did not ask about ACEs at all (n=88). Most of these participants (65%) only asked about ACEs occasionally (n=317). A total of 376 participants answered the question whom they asked about ACEs; 17% asked only the parents (n=64), 9.6% asked only the children (n=36), and 73.4% asked both the parents and the children (n=276).
Figure 2 shows the results of the 375 answers of question 6, “Which ACEs were enquired about?” The five most frequently mentioned ACEs were divorce (n=288; 76.8%), bullying (n=265; 70.7%), physical domestic violence (n=184; 49.1%), parental psychiatric diseases (n=205; 54.7%) and sexual abuse (n=164; 43.7%). Experiences that were asked about least frequently included deportation of a family member (n=22; 5.9%), gender discrimination (n=9; 2.4%) and racism (n=17; 4.5%).
Graphical display of Dutch pediatric healthcare provider responses to survey question 6: “Which adverse childhood experiences (ACEs) do you ask for?”
The personal remarks of the participants who asked their patients or the parents about ‘other ACEs’ are clustered in Table 3. A few participants reported asking about financial problems (n=2; 0.5%), cyber or school bullying (n=5; 1.3%) or traumatic hospital experiences or medical issues of the parents or grandparents (n=2; 0.5%). Most of the comments of the participants were about asking about ACEs in general questions, such as asking whether any major life events had happened (n=49; 13%). Other participants explained that they asked for specific ACEs depending on the situation or on specific complaints (n=26; 6.9%). Of the 453 participants who responded to the question about their familiarity with the fact that the consequences of toxic stress can be reversed with early interventions, 62.9% answered ‘yes’ (n=285), 30.7% ‘no’ (n=139), and 6.4% had ‘heard of this occasionally’ (n=29).
Of the 444 participants who completed the entire questionnaire, 7% were not interested in more information on this subject (n=31). Of the 411 participants who were interested in more knowledge (93%) on the subject, 55% wished to be informed through a symposium or congress (n=244), 49.8% through e-learning (n=221), 38.3% through a guideline (n=170), 24.1% through a website (n=107), 24.5% through a workshop (n=109) and 26.6% through a magazine (n=118). In the open-ended section of the questionnaire, participants suggested other options, such as books or films, newsletters, collaboration, and providing information through the national professional associations.
Discussion
The purpose of this study was to assess the extent to which PHCPs in the Netherlands are aware of ACEs and of the toxic stress response to ACEs, as well as to find out whether or not ACE screenings are performed in the Netherlands and if so, to what extent Dutch PHCPs screen for ACEs. To our knowledge, our study is the first of its nature investigating these questions in the Netherlands.
Our findings revealed a low rate of standard screening for all ACEs (11%), although this rate was a little higher than the rate found in the United States in 2016 (4%).18 Direct comparison was not possible, because in the US, pediatricians play a significant role in prevention and in the primary care for pediatric patients, whereas in the Netherlands, this role is primarily played by (youth) public health doctors rather than by pediatricians. The low standard screening rates were clarified through analysis of the open field responses, which showed that most participants did ask about ACEs in general or more specifically but only if they felt that there was a reason to do so. What would constitute such an indication was not clarified. Hence, further research should investigate what physicians consider a valid indication for screening for ACEs and how they further explore and act upon identified ACEs in their daily practice.
The results of our survey showed that only two thirds of the participants knew about ACEs and only one third knew about the toxic stress response; these participants were aware that the toxic stress response was not only associated with mental health problems but also with poor physical health. While the majority of the participants in this study appear to have some knowledge of ACEs, the original ACEs Study and more recent studies on the relationship between ACEs and toxic stress seem to have had insufficient impact to facilitate the implementation of the knowledge and science of toxic stress into clinical practice within the entire Dutch pediatric community. It is possible that the rate of awareness in the general pediatric community is even lower than our findings suggest, considering the likelihood of a social desirability bias, because participants may not have wanted to admit not knowing about experiences that have a significant impact on the health of their patients.
Another important finding was that there is no standard way of screening for ACEs in the Dutch pediatric health care system and that some ACEs were hardly asked for. The participating Dutch PHCPs only asked for some specific ACEs if they felt it was necessary to do so, and they merely explored in a general way if major life events had happened by asking open-ended questions. The absence of standard screening for ACEs in the Netherlands tallies with the ongoing discussion about possible pitfalls of standard screening and the lack of validated screening tools. However, various studies on standard ACE screening have already demonstrated positive results on parental acceptance and on the feasibility of ACE screening in a healthcare setting, showing that screening contributes to earlier detection of and intervention against toxic stress.17,20-24
We therefore believe it is of great importance to develop screening tools or to implement existing universal screening tools to enable Dutch PHCPs to easily screen for all ACEs in daily clinical practice. Together with the growing global knowledge that all ACEs indeed constitute a risk factor for toxic stress, our findings underscore the need for earlier detection and intervention in the Netherlands.14 Combining expertise and best practices into a national guideline may contribute to the development of an ethical and trauma-sensitive approach for ACE screening and early interventions in healthcare.
A potential limitation of this study could be that some participants may have been confused by the terms “familiarity” and “toxic stress” as used in the questionnaire. For example, various studies and publications used different terms in the past to address phenomena that were similar to toxic stress, such as chronic stress, early life stress, traumatic stress, and early childhood adversity. In this survey, we focused only on the respondents’ familiarity with the term toxic stress. It is, therefore, possible that the participants’ answers may not be a true reflection of their experience with, or their understanding of the phenomenon of toxic stress, but merely of their familiarity with the term. On the other hand, in the open field responses, only a few respondents claimed to be familiar with other terminology for the same phenomena.
For future research, it is advisable to consider using terminologies in a broader perspective, as the term Early Life Stress (ELS) has gained more acceptance in Europe. In September 2019, a declaration was signed by members of the European Union for School and University Health and Medicine (EUSUHM), stating that the Youth Health Care is committed to early identification of ELS, to preventing ELS by promoting the mentalizing capability of parents, and to promoting resilience.26 Further collaboration between all PHCPs, mental health care specialists and professionals in the social domain will help breaking the cycle of intergenerational problems of toxic stress due to ACEs and will contribute to fostering healthier children and a healthier society.
Another limitation of this study could be that some participants may have been confused by the question whether respondents screened the parents, the children, or both for ACEs. Here we meant whether they asked either of them about the occurrence of ACEs in the children; in retrospect, the authors realized that this question could have been wrongly interpreted and potentially be understood to mean whether they screened for parental ACEs. In the open field responses, however, there was no indication that such a misunderstanding or confusion had indeed occurred. Since parental ACE screening is of predictive value for the development of their children, we recommend that future research be more explicit in asking about both items.10
The response rate of this online survey was 15%, and 12% completed the questionnaire, which was lower than the response rate of at least 20% that we expected for an online survey of this nature.27 However, it is unclear how many members actually read the bi-weekly newsletter and if they did, it is unknown how many saw the invitation and the link to the questionnaire. All the questions were answered by different numbers of participants, and the different percentages were used in the results for the correct interpretation. We asked the national professional association of pediatrics and youth physicians for an explanation for the low response rate. Unfortunately, no clear explanation could be given, except that in their experience, most other online surveys for pediatricians had even lower response rates. For future research we strongly recommend using the bi-weekly newsletter of the national professional association of pediatrics and youth physicians again, so that comparable prospective data can be achieved. Also achieving collaboration with the national professional association of general practitioners on this matter is of importance to future research. Due to the COVID-19 pandemic more awareness about toxic stress has grown and it can be of interest to see how that relates to growth in the knowledge of ACEs and their impact on child development.
This study adds empirical information to the literature on ACE screening. The majority, but far from all of the participating physicians, were aware of ACEs as well as of the potential reversibility of the negative effects of toxic stress. Also, an overwhelming majority of 93% of the participants wished to receive more knowledge on this topic in different ways. Any future initiatives on this matter will contribute to more awareness among Dutch PHCPs and brings us closer to implementing this science into practice.
The results of this study demonstrate that the Dutch healthcare system needs to start addressing toxic stress, which begins with incorporating the science and knowledge of ACEs and toxic stress into daily practice, as the AAP recommended in 2012. We believe there is an urgent need for generating awareness among all the relevant health care professions, preferably starting at the level of specialty training for residents, and for implementing the standard screening of ACEs at the national level. Also, our findings underscore the need to initiate a collaborative effort that combines expert knowledge and available best practices in developing an effective and validated screening tool that includes all the risk factors for toxic stress as well as the buffering factors.
Our recommendation is to start implementing standard ACE screening within pediatric healthcare settings, making sure that no ACEs are forgotten. This is of importance due to important synergistic effects on the long-term health outcomes and because screening provides direct opportunities for parental education and for offering help in person. Within a broad, cross-border and prospective follow-up research setting, future studies should view a combination of ACEs, buffering factors, current stress-related symptoms, biomarkers, demographic information and development as well as medical care from the biopsychosocial perspective, leading the way to addressing the public health problem of toxic stress.
Conclusion
This survey demonstrated that as recently as 2019, still only two-thirds of Dutch PHCPs were aware of ACEs, and only one-third were aware of toxic stress. While most participants acknowledged awareness of the role that toxic stress plays in the physical and mental health consequences of ACEs later in life, just 17% perform standard ACE screening.
Since 93% of the participating PHCPs were interested in learning more about ACEs, we advocate that insight into the effects of ACEs and toxic stress be included as a core competency in the training programs of PHCPs. Besides, the small percentage of physicians who performed standard screening of all ACEs underscores the need for standard ACE screening guidelines to support early recognition and adequate treatment of children suffering with toxic stress.
Acknowledgments
The authors wish to thank Dr. Ralf P. Walbeehm for his feedback and editorial advice during the preparation of the manuscript.
Footnotes
Disclosures: The authors declare that no funds, grants, or other support was received during the preparation of this manuscript, and no personal conflicts of interest.
- Received February 23, 2022.
- Revision received August 6, 2022.
- Accepted September 26, 2022.
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