Parent perspectives on adverse childhood experiences & unmet social needs screening in the medical home: a qualitative study

OBJECTIVES: To explore parental perspectives regarding disclosure of child and parental adverse childhood experiences (ACE) and family unmet social needs (USN) and to elicit parental recommendations for screening in the pediatric medical home. METHODS: We conducted a qualitative study using a purposive sample of English- and Spanish-speaking parents in our urban academic community clinic. Between January 2018 and March 2019, each parent underwent one semi-structured interview that was audiotaped, transcribed, and independently coded in Atlas.ti by two study team members. Data analysis was based in constructivist grounded theory methodology to identify common themes and sub-themes. RESULTS: We interviewed 25 English-speaking and 15 Spanish-speaking parents who were mostly female, racial/ethnic minorities with ≥1 ACE. English-speaking subjects were more likely to have a high school degree and be single parents. Four themes were identified: (1) Pediatricians should ask about ACE and USN. (2) Disclosure is a longitudinal process, not a discrete event. (3) Barriers to disclosure are significant, involving concrete and emotional risks for the family. (4) Trauma-informed providers and practices support disclosure. CONCLUSIONS: Families support pediatricians addressing ACE and USN in the medical home despite significant barriers. Even if providers screen using trauma-informed principles, parents may prefer not to disclose ACE initially because they regard disclosure as a stepwise process. These findings contribute to a new conceptual framework for thinking of ACE screening not merely as a way to generate information, but as an interactive, therapeutic relationship-building activity irrespective of whether or when it produces disclosure.