the collaborative adverse childhood experiences study (caces): evaluating the utility of adverse...
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The Collaborative Adverse Childhood Experiences Study (CACES): Evaluating the Utility of
Adverse Childhood Experiences (ACE) Health Surveillance in US Military Personnel
Jamie D. Davis, PhDClinical Research Psychologist, Associate Investigator
Ronnie Robinson, MSProject Director
COL Charles C. Engel, MD, MPH, MC, USADHCC Chief, Associate Investigator
Background
National Defense Authorization Act - DoD mandate to implement baseline health surveillance
CDC’s ACE results (Dube, et al, 2003): 62% males & 66% females experienced > ACE 65 - 98% chance of experiencing > ACE Negative health outcomes in adulthood
Military populations & ACE (Rosen, et al, 1996; Smikle, et al, 1996): 56% males 66% females experienced > ACE Health risk behaviors & negative health outcomes in adulthood Greater attrition during basic training & first year of service
ASDHA convened a multi-agency collaboration – Army, Navy, Air Force, CDC, and VA – to investigate ACE military health surveillance
Dube, S. R., Felliti, V. J., Dong, M., Giles, W. H., & Anda, R. F. (2003). The impact of adverse childhood experiences on health problems: evidence from four birth cohorts dating back to 1900. Prev Med, 37, 268-277.
Rosen, L. N. & Martin, L. (1996). Impact of Childhood Abuse History on Psychological Symptoms Among Male and Female Soldiers in the U.S. Army. Child Abuse Negl, 20, 1149-1160.
Smikle, C. B., Fiedler, E., Sorem, K. A., Spencer, D. K., & Satin, A. J. (1996). The Impact of Sexual Abuse on Job Attrition in Military Recruits. Mil Med, 161, 146-148.
Literature Review Findings
ACE are relatively common & clearly linked to multiple health risks & outcomes (Dube, et al, 2003)
Acceptability of ACE questions for respondents is unclear & likely linked to response validity (Olson et al., 2004; Young et al., 2006)
Confidentiality assurances
Willingness to respond to questions
As a population health metric ACE surveillance may increase our understanding of risk behavior, social & individual medical problems, & intervention opportunities
Dube, S. R., Felliti, V. J., Dong, M., Giles, W. H., & Anda, R. F. (2003). The impact of adverse childhood experiences on health problems: evidence from four birth cohorts dating back to 1900. Prev Med, 37, 268-277.
Olson, C. B., Stander, V. A., & Merrill, L. L. (2004). The Influence of Survey Confidentiality and Construct Measurement in Estimating Rates of Childhood Victimization Among Navy Recruits. Mil Psychol, 16, 53-69.
Young, S. Y. N., Leard, C. A., Hansen, C. J., Chervak, M. C., Hauret, K. G., Spooner, C. S. et al. (2006). The Recruit Assessment Program (RAP) Experience With Adverse Childhood Experiences (ACE) Questions (Rep. No. NHRC.06-04).
The Expert Review Panel (ERP)
Mission: provide expert input and perspective on ACE surveillance in the military
Membership: Nominated by project steering committee
Nationally respected, multidisciplinary subject matter experts
Expertise in military medicine, psychiatry, psychology, epidemiology, abuse, medical ethics, legal, primary care, & occupational medicine
Representation from key government stakeholders (DoD, DVA, DHHS)
Method: Critically review ACE, public health, & other relevant literature, hear relevant briefs from military and other experts
Deliverable: written recommendations on feasibility & utility of using ACE data for routine military health surveillance
ERP Members
Shanta Dube, PhD, MPH, Centers for Disease Control & Prevention
Charles W. Hoge, PhD, Walter Reed Army Institute of Research James E. McCarroll, PhD, MPH, Uniformed Services University
of the Health Sciences Patricia Resick, PhD, VA Boston Healthcare System & Boston
University Desmond Runyan, MD, DrPH, University of North Carolina Mark Small, PhD, JD Clemson University Sandra M. Stith, PhD, LMFT, Virginia Polytechnic Institute &
State University Cynthia J. Thomsen, PhD, Northern Illinois University
Steering Committee
David W. Armstrong, PhD, FACSM, Deployment Health Clinical Center Jamie D. Davis, PhD, Deployment Health Clinical Center Charles C. Engel, MD, MPH, Deployment Health Clinical Center Cynthia T. Ferguson, MSN, LCDR US Navy Howard N. Garb, PhD, Lackland Air Force Base Roger L. Gibson, PhD, MPH, DVM, Armed Force Epidemiological Board David W. Lloyd, LLM, Office of the Deputy Undersecretary of Defense John Newby, DSW, Uniformed Services University of Health Sciences Michael R. Peterson, DVM, MPH, DrPH, TRICARE Management Activity Bruce Ruscio, DrPH, Office of the Assistant Secretary of Defense, Health Affairs Margaret Ryan, MD, MPH, Center for Deployment Health Research Christina Spooner, MS, Center for Deployment Health Research Katherine A. Surman, CAPT, NC, US Navy, Office of the Assistant Secretary of
Defense for Health Affairs, Clinical and Program Policy Sylvia Young, MD, MPH, Center for Deployment Health Research
ERP Recommendations
Recommendation One: It is premature to implement a DoD-wide ACE surveillance program
Gaps regarding predictive validity
Military & medical goals of ACE surveillance are ambiguous
ACE-specific interventions lack evidence base
Potential for misuse of ACE surveillance data is significant
ERP Recommendations
Recommendation Two: Develop a military program of
longitudinal, prospective studies
Currently a paucity of these data available to support or refute the potential utility of a military ACE surveillance program
Clarify predictive validity
Clarify mediator & moderator variables
ERP Recommendations
Recommendation Three: A thorough examination of the ethical/legal implications of military-wide ACE surveillance
should be considered What are the ultimate goals?
What are the legal risks associated with these data?
Could harm occur as a consequence of collecting these data?
How can data be safeguarded over time and in changing contexts?
ERP Recommendations
Recommendation Four: If a DoD-wide ACE surveillance program is initiated, data should be collected without identifiers
Ensure valid & reliable information
Safeguards against misuse
Protects against data breaches involving highly sensitive information
May reconsider use of identifiers after clarification of current program ambiguities
ERP Recommendations
Recommendation Five: Before implementing a DoD-wide ACE surveillance system, the purposes of this surveillance should be clearly defined
Potential for misuse is real though exact risk unknown
Established link between ACE & several future health risks
Purpose of the program has crucial implications for implementation
Limitations
A panel comprised of different members may have made different conclusions & recommendations
Differences in individual discipline and government agency perspectives
The impact of idiosyncratic views & interests
Influence of group dynamics
Acceptability of ACE Questions in Routine Military Health Surveillance: A Qualitative Study
Background – current research findings & recommendations derived from the CACES Conference
Objective – to explore the perceptions & attitudes of service members & spouses regarding using ACE questions for routine health surveillance
Purposive sample - views may vary in important ways
Recruitment – WAMC primary care clinic & Robinson clinic
Participants
784 individuals were screened
615 individuals completed the questionnaire (78% response rate)
342 (56%) individuals met inclusion criteria (> 1 ACE)
41 (~8%) individuals agreed to participate
Officers were significantly less likely than enlisted personnel or spouses to report an ACE
Participants
Length of Military Affiliation
Gender
Service Member Spouse
< 5 Years > 5 Years < 5 Years > 5 Years
Female 7 6 7 5
Male 8 8--* --*
*Unsuccessful in recruiting male spouses
Qualitative Research StudyMethods
Interviews audio-recorded by 2 experienced qualitative interviewers
Semi-structured interviewer’s guide General military health surveillance Surveillance for psychiatric disorders Surveillance for ACE Implications of including ACE surveillance data in military
medical records
Interviews lasted approximately 30 minutes
Methods
Each interview was transcribed verbatim & analyzed for emerging themes
Independent reviews were conducted of all transcripts
Transcripts were analyzed to determine
How well identified themes matched anticipated thematic area Discover unanticipated themes Generate hypotheses concerning unexpected themes
Qualitative Research StudyResults
Concerns about Confidentiality General beliefs about privacy safeguards
Privacy is perceived to be inherently lacking in military culture
Breaches in patient confidentiality are possible
Many interviewees identified specific examples from personal or peer experience
Results
Value of Standardized Health Surveillance
Service members & spouses are generally receptive to health surveillance programs
Concerns about the potential for information to be used to stigmatize or segregate certain individuals or groups
Intrusiveness, burden, &/or how information may be used moderates views
Results
Value of Mental Health Surveillance
Mental health is viewed as essential to troop readiness & well-being
Some interviewees commented on the devastating consequences of poor mental health
BUT, some commanders are perceived to view mental health issues as outside their scope of command responsibility
Results
Uncertainty over the Usefulness of ACE
Participants questioned how one can treat a childhood event in adults – i.e., the practical usefulness of ACE data
Many participants failed to see or understand the relevance of childhood experiences to current behavior & well-being in adulthood
Many related concerns about potential for negative career impact to markedly reduce response validity
Results
Unanticipated Theme: Building Military Trust & Confidence
Many participants felt that competent implementation of ACE surveillance could foster trust and confidence
Participant suggestions regarding how the military services could foster trust through competent implementation…
– Address the confidentiality of the system– Use anonymous reporting methods (e.g., online
surveys vs. medical records)– Communicate program intent openly & honestly– Communicate the benefits for the service member
Overall Conclusions
Longitudinal, prospective studies are needed to determine predictive validity of ACE
If ACE surveillance is implemented, service members should be fully informed about and consulted with about the program including potential health benefits
Confidentiality reassurances are advised to the maximum extent possible. Lack of same is likely to reduce trust & lead to inaccurate exposure reporting
It is not recommended that DoD implement military health surveillance of ACE at this time although a link between ACE & future behavior is likely
Limitations
Sample included only one military installation
Reliance on retrospective ACE reporting which may be affected by the passage of time on memory
Relatively small sample – a large representative sample may achieve different results
Questions, Information,Assistance
DoD Deployment Health Clinical Center Walter Reed Army Medical CenterBuilding 2, Room 3G046900 Georgia Ave, NWWashington, DC 20307-5001 E-mail: [email protected]: www.PDHealth.mil
The views expressed in this presentation are those of the authors and do
not necessarily represent the official policy or position of the Deployment
Health Clinical Center, Walter Reed Army Medical Center, Department of the
Defense, or the United States Government.
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