The Role of Trauma in Disparities for Cancer-Related Health: A Call to Action

Cancer is the second leading cause of death in the United States. In this brief report, we describe the current literature on interpersonal trauma (i.e., sexual abuse and intimate partner violence) and cancer. Concordant with the general population, between 20% and 50% of cancer patients have experienced interpersonal trauma. Experiences with interpersonal trauma not only appear to increase risk for developing cancer, but may also act as a roadblock to accessing appropriate preventive testing and to receiving adequate support during cancer care. Healthcare providers can play an important role in making cancer-related care more trauma-informed

“I\u27ll do whatever as long as you keep telling me that I’m important”: A case study illustrating the link between adolescent dating violence and sex trafficking victimization

Background: Approximately 10% of U.S. high school-attending youth are physically abused by a dating partner each year. Many sequelae of dating violence have been documented, but the dating violence literature is lacking information about commercial sexual exploitation as a possible outcome of an abusive dating relationship. Conversely, scholarship on sex trafficking victimization has documented that some girls are enticed into sex work by exploitative partners who initially pretend to be dating partners, but the research lacks specificity about why and how the girls become vulnerable to these destructive relationships. This case series chronicles the experiences of four women who were commercially sexually exploited in the U.S. as minors, identifies common themes cross their narratives, and organizes these themes into a proposed framework for understanding a possible pathway from safety to unsafe dating to sex trafficking victimization. Methods: We conducted in-depth qualitative interviews with four adult women who had firsthand experience as victims of domestic minor sex trafficking. Participants were recruited through an organization that serves sex trafficking survivors. A constructivist grounded approach was used for data analysis. Participants’ narratives are presented, as well as illustrative quotes that typify each of the primary themes identified. Results: There were six primary themes that emerged from the cases’ narratives. Factors that made girls vulnerable to entering into abusive dating relationships and subsequently to experiences as sex trafficked minors included: (1) feeling physically unattractive and unimportant; (2) lacking examples of healthy relationships; (3) experiencing sexual abuse that caused subsequent dissociation and emotional debilitation; (4) being flattered by romantic gestures early in an abusive dating relationship and becoming emotionally attached; (5) gaining confidence from dating someone with higher social status; and (6) experiencing short-term satisfaction from out-earning other sex workers. Secondary themes that merit further investigation included having conflicts with guardians, engaging in criminal behavior at the request of their dating partner, and developing substance dependence that made it difficult to exit sex work. Discussion: Findings support the conclusions that one pathway into commercial sexual exploitation for minors is via dating partners, and that some minors are motivated to engage in sex work out of devotion to their dating partners rather than fear of violent retribution. A proposed framework for understanding how youth become vulnerable to sexual exploitation by a dating partner includes pre-dating, early phase dating, and late phase dating factors. Some pre-dating factors, for example, include feeling insecure, being bullied by peers, and having conflict with a guardian. Early phase dating factors include being impressed by the high social status of a new love interest and romantic gestures. Late phase dating factors include engaging in criminal activity to please the dating partner, and being physically, sexually, financially and emotionally abused. Additional empirical research that replicates and expands the proposed framework is encouraged, with the long-term objective of improving both dating violence and sexual exploitation prevention initiative

The 30 Million–Word Gap Relevance for Pediatrics

As many as 40% to 50% of the children pediatric clinicians serve are growing up in low-income households. Among the myriad physical and mental health sequelae of early adversity and toxic stress, language development appears to be one area particularly vulnerable to the stressors associated with poverty. The effects of poverty on language development have been documented in children as young as 9 months, becoming more clinically evident by 24 months.1 The consequences of early adversity–related language delays may be profound, leading to later learning delays, school failure, and lifelong social and economic consequences.2 This income-related gap in children’s language development has been linked in numerous studies to the quantity and quality of language input children receive from their parents, family members, and caregivers. Hart and Risley3 carried out the landmark study documenting this influence of children’s early environments on their later vocabulary growth. They observed that young children from low-income families heard approximately 600 words per hour compared with 2100 words per hour for children from high-income families. Extrapolating from this hourly discrepancy data, they estimated that by the time children reached age 4 years, those from higher-income families were likely to have heard roughly 30 million more words than low-income children. In addition, lower-income parents have been observed to use fewer complex sentences and rare vocabulary words, ask fewer questions of children, and use more prohibitives and directives—language that tells children what to do and not do—rather than pose comments that might elicit conversation. This qualitative and quantitative difference in language exposure, the “word gap,” is significant in that it often leads to later disparities in children’s academic achievement via effects not only on language development2 but also on cognitive processing1 and building self-regulation skills.4 Numerous community-based interventions have been shown to be effective in improving children’s language learning environments and outcomes.5 Some of the largest-scale endeavors include Providence Talks (a program in which low-income families with young children in Providence, Rhode Island, are given audio-recording technology that provides feedback about how many words their children hear every day), Georgia’s Talk to Me Baby program, and the Talking Is Teaching initiative of Too Small to Fail. However, some recent commentators have criticized the emphasis placed on word gap initiatives, with opposition to the “simplistic” approach of focusing on number of words spoken as a solution to poverty’s health effects as well as concern for implicit bias in the way researchers describe low-income and minority parenting.6 We argue that emphasis on the word gap in pediatric practice is not only appropriate but also a valuable tool for partnering with families and teaching trainees

Trafficking and Domestic Violence: Where Are We and Where Are We Going

Editors explain their view on the intersection of commercial sexual exploitation of children (CSEC) and domestic violence

Physical health outcomes of childhood exposure to intimate partner violence: A systematic review.

A Systematic Review Physical Health Outcomes of Childhood Exposure to Intimate Partner Violence: http://www.pediatrics.org/cgi/content/full/117/2/e278 located on the World Wide Web at: The online version of this article, along with updated information and services, is The authors have indicated they have no financial relationships relevant to this article to disclose. ABSTRACT BACKGROUND. Children exposed to intimate partner violence (IPV) are at increased risk for adverse mental and behavioral health sequelae, as has been documented by both systematic reviews and meta-analyses. Studies addressing the physical health impact of childhood IPV exposure, however, have not been summarized in a manner that might facilitate additional hypothesis-driven research and accelerate the development of targeted interventions

Addressing Psychosocial Adversity Within the Patient-Centered Medical Home: Expert-Created Measurable Standards

The Patient-Centered Medical Home (PCMH) may be improved by embedding identification and response for patients’ experiences with psychosocial adversity, but how this might optimally occur in practice has not been well-specified. We sought input from an expert panel to define feasible elements that could adapt the PCMH to adequately respond to patients’ experiences with psychosocial adversity. From December 2012 through September 2013, we used a Delphi process to systematically obtain expert opinions and reach consensus. We invited 37 experts to participate in three successive and iterative rounds of questionnaires, with each round based on aggregated, de-identified data from the prior round. We first asked experts to generate elements to adapt the PCMH, using the National Committee for Quality Assurance (NCQA’s) established six PCMH standards as the foundation. We then asked the experts to rate these elements on a 5-point Likert scale, and finally specify what they considered the most and least valuable elements. Eighteen of the 37 (49%) invited experts responded to the first survey, and constituted our sample. Experts identified 35 elements that fell under the six NCQA standards. The top rated elements included using a screening tool to identify adversity; training providers to address psychosocial adversity; having a team member with mental health expertise; providing culturally-competent care; and having written patient information related to adversity and coping. This study derived key elements that may enhance the PCMH’s ability to improve patient outcomes by purposefully identifying and responding to their psychosocial adversity

Identifying and making recommendations for pediatric anxiety disorders in primary care settings: a video-based training

INTRODUCTION: Pediatric anxiety disorders have high rates of prevalence and confer risk for later disorders if they go undetected. In primary care, they are underdiagnosed, partly because pediatricians often lack relevant training. We developed a brief, video-based training program for pediatric residents aimed at improving early identification of anxiety disorders in primary care. METHODS: Video content was consistent with the American Academy of Pediatrics Behavioral Health Competencies, as applied to the evaluation of anxiety disorders and guidance for discussing treatment options. This training can be delivered in two formats: videos (43 minutes) can be shown in a live, group-based format, or accessed via an online, asynchronous training. We tested this training program using both formats and developed surveys to evaluate knowledge about child anxiety, perceived evaluation skills, and satisfaction with the training. We also developed a video-based vignette to measure sensitivity to detecting disorders (how much the condition is interfering, diagnostic severity, and referral urgency). RESULTS: Pediatric residents from two residency programs completed the training and pre- and posttraining assessments to evaluate program efficacy. Residents' knowledge and perceived evaluation skills increased posttraining, with large effect sizes. Residents also demonstrated increased sensitivity to detecting anxiety disorders on the vignette-based assessment and reported high levels of satisfaction. DISCUSSION: Our results suggested that residents participating in this training improved their evaluation skills and that residents found the training beneficial. Video-based trainings can significantly supplement existing education. This cost-effective and minimally burdensome training program can be used to enhance resident education in a much-needed area.Published versio

The context of violent disagreements between parents: a qualitative analysis from parents’ reports

Intimate partner violence (IPV) is a prevalent public health problem that affects millions of families. Much of what is known about IPV comes from quantitative studies that often "count" acts of IPV without exploring in depth the circumstances surrounding the violence, thereby leaving critical questions unanswered; existing qualitative studies tend to focus solely on women’s perspectives. There is a dearth of dyadic qualitative research exploring the context of IPV in families with children, thus hindering the development of effective interventions for families experiencing IPV. Seven heterosexual couples were recruited from a University-based family therapy clinic to participate in qualitative interviews. Couples were eligible if they had experienced severe verbal or any physical aggression during the past 4 months; had ≥ one child living in the household; were English-speaking; and were ≥ 18. Each individual was interviewed separately. Key topics explored included specific types of violence used by men and women; primary triggers and the context surrounding aggressive disagreements; degree to which the child(ren) were exposed; and perceived consequences for adults and children. All couples listed household responsibilities and parenting as key IPV triggers. Couples with infants reported that parenting disagreements were particularly heated, with women using aggression due to frustration about their partners’ lack of support. Couples also described substance use, wanting to be heard, and prior violence histories as triggers or as the background context for IPV episodes. Children were present during IPV and often intervened in conflicts involving severe violence. Parents’ perceptions of the effects of IPV on their children ranged from minimal to major emotional distress, with men describing more significant impact than women. When describing acute triggers, parents most commonly mentioned that arguments were instigated by concerns about the division of household labor and parenting, a finding that may have significant implications for intervention development; this was particularly notable for parents of infants. Our findings emphasize the need for innovative programs that help parents cope with the stresses of raising a family as well as programs that directly address the consequences of IPV for children.https://doi.org/10.1186/1471-2458-14-132

A case study in leveraging strategic partnerships through trust-based philanthropy

This practice note highlights a case study of leveraging strategic partnerships through trust-based philanthropy, a set of practices rooted in values, relationship building, mutual learning, and equity. It describes the motivations, planning, and execution of a symposium organized by, and held for, a Foundation and four of its grantees. The symposium led to the development of sustained pathways between and among the partners, resulting in productive collaborations and shared projects. This case study is shared to illustrate the argument that it is the responsibility of funders, and certainly in their self-interest, to eliminate competition between organizations to whom they provide financial resources and support. By facilitating trust and collaboration, funders are uniquely positioned to foster collective, higher-impact work. © 2024 The Authors. Journal of Philanthropy and Marketing published by John Wiley & Sons Ltd

Barriers and Facilitators to Integrating Health Service Responses to Intimate Partner Violence in Low- and Middle-Income Countries: A Comparative Health Systems and Service Analysis.

This systematic review synthesizes 11 studies of health-sector responses to intimate partner violence (IPV) in low- and middle-income countries. The services that were most comprehensive and integrated in their responsiveness to IPV were primarily in primary health and antenatal care settings. Findings suggest that the following facilitators are important: availability of clear guidelines, policies, or protocols; management support; intersectoral coordination with clear, accessible on-site and off-site referral options; adequate and trained staff with accepting and empathetic attitudes toward survivors of IPV; initial and ongoing training for health workers; and a supportive and supervised environment in which to enact new IPV protocols. A key characteristic of the most integrated responses was the connection or "linkages" between different individual factors. Irrespective of their service entry point, what emerged as crucial was a connected systems-level response, with all elements implemented in a coordinated manner