Preliminary Recommendations for Assessing Adverse Childhood Experiences in Clinical Practice With Indigenous Clients

Elaine Toombs, Jessie Lund, and Christopher J. Mushquash

Citation

Toombs, E., Lund, J., and Mushquash, C. J. (2021). Preliminary Recommendations for Assessing Adverse Childhood Experiences in Clinical Practice With Indigenous Clients. Journal of Health Service Psychology, 47(2). https://doi.org/10.1007/s42843-021-00035-4

Abstract

Adverse childhood experiences (ACEs) have been associated with increased mental health difficulties across a lifespan. Given increased health disparities among Indigenous populations compared to non-Indigenous populations, screening for ACEs is particularly relevant as it can inform future preventative care and treatment approaches. There has been no literature to date about how to best integrate these practices into routine psychological assessment with Indigenous clients. We describe five recommendations for assessing ACEs with Indigenous clients that are based on anecdotal research and clinical practices but aligned with standard evidence-based assessment practices. The preliminary recommendations for ACE assessment are: (1) determine the relevance of the assessment, (2) convey a sense of purpose and meaning during assessment, (3) use therapeutic assessment techniques, (4) use the ACE model for further client psychoeducation, and (5) use culturally relevant measurement techniques. These suggestions may provide a more meaningful and culturally relevant psychological assessment, but research is needed to support them.

References

Aggarwal, N. K., Jarvis, G. E., Gómez-Carrillo, A., Kirmayer, L. J., & Lewis-Fernández, R. (2020). The Cultural Formulation Interview since DSM-5: Prospects for training, research, and clinical practice. Transcultural Psychiatry, 57(4), 496–514. https://doi.org/10.1177/1363461520940481

Alberton, A. M., Angell, G. B., Gorey, K. M., & Grenier, S. (2020). Homelessness among Indigenous peoples in Canada: The impacts of child welfare involvement and educational achievement. Children and Youth Services Review, 111, 104846. https://doi.org/10.1016/j.childyouth.2020.104846

Alexander, J. H., Callaghan, J. E., & Fellin, L. C. (2018). Genograms in research: participants’ reflections of the genogram process. Qualitative Research in Psychology, 1–21. https://doi.org/10.1080/14780887.2018.1545066

American Psychiatric Association (APA). (2013). Cultural Formulation. In Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (pp. 749–759). American Psychiatric Publishing.

American Psychological Association. (2002). Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. Washington, DC: American Psychological Association. American Psychologist, 62, 271–286. https://doi.org/10.1037/0003-066X.58.5.377

Andriessen, K., Krysinska, K., Draper, B., Dudley, M., & Mitchell, P. B. (2018). Harmful or helpful? A systematic review of how those bereaved through suicide experience research participation. Crisis, 39(5), 364–376. https://doi.org/10.1027/0227-5910/a000515

Ansloos, J., Stewart, S., Fellner, K., Goodwill, A., Graham, H., McCormick, R., Harder, H., & Mushquash, C. (2019). Indigenous peoples and professional training in psychology in Canada. Canadian Psychology/Psychologie canadienne, 60(4), 265–280. https://doi.org/10.1037/cap0000189

Assembly of First Nations & Health Canada. (2015). The First Nations mental wellness continuum framework. http://health.afn.ca/uploads/files/24-14-1273-fn-mental-wellness-framework-en05_low.pdf

Baijius, W., & Patrick, R. J. (2019). “We Don’t Drink the Water Here”: The Reproduction of Undrinkable Water for First Nations in Canada. Water, 11(5), 1079–1097. https://doi.org/10.3390/w11051079

Bellis, M.A., Lowey, H., Leckenby, N., Hughes, K. & Harrison, D. (2013). Adverse childhood experiences: Retrospective study to determine their impact on adult health behavior and health outcomes in a UK population. Journal of Public Health, 36(1), 81–91. https://doi.org/10.1093/pubmed/fdt038

Benuto, L. T., Casas, J., & O’Donohue, W. T. (2018). Training culturally competent psychologists: A systematic review of the training outcome literature. Training and Education in Professional Psychology, 12(3), 125–134. https://doi.org/10.1037/tep0000190

Bethune, R., Absher, N., Obiagwu, M., Qarmout, T., Steeves, M., Yaghoubi, M., … & Farag, M. (2019). Social determinants of self-reported health for Canada’s Indigenous peoples: a public health approach. Public Health, 176, 172–180. https://doi.org/10.1016/j.puhe.2018.03.007

Blake, J., Leppma, M., Mamboleo, G., Nauser, J., O’Toole, H., & Chan, F. (2020). Attachment and Hope as a Framework for Improving Depression Outcomes for Trauma Patients. Journal of Applied Rehabilitation Counseling, 51(2), 94–114. https://doi.org/10.1891/jarc-d-19-00005

Bolton, J. (2014). Further thoughts on the 4P Model. Philosophy, Psychiatry, & Psychology, 21(3), 215–218. https://doi.org/10.1353/ppp.2014.0027

Bombay, A., Matheson, K., & Anisman, H. (2011). The impact of stressors on second generation Indian residential school survivors. Transcultural Psychiatry, 48(4), 367–391.  https://doi.org/10.1177/1363461511410240

Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16(3), 252–260. https://doi.org/10.1037/h0085885

Bürgin, D., O’Donovan, A., d’Huart, D., di Gallo, A., Eckert, A., Fegert, J., … & Boonmann, C. (2019). Adverse Childhood Experiences and Telomere Length: A Look into the Heterogeneity of Findings. Frontiers in Neuroscience, 13(490), 1–14. https://doi.org/10.3389/fnins.2019.00490

Caldwell, J., & Sinha, V. (2020). (Re) Conceptualizing Neglect: Considering the Overrepresentation of Indigenous Children in Child Welfare Systems in Canada. Child Indicators Research, 13(2), 481–512. https://doi.org/10.1007/s12187-019-09676-w

Canadian Psychological Association & The Psychology Foundation of Canada. (2018). Psychology’s Response to the Truth and Reconciliation Commission of Canada’s Report. https://cpa.ca/docs/File/Task_Forces/TRC%20Task%20Force%20Report_FINAL.pdf

Causadias, J. M., Vitriol, J. A., & Atkin, A. L. (2018). Do we overemphasize the role of culture in the behavior of racial/ethnic minorities? Evidence of a cultural (mis) attribution bias in American psychology. American Psychologist, 73(3), 243–255. http://dx.doi.org/10.1037/amp0000099

Cave, L., Shepherd, C. C., Cooper, M. N., & Zubrick, S. R. (2019). Racial discrimination and the health and wellbeing of Aboriginal and Torres Strait Islander children: Does the timing of first exposure matter?. SSM-Population Health, 9, 100492. https://doi.org/10.1186/s12939-019-1045-8

Cénat, J. M. (2020). How to provide anti-racist mental health care. The Lancet Psychiatry, 7(11), 929–931. https://doi.org/10.1016/ S2215-0366(20)30309-6

Cooke, M., Mitrou, F., Lawrence, D., Guimond, E., & Beavon, D. (2007). Indigenous well-being in four countries: an application of the UNDP’S human development index to indigenous peoples in Australia, Canada, New Zealand, and the United States. BMC International Health and Human Rights, 7(1), 9–20. https://doi.org/10.1186/1472-698X-7-9

Currie, C. L., Copeland, J. L., & Metz, G. A. (2019). Childhood racial discrimination and adult allostatic load: The role of Indigenous cultural continuity in allostatic resiliency. Social Science & Medicine, 241, 112564. https://doi.org/j.socscimed.2019.112564

Dube, S. R., Felitti, V. J., Dong, M., Chapman, D. P., Giles, W. H., & Anda, R. F. (2003). Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study. Pediatrics, 111(3), 564–572. https://doi.org/10.1542/peds.111.3.564

Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventative Medicine, 14(4), 245–258. https://doi.org/1016/s0749-3797(98)00017-8

Finkelhor, D. (2018). Screening for adverse childhood experiences (ACEs): Cautions and suggestions. Child Abuse & Neglect, 85, 174–179. https://doi.org/10.1016/j.chiabu.2017.07.016

Finn, S. E., & Tonsager, M. E. (1997). Information-gathering and therapeutic models of assessment: Complementary paradigms. Psychological Assessment, 9(4), 374–385. https://doi.org/10.1037/1040-3590.9.4.374

Hajizadeh, M., Hu, M., Bombay, A., & Asada, Y. (2018). Socioeconomic inequalities in health among Indigenous Peoples living off-reserve in Canada: trends and determinants. Health Policy, 122(8), 854–865. https://doi.org/10.1016/j.healthpol.2018.06.011

Hamby, S., Schultz, K., & Elm, J. (2020). Understanding the burden of trauma and victimization among American Indian and Alaska native elders: historical trauma as an element of poly-victimization. Journal of Trauma & Dissociation, 21(2), 172–186. https://doi.org/10.1080/15299732.2020.1692408

Jaffe, A. E., DiLillo, D., Hoffman, L., Haikalis, M., & Dykstra, R. E. (2015). Does it hurt to ask? A meta-analysis of participant reactions to trauma research. Clinical Psychology Review, 40, 40–56. https://doi.org/10.1016/j.cpr.2015.05.004

Jennings, W., Bond, C., & Hill, P. S. (2018). The power of talk and power in talk: a systematic review of Indigenous narratives of culturally safe healthcare communication. Australian Journal of Primary Health, 24(2), 109–115. https://doi.org/10.1071/PY17082

Kalmakis, K. A., & Chandler, G. E. (2015). Health consequences of adverse childhood experiences: a systematic review. Journal of the American Association of Nurse Practitioners, 27(8), 457–465. https://doi.org/10.1002/2327-6924.12215

Karatzias, T., Shevlin, M., Fyvie, C., Grandison, G., Garozi, M., Latham, E., … & Hyland, P. (2020). Adverse and benevolent childhood experiences in Posttraumatic Stress Disorder (PTSD) and Complex PTSD (CPTSD): implications for trauma-focused therapies. European Journal of Psychotraumatology, 11(1), 1793599. https://doi.org/10.1080/20008198.2020.1793599

King, M., Smith, A., & Gracey, M. (2009). Indigenous health part 2: the underlying causes of the health gap. The Lancet, 374(9683), 76-85. http://www.indiaenvironmentportal.org.in/files/Indigenous%20health%20part%202.pdf

Langa, M. E., & Gone, J. P. (2019). Cultural context in DSM diagnosis: An American Indian case illustration of contradictory trends. Transcultural Psychiatry, 57(4), 567–580. https://doi.org/10.1177/1363461519832473

Levkoe, C. Z., Ray, L., & Mclaughlin, J. (2019). The Indigenous Food Circle: Reconciliation and resurgence through food in Northwestern Ontario. Journal of Agriculture, Food Systems, and Community Development, 9(Suppl. 2), 101–114. https://doi.org/10.5304/jafscd.2019.09B.008

Luther, A. (2019). Developing a More Culturally Appropriate Approach to Surveying Adverse Childhood Experiences Among Indigenous Peoples in Canada. (Master’s Thesis). https://uwspace.uwaterloo.ca/.

Ma, J., Fallon, B., & Richard, K. (2019). The overrepresentation of First Nations children and families involved with child welfare: findings from the Ontario incidence study of reported child abuse and neglect 2013. Child Abuse & Neglect, 90, 52–65. https://doi.org/10.1016/j.chiabu.2019.01.022

Maguire-Jack, K., Font, S. A., & Dillard, R. (2020). Child protective services decision-making: The role of children’s race and county factors. American Journal of Orthopsychiatry, 90(1), 48–62. https://doi.org/10.1037/ort0000388

Mashford-Pringle, A., Ring, I., Al-Yaman, F., Waldon, J., & Chino, M. (2019). Rethinking health services measurement for Indigenous populations. Statistical Journal of the IAOS, 35(1), 139–146. https://doi.org/10.3233/SJI-180465

McAdam, L., & Davis, C. (2019). Confronting power, privilege and oppression in trauma-informed school-based work: Framing the ALIVE model within critical race theory. Drama Therapy Review, 5(1), 85–101. https://doi.org/10.1386/dtr.5.1.85_1

McQuaid, R. J., Bombay, A., McInnis, O. A., Humeny, C., Matheson, K., & Anisman, H. (2017). Suicide ideation and attempts among First Nations peoples living on-reserve in Canada: The intergenerational and cumulative effects of Indian residential schools. The Canadian Journal of Psychiatry, 62(6), 422–430.  https://doi.org/10.1177/0706743717702075

Mersky, J. P., Lee, C. T. P., & Gilbert, R. M. (2019). Client and provider discomfort with an adverse childhood experiences survey. American Journal of Preventive Medicine, 57(2), e51–e58. https://doi.org/10.1016/j.amepre.2019.02.026

McLennan, J. D., McTavish, J. R., & MacMillan, H. L. (2019). Routine screening of ACEs: Should we or shouldn’t we?. In G. J. Asmundson, & T.O. Afifi (Eds.), Adverse Childhood Experiences: Using Evidence to Advance Research, Practice, Policy and Prevention (pp. 145-159). Academic Press.

Miller, W. R., & Rollnick, S. (2013). Applications of motivational interviewing.Motivational interviewing: Helping people change (3rd edition). Guilford Press.

Munoz, R. T., Hanks, H., & Hellman, C. M. (2020). Hope and resilience as distinct contributors to psychological flourishing among childhood trauma survivors. Traumatology, 26(2), 177–184. https://doi.org/10.1037/trm0000224

Mushquash, C. J., & Bova, D. L. (2007). Cross-cultural assessment and measurement issues. Journal on Developmental Disabilities, 13(1), 53–65. https://oadd.org/journal/volume-13-number-1-developmental-disabilities-and-the-native-canadian-community/

Narayan, A. J., Rivera, L. M., Bernstein, R. E., Harris, W. W., & Lieberman, A. F. (2018). Positive childhood experiences predict less psychopathology and stress in pregnant women with childhood adversity: A pilot study of the benevolent childhood experiences (BCEs) scale. Child Abuse & Neglect, 78, 19–30. http://doi.org/10.1016/j.chiabu.2017.09.022

Park, C. L. (2010). Making sense of the meaning literature: an integrative review of meaning making and its effects on adjustment to stressful life events. Psychological Bulletin, 136(2), 257–301. https://doi.org/10.1037/a0018301

Radford, A., Toombs, E., Zugic, K., Boles, K., Lund, L., & Mushquash, C. J. (October 15, 2020).  Examining Adverse Childhood Experiences (ACEs) within Indigenous populations: A systematic review. [Manuscript submitted for publication]. Lakehead University.

Read, J., Harper, D., Tucker, I., & Kennedy, A. (2018). Do adult mental health services identify child abuse and neglect? A systematic review. International Journal of Mental Health Nursing, 27(1), 7–19. https://doi.org/10.1111/inm.12369

Reading, C. L., & Wien, F. (2009). Health inequalities and the social determinants of Aboriginal peoples’ health. Prince George, BC: National Collaborating Centre for Aboriginal Health.

Rhee, T. G., Barry, L. C., Kuchel, G. A., Steffens, D. C., & Wilkinson, S. T. (2019). Associations of adverse childhood experiences with past‐year DSM‐5 psychiatric and substance use disorders in older adults. Journal of the American Geriatrics Society, 67(10), 2085–2093. https://doi.org/10.1111/jgs.16032

Shepherd, C. C., Li, J., Cooper, M. N., Hopkins, K. D., & Farrant, B. M. (2017). The impact of racial discrimination on the health of Australian Indigenous children aged 5–10 years: analysis of national longitudinal data. International Journal for Equity in Health, 16(116), 1–12. https://doi.org/10.1186/s12939-017-0612-0

Skewes, M. C., & Blume, A. W. (2019). Understanding the link between racial trauma and substance use among American Indians. American Psychologist, 74(1), 88–100. https://doi.org/ 10.1037/amp0000331

Stavropoulos, K. K. M., Bolourian, Y., & Blacher, J. (2018). Differential diagnosis of autism spectrum disorder and post traumatic stress disorder: two clinical cases. Journal of Clinical Medicine, 7(4), 71–82. https://doi.org/10.3390/jcm7040071

Strathearn, L., Giannotti, M., Mills, R., Kisely, S., Najman, J., & Abajobir, A. (2020). Long-term cognitive, psychological, and health outcomes associated with child abuse and neglect. Pediatrics, 146(4), e20200438. https://doi.org/10.1542/peds.2020-0438

Truth and Reconciliation Commission of Canada. (2015).  Honouring the truth, reconciling for the future. http://www.myrobust.com/websites/trcinstitution/File/Reports/Executive_Summary_English_Web.pdf

Toombs, E. (2021). Examining Adverse Childhood Experiences in a First Nations treatment-seeking population. (Doctoral Dissertation, Lakehead University). https://knowledgecommons.lakeheadu.ca/bitstream/handle/2453/4756/ToombsE2021d-1a.pdf?sequence=1&isAllowed=y

Turabian, J. L. (2017). Family genogram in general medicine: A soft technology that can be strong. an update. Research in Medical and Engineering Sciences, 3, 1–6. https://doi.org/10.31031/rmes

Warne, D., & Lajimodiere, D. (2015). American Indian health disparities: Psychosocial influences. Social and Personality Psychology Compass, 9(10), 567–579. https://doi.org/10.1111/spc3.12198

Warne, D., & Wescott, S. (2019). Social determinants of American Indian nutritional health. Current Developments in Nutrition, 3(2) 12–18. https://doi.org/10.1093/cdn/nzz054

Weinberg, M., Besser, A., Zeigler-Hill, V., & Neria, Y. (2016). Bidirectional associations between hope, optimism and social support, and trauma-related symptoms among survivors of terrorism and their spouses. Journal of Research in Personality, 62, 29–38. https://doi.org/10.1016/j.jrp.2016.03.002

Wilk, P., Maltby, A., & Cooke, M. (2017). Residential schools and the effects on Indigenous health and well-being in Canada—a scoping review. Public health reviews, 38(1), 8–31. https://doi.org/10.1186/s40985-017-0055-6

Yeater, E. A., & Miller, G. F. (2014). ‘Sensitive’-Topics Research: Is It Really Harmful to Participants?. APS Observer, 27(5), https://www.psychologicalscience.org/observer/sensitive-topics-research-is-it-really-harmful-to-participants/comment-page-1