BACKGROUND:

Involvement with Child Protective Services (CPS) provides an opportunity to recognize those children at risk for ongoing adverse childhood experiences (ACEs). The relationship between ACEs and child health among CPS-involved children and the role of primary care providers (PCPs) in moderating this relationship is unknown.

METHODS:

We conducted a convergent mixed-methods study of caregivers of children age 2 to 12 years with a CPS finding of physical abuse, modeling the association between cumulative ACEs and child health-related quality of life (HRQoL) using the PedsQL4.0, a validated 23-item survey of multidimensional health, with and without the moderator of a patient-centered medical home. Interviews elicited descriptions of a child’s experience with ACEs, the impact of ACEs on child health, and the role of a PCP in this context.

RESULTS:

One hundred seventy-eight surveyed caregivers reported a mean of 5.5 (±3.3) ACE exposures per child. In a fully adjusted model, each ACE resulted in a 1.3-point (95% confidence interval: 0.7–2.0) reduction in HRQoL, a clinically important difference in HRQoL associated with ACE exposures. This association was explained by reduced psychosocial HRQoL and was not moderated by a patient-centered medical home. Twenty-seven interviewed caregivers described the influence of ACEs on a child’s health. Many felt that a trusted PCP could support a child’s well-being after such experiences.

CONCLUSIONS:

Children with CPS involvement have ACE exposures that are associated with reduced HRQoL. Although PCPs are often unaware of CPS involvement or other ACEs, many caregivers welcome the support of a child’s PCP in improving child well-being after adversity.

What’s Known on This Subject:

An accumulation of childhood adversities is associated with lifelong physical and mental health challenges. The moment of Child Protective Services involvement for abuse is a moment to provide medical and social supports for children with risk for ongoing adverse experiences.

What This Study Adds:

Children with a Child Protective Services finding of physical abuse carry a high burden of accumulated adversities. These adversities are associated with lower health-related quality of life. Caregivers identify pediatricians as potential support for children struggling with health after adversity.

Every year, 1 in 100 children in the United States is identified as a victim of child abuse by Child Protective Services (CPS).1  Despite mandated child welfare involvement, many children remain at high risk of ongoing exposure to adverse childhood experiences (ACEs) such as parental substance abuse, mental illness, and family violence. Past researchers have identified associations between cumulative ACEs and negative health outcomes.26  Recent findings suggest that negative outcomes associated with ACEs may be ameliorated through interventions to treat effects of previous adversities and prevent accumulation of additional adversities.7,8  Our research grows from a recognition that CPS involvement provides a window of opportunity to identify and engage with children most likely to benefit from such interventions.

Yet CPS is not designed to provide longitudinal relationships necessary to improve the health and well-being of children after abuse. In contrast, longitudinal relationships are central to the continuous care from birth through early adulthood provided in the patient-centered medical home (PCMH).9,10  Although commonly associated with the care of children with complex, chronic medical needs, the PCMH may also serve as a safety net for children with complex, chronic social needs to prevent abuse in children at risk and to address toxic stress in children after abuse.11,12 

Our previous research with mothers of children with a history of abuse identified a common desire for longitudinal support after CPS case closure to address challenges such as caregiver mental illness, financial insecurity, and child behavior problems.13  Few mothers identified a child’s primary care provider (PCP) as a potential source of such support despite growing recognition that a PCMH can and should provide the resources needed to effectively address these issues.1416  We undertook the current study to (1) examine the association between parent-reported ACEs and child health-related quality of life (HRQoL) and (2) understand the role of a PCMH in supporting child well-being among children with a recent CPS finding of physical abuse.

Quantitative survey data and qualitative interview data were collected simultaneously and assigned equal priority throughout data collection, analysis, and interpretation in this convergent mixed-methods study.17 

Participants were English- or Spanish-speaking parental caregivers of children 2 to 12 years of age remaining at home after a CPS investigation resulting in a substantiated finding of child physical abuse between November 2015 and March 2017.

The Utah Division of Child and Family Services (DCFS) introduced this research to eligible caregivers within 6 weeks of CPS case closure. Interested caregivers were contacted by a University of Utah investigator to obtain informed consent. Consenting caregivers completed a 45- to 60-minute telephone survey. A subset completed a 30- to 75-minute interview, with purposeful sampling to maximize variation across child and caregiver characteristics. Interviews were conducted by 2 investigators (EG and KAC), audio-recorded, and transcribed in Spanish or English.

The Institutional Review Boards of the University of Utah and the Utah Department of Human Services approved all study procedures.

Quantitative

Caregivers identified adverse experiences for their child through a modified ACEs instrument capturing 10 traditional ACEs and 7 additional ACEs drawn from the literature to provide a total score between 0 and 17 (Supplemental Figure 3).2,18,19 

Qualitative

We conducted semistructured interviews in which caregivers described a difficult experience for their child (Question 1, Supplemental Figure 4). We adopted a phenomenological approach to explore the lived experiences of caregivers guiding a child through a traumatic event.20 

Child well-being was expressed as caregiver-reported HRQoL. The PedsQL4.0 is a 23-item survey of physical and psychosocial health that provides total and subscale scores between 0 and 100. Higher scores reflect better HRQoL. The PedsQL4.0 has been validated in multiple settings, with a mean total score of 83.0 ± 14.8 among healthy children age 2 to 18 years and a minimal clinically important difference of ±4.5.2123 

Quantitative

We hypothesized that support provided by a PCMH might moderate negative effects of ACEs on HRQoL. PCMH was defined by caregiver responses to the AHRQ Consumer Assessment of Healthcare Providers and Systems Clinician and Group Surveys.24 

Qualitative

Caregivers were asked to describe their child’s PCP and when that provider had helped with a “difficult problem” (Question 7, Supplemental Figure 4). If caregivers could not provide an example, probes explored the response of the PCP to recent CPS involvement.

We used DCFS-reported demographics to describe the eligible sample and caregiver-reported demographics to describe surveyed participants. The 5-item Children with Special Health Care Needs (CSHCN) Screener was used to identify CSHCN, who were expected to have lower HRQoL.25,26  The General Self-Efficacy Scale identified low caregiver self-efficacy, because this might reduce caregiver ability to identify and access resources supporting child well-being.27  The Patient Health Questionnaire-4 captured symptoms of caregiver depression and anxiety, which might influence perceptions of child well-being.28 

Quantitative

A total of 174 survey participants was needed for 90% power to detect the minimal clinically important difference in HRQoL (±4.5 points) between children with low, medium, and high levels of ACEs.

Qualitative

We sought to interview caregivers to thematic saturation, or the point at which no new themes emerged from the narratives.20 

Quantitative

Descriptive statistics of the eligible population and the participating sample were compared. We defined total ACEs as the count of different adversity types (0–17) and categorized children into low, moderate, and high exposure groups based on counts falling below, within, and above the interquartile range of ACEs for the survey sample, respectively. We compared HRQoL reported for our sample to previously published population norms of children with and without chronic illnesses including ADHD, asthma, and diabetes.22,29  Covariates with a bivariate association with our exposure (ACEs), outcome (HRQoL), or moderator (PCMH) at a level of P ≤ .25 were included in multivariable linear regression models to provide adjusted estimates of the association between ACEs and HRQoL.

Qualitative

Interviews were initially read by 2 investigators (EG and KAC) in the original language. These investigators proposed codes for salient concepts as they emerged during rereading. To ensure code consistency and reduce potential bias, transcripts and proposed codes were provided to a University of Utah qualitative research team composed of 4 coders. This team reanalyzed English-language transcripts using a similar open-coding approach, meeting regularly for intercoder adjudication for code reliability and agreement. Exemplar quotes for codes were identified through both of these processes, with Spanish-language quotes translated by a native Spanish-speaking investigator (EG).

Convergent

During data collection, descriptive statistics of survey participants were maintained to ensure sampling of caregivers with both typical and outlier experiences for interviews. The sampling matrix and interview guide were revised on the basis of emerging results. During data analysis, quantitative findings were used to explore emerging qualitative themes, while unanticipated qualitative themes inspired secondary quantitative analyses. During interpretation, qualitative themes provided context for quantitative findings, whereas quantitative findings highlighted themes within our qualitative data with potentially generalizable implications.17,30 

DCFS identified 646 eligible caregivers with a recent CPS finding of physical abuse in a child age 2 to 12 years. Caregivers contacted by the study team (n = 319, 49.4%) had fewer maltreatment types supported in the recent CPS investigation (1.5 vs 1.7), lower rates of previous CPS involvement (24.8% vs 35.8%), and less concern for domestic violence–related child abuse (13.5% vs 19.3%) or drug exposure and/or child endangerment (6.9% vs 14.1%) than noncontacted caregivers (all P < .05).

Among caregivers contacted for study consent, 178 (55.5%) completed the survey. Twenty-seven caregivers completed an interview. Participating caregivers were less likely to have a finding of neglect (3.4%) than caregivers declining participation (9.2%). Spanish-speaking caregivers were more likely to consent (88.0%) than English-speaking caregivers (52.7%) (all P < .05).

Surveyed caregivers averaged age 34.2 years, with 39.1% living in households below the federal poverty level. Fourteen percent endorsed concerning levels of emotional distress, and 15.3% had low self-efficacy. Children averaged age 7.2 years, with 14.7% identified as a racial minority and 29.4% of Hispanic or Latinx ethnicity. Almost half (46.3%) met CSHCN criteria (Table 1).

TABLE 1

Baseline Demographics

Surveyed Caregivers n = 177 (%)Interviewed Caregivers n = 27 (%)
Caregivers   
 Age, y, mean (± SD) 34.2 (±7.4) 33.9 (±8.5) 
 Maternal caregivera 153 (86.4) 22 (81.5) 
 Spanish-language preference 22 (12.4) 8 (29.6) 
 No high school degree 27 (15.3) 6 (22.2) 
 Below federal poverty level 69 (39.0) 11 (40.7) 
 Anxious or depressive symptomsb 25 (14.1) 5 (18.5) 
 Low self-efficacyc 27 (15.3) 7 (25.9) 
Children   
 Age, y, mean (± SD) 7.2 (±2.7) 7.3 (±2.6) 
 Male sex 113 (63.8) 18 (66.7) 
 Minority race or ethnicityd 74 (41.8) 15 (55.6) 
 Special health care neede 82 (46.3) 13 (48.2) 
Health care   
 Public payer 84 (48.0) 16 (59.3) 
 Uninsured 17 (9.6) 3 (11.1) 
 Identified PCP 159 (90.4) 25 (92.6) 
Child welfaref   
 >1 form of child maltreatment 43 (24.3) 8 (29.6) 
 Past CPS involvement in household 49 (27.7) 10 (37.0) 
 In-home postinvestigation services 40 (22.6) 9 (33.3) 
Surveyed Caregivers n = 177 (%)Interviewed Caregivers n = 27 (%)
Caregivers   
 Age, y, mean (± SD) 34.2 (±7.4) 33.9 (±8.5) 
 Maternal caregivera 153 (86.4) 22 (81.5) 
 Spanish-language preference 22 (12.4) 8 (29.6) 
 No high school degree 27 (15.3) 6 (22.2) 
 Below federal poverty level 69 (39.0) 11 (40.7) 
 Anxious or depressive symptomsb 25 (14.1) 5 (18.5) 
 Low self-efficacyc 27 (15.3) 7 (25.9) 
Children   
 Age, y, mean (± SD) 7.2 (±2.7) 7.3 (±2.6) 
 Male sex 113 (63.8) 18 (66.7) 
 Minority race or ethnicityd 74 (41.8) 15 (55.6) 
 Special health care neede 82 (46.3) 13 (48.2) 
Health care   
 Public payer 84 (48.0) 16 (59.3) 
 Uninsured 17 (9.6) 3 (11.1) 
 Identified PCP 159 (90.4) 25 (92.6) 
Child welfaref   
 >1 form of child maltreatment 43 (24.3) 8 (29.6) 
 Past CPS involvement in household 49 (27.7) 10 (37.0) 
 In-home postinvestigation services 40 (22.6) 9 (33.3) 

Italicized variables are included in all multiple variable regression models based on association with predictor (total ACEs), outcome (total HRQoL), or moderator (PCMH) at a level of P ≤ .25.

a

Includes biological mother, adoptive mother, grandmother, or aunt.

b

Moderate or severe psychological distress in parental caregiver as indicated by a score ≥6 on the Patient Health Questionnaire-4.

c

Low self-efficacy in parental caregiver as indicated by a score ≤30 on the General Self-Efficacy Scale.

d

Includes 26 children of minority race (14.8%) and 51 children of Hispanic or Latinx ethnicity (29.0%).

e

Caregiver identifies ≥1 current functional limitations or service needs as a result of ongoing physical, emotional, behavioral, developmental, or health conditions on the CSHCN Screener.

f

Child welfare history was associated with ACEs and HRQoL in bivariate analysis but not included in multivariable model because of theoretical collinearity with ACEs.

Surveyed caregivers endorsed an average of 5.5 (±3.3) ACEs for each child. Low-, moderate-, and high-exposure categories were defined by 0 to 3, 4 to 7, and 8 to 17 ACEs, respectively. The frequency of different ACEs ranged from parental divorce or separation (61.6%) to severe social isolation (1.1%) (Fig 1). Although all children in the study had a recent CPS investigation finding of physical abuse, 40.7% of caregivers did not identify physical abuse as an adversity experienced by their child.

FIGURE 1

Frequency of parent-reported ACEs in children 2 to 12 years of age after a CPS finding of child physical abuse.

FIGURE 1

Frequency of parent-reported ACEs in children 2 to 12 years of age after a CPS finding of child physical abuse.

Interviews supported these findings. Although some participants described physical abuse or witnessed violence when asked to share a difficult experience for their child, many identified emotional traumas, such as kidnapping by an abusive parent, witnessing arrest of a parent, or separation from a supportive parent because of divorce, foster care, or incarceration (Table 2A).

TABLE 2

Caregiver Descriptions of ACEs, Child Well-Being, and PCP Relationships: Participants Identified Based on Relationship to Child, Age, Race, Ethnicity, and Language of Interview

ThemeCodeQuote
A: ACEs: tell me about something that your child has experienced in his or her life that has been particularly hard or difficult for him or her. Physical trauma ID5:Mother:41:W:NH:English 
  It was over my son having an accident in his pants. And my ex, who is not his biological father, started beating on him, so I threw myself over him and I got kicked off of him across the room. And [child] started being beaten, so I threw myself back on top of him. Then I got punched in the head repetitively. [My child] was screaming. I was screaming, obviously. We were punched, kicked, drop-kicked, and everything. It was very fearful, very emotional, very scared. 
  ID226:Mother:29:W:NH:English 
  [My son] said that he had a really hard time even saying the words, you know, “Daddy smacked me in the face,” or he had a really hard time describing how it felt. That incident you can tell was very traumatic, which was hard for me because we had never talked about that incident since it occurred. 
  ID47000:Mother:33:W:H:Spanish 
  He didn’t want to tell me when the teacher hit him, he didn’t want to tell me…he finally says, “I do not want to tell you because you’re going to go fight with the teacher.” I said, “Fight for what reason? What did the she do? What did the teacher do to you?” Then he said, “Well, she hit me.” “What do you mean she hit you?” “Yes, she hit me,” he told me. I said, “Where did she hit you?” This was the moment he showed me his head. He told me, “She hit me here.” 
 Emotional trauma ID46000:Mother:31:W:H:Spanish 
  What happened was that the aunt of my son...entered my house and hit me. She hit me…. So then I just grabbed my son, because he was crying. I just grabbed him and I told him to calm down, that everything was fine. Then, when I grabbed my son, I just grabbed the only thing I could, I grabbed my phone and dialed 911 and told them what was happening. And then the police arrived. 
  ID328:Mother:29:AI/AN:NH:English 
  Her seeing her dad pick me up and throw me like that and then lie about it. Because he said that I slipped and I didn’t slip, and she just – it just affected her so bad, I mean, emotionally and mentally. Because she saw it and she had to lie about it and she didn’t feel safe around her dad. 
  ID131:Aunt:36:W:NH:English 
  [Their mother] left them in a car for I guess some time while she was, who knows, doing what, I have no idea. But I do recall that conversation. They were very scared. They didn’t know where she was, they didn’t know where they were. We were able to find them through the find my iPhone app, which was obviously good, but…very traumatic experience, very scared…something kids just don’t need to go through, period. 
  ID94:Grandmother:61:W:NH:English 
  What ended up happening is my husband ended up dying. So [my grandson], again, 3 years after he met him, and he’s the only daddy that he remembers. He died of lung cancer. He watched him go down. That also is a trauma for him. So every way, if he’s loved somebody, if something has happened where he has said something where they can’t see him anymore or they have died. 
  ID21000:Father:29:W:H:Spanish 
  [His mother] preferred to go with that man, with that person, than to have her children by her side. Without any explanation she just grabbed and left. I mean, she abandoned them then. ... Well [my son] was very attached to her and would say, “Well, how…? I am very attached to her and she is abandoning me” 
B: ACEs and child well-being: How do you think that this difficult experience might have affected your child’s well-being? Physical well-being ID209:Mother:32:W:NH:English
His physical health is pretty good, he has an immune system like steel box, nothing gets in there. If he does get sick, it kicks his butt, but within 3 days, he is right back to being healthy. I have 3 kids and he is the only one who will eat broccoli before he will even touch cupcakes. 
  ID47000:Mother:33:W:H:Spanish 
  Well, I think it is that my son is well, both emotionally and physically, that they care about my child’s health, about his total well-being, which would be about how my son lives. Well, everything. Be aware and worry about everything, both for education and health, for everything. 
  ID328:Mother:29:AI/AN:NH:English 
  Her physical health and stuff, she’s excellent. Like her height and her weight and stuff just like health wise, she’s above average. So she’s really good and she doesn’t have any allergies or anything like that. She’s very healthy. She’s tall for her age. Health wise and dental wise, she’s good. Like she’s perfect. 
 Emotional well-being ID494:Mother:35:W:NH:English 
  I feel like she’s still dealing with that anger. Right now she’s exhibiting signs of not hearing me when I talk to her and when I tell her to do something, she will ignore me. 
  ID131:Aunt:36:W:NH:English 
  She’s 4 now, I’ve had her more of her life than her mother or her father has had her. So, I think that that right there is just a super traumatic experience, and it’s very confusing for her, not knowing where she belongs or where her place is, where her parents are, why doesn’t she have a mom and dad, why does she go back and forth from my house to another person’s house. I think that that has been a big effect on her and her view on life. 
  ID46000:Mother:31:W:H:Spanish 
  When my son falls asleep, at night he gets up scared. He gets up and tells me, “Mommy, mommy, there comes [my aunt], get up, mommy, mommy” and shouts it. And there are times he still does. Yes, it is the most difficult thing he has seen, because he has never seen anything like that. He had never seen anything, nothing, absolutely nothing like this. He had never seen this. 
  ID28000:Mother:33:W:H:Spanish 
  He sits down and stays quite sad. “What’s going to happen, mommy? Are you okay?,” he always becomes pensive, he sits down and remains quite calm. “What happened?” or “what will happen?” or “what is this?” He's small, he doesn't know, he just asks. 
C: PCP response: Tell me about the person who sees your child for medical care. Help with a difficult problem ID494:Mother:35:W:NH:English 
  We really haven’t had any difficult problems with her where [my child’s doctor] been able to help. 
  ID541:Father:32:W:NH:English 
  She’s cried when he gave her a shot and then helps to make her feel better afterward. Besides that I don’t really have any examples… 
  ID336:Mother:27:W:H:English 
  Just seeing her about diabetes, giving us information on how to change his diet, more things to do. I can call her any time if I have any questions, anything; she just gives me so much information that’s helpful. You know, like explaining like his blood work to me and what this is or what she tested for. 
  ID514:Father:31:W:NH:English 
  [My son] was having problems going to the bathroom…It was like 2:30 or 3 o’clock in the morning. [My son’s doctor] helped us with everything. We ended up going over and getting some blood tests done at [the hospital]. He kept us in the loop every minute that the tests were going on. 
  ID5:Mother:41:W:NH:English 
  [My son] had started being very depressed, very closed off, very angry, very always wanting to be alone. So I took him to the doctor and they got concerned about depression, and how there was nothing enjoyable to him anymore. So they put him on antidepressants and we did weekly check-ins to make sure that the antidepressant wasn’t going to cause any suicidal thoughts or anything like that…his doctor would always have me leave the room and ask [my son], “How are you doing? Your mom isn’t in here. You don’t have to worry about hurting her feelings or worrying her. How are you doing?” 
 Support after CPS involvement ID28000:Mother:33:W:H:Spanish 
  He has been my doctor since I was pregnant. And when my son was born, he was ill for 1 month. He had pneumonia and he got very sick. And [the doctor] was, really, well aware of my son. And I think that is how he has helped me, in that my child is well. Then regularly, he has continued to see him when he goes to his vaccination appointments and…I feel confident in them. Because my son was very sick since he was little. They gave me confidence that everything would be fine. 
  ID209:Mother:32:W:NH:English 
  [The doctor] always said, if you have a problem bring [your son] in to me and I will do whatever I can to help you. He reminds me every time we see him, even if it is an appointment for one of my other kids. He knows that there is that history for my son, but he has also said that in regards to my other kids. It is comforting to know that he has been so supportive. 
  ID292:Mother:29:W:H:English 
  So we always talk and I told [the doctor] [about the abuse], and he was concerned…I was like 16 when I had my first son. I was just a small kid taking my baby to him and with no support. So he seen me go through a lot, and I would always talk to him. And he would just tell me there's always help. 
 Imagining the unknown ID328:Mother:29:AI/AN:NH:English 
  I think [the doctor] probably would be really concerned to make sure [my daughter] is getting the help she needs to overcome it. Like therapy, she’d probably ask to make sure she’s eating well and suggesting things in a good manner. 
  ID48000:Mother:30:W:H:Spanish: 
  He is a good pediatrician, pediatrician; he is one of those doctors who not only goes to the office and sees you and remembers you. He is one of the doctors that if he sees you in the street, he… will greet you and remember you by name and asks me about my son, my children. And if I have not taken them to the check-up, he is on the lookout and says, “Hey, you have not taken the children to the pediatrician, to have them checked. You need to make an appointment” and so on. [But]…I hardly comment much on [CPS involvement] to him. Simply, when I go to visit him, he begins to talk about the changes in his body, in the way that he should not let anyone touch him unless his mother is there, so that's it. 
  ID396:Mother:24:W:H:English 
  I don’t know what [the doctor’s] reaction would be. I really don’t know. I’d hope she doesn’t judge. 
  ID268:Mother:28:AI/AN:NH:English 
  I think that [the doctor] would be a little more understanding with [my child]. I think he’d slow down and take more time and I guess he’d be more understanding, and a little more attentive. 
ThemeCodeQuote
A: ACEs: tell me about something that your child has experienced in his or her life that has been particularly hard or difficult for him or her. Physical trauma ID5:Mother:41:W:NH:English 
  It was over my son having an accident in his pants. And my ex, who is not his biological father, started beating on him, so I threw myself over him and I got kicked off of him across the room. And [child] started being beaten, so I threw myself back on top of him. Then I got punched in the head repetitively. [My child] was screaming. I was screaming, obviously. We were punched, kicked, drop-kicked, and everything. It was very fearful, very emotional, very scared. 
  ID226:Mother:29:W:NH:English 
  [My son] said that he had a really hard time even saying the words, you know, “Daddy smacked me in the face,” or he had a really hard time describing how it felt. That incident you can tell was very traumatic, which was hard for me because we had never talked about that incident since it occurred. 
  ID47000:Mother:33:W:H:Spanish 
  He didn’t want to tell me when the teacher hit him, he didn’t want to tell me…he finally says, “I do not want to tell you because you’re going to go fight with the teacher.” I said, “Fight for what reason? What did the she do? What did the teacher do to you?” Then he said, “Well, she hit me.” “What do you mean she hit you?” “Yes, she hit me,” he told me. I said, “Where did she hit you?” This was the moment he showed me his head. He told me, “She hit me here.” 
 Emotional trauma ID46000:Mother:31:W:H:Spanish 
  What happened was that the aunt of my son...entered my house and hit me. She hit me…. So then I just grabbed my son, because he was crying. I just grabbed him and I told him to calm down, that everything was fine. Then, when I grabbed my son, I just grabbed the only thing I could, I grabbed my phone and dialed 911 and told them what was happening. And then the police arrived. 
  ID328:Mother:29:AI/AN:NH:English 
  Her seeing her dad pick me up and throw me like that and then lie about it. Because he said that I slipped and I didn’t slip, and she just – it just affected her so bad, I mean, emotionally and mentally. Because she saw it and she had to lie about it and she didn’t feel safe around her dad. 
  ID131:Aunt:36:W:NH:English 
  [Their mother] left them in a car for I guess some time while she was, who knows, doing what, I have no idea. But I do recall that conversation. They were very scared. They didn’t know where she was, they didn’t know where they were. We were able to find them through the find my iPhone app, which was obviously good, but…very traumatic experience, very scared…something kids just don’t need to go through, period. 
  ID94:Grandmother:61:W:NH:English 
  What ended up happening is my husband ended up dying. So [my grandson], again, 3 years after he met him, and he’s the only daddy that he remembers. He died of lung cancer. He watched him go down. That also is a trauma for him. So every way, if he’s loved somebody, if something has happened where he has said something where they can’t see him anymore or they have died. 
  ID21000:Father:29:W:H:Spanish 
  [His mother] preferred to go with that man, with that person, than to have her children by her side. Without any explanation she just grabbed and left. I mean, she abandoned them then. ... Well [my son] was very attached to her and would say, “Well, how…? I am very attached to her and she is abandoning me” 
B: ACEs and child well-being: How do you think that this difficult experience might have affected your child’s well-being? Physical well-being ID209:Mother:32:W:NH:English
His physical health is pretty good, he has an immune system like steel box, nothing gets in there. If he does get sick, it kicks his butt, but within 3 days, he is right back to being healthy. I have 3 kids and he is the only one who will eat broccoli before he will even touch cupcakes. 
  ID47000:Mother:33:W:H:Spanish 
  Well, I think it is that my son is well, both emotionally and physically, that they care about my child’s health, about his total well-being, which would be about how my son lives. Well, everything. Be aware and worry about everything, both for education and health, for everything. 
  ID328:Mother:29:AI/AN:NH:English 
  Her physical health and stuff, she’s excellent. Like her height and her weight and stuff just like health wise, she’s above average. So she’s really good and she doesn’t have any allergies or anything like that. She’s very healthy. She’s tall for her age. Health wise and dental wise, she’s good. Like she’s perfect. 
 Emotional well-being ID494:Mother:35:W:NH:English 
  I feel like she’s still dealing with that anger. Right now she’s exhibiting signs of not hearing me when I talk to her and when I tell her to do something, she will ignore me. 
  ID131:Aunt:36:W:NH:English 
  She’s 4 now, I’ve had her more of her life than her mother or her father has had her. So, I think that that right there is just a super traumatic experience, and it’s very confusing for her, not knowing where she belongs or where her place is, where her parents are, why doesn’t she have a mom and dad, why does she go back and forth from my house to another person’s house. I think that that has been a big effect on her and her view on life. 
  ID46000:Mother:31:W:H:Spanish 
  When my son falls asleep, at night he gets up scared. He gets up and tells me, “Mommy, mommy, there comes [my aunt], get up, mommy, mommy” and shouts it. And there are times he still does. Yes, it is the most difficult thing he has seen, because he has never seen anything like that. He had never seen anything, nothing, absolutely nothing like this. He had never seen this. 
  ID28000:Mother:33:W:H:Spanish 
  He sits down and stays quite sad. “What’s going to happen, mommy? Are you okay?,” he always becomes pensive, he sits down and remains quite calm. “What happened?” or “what will happen?” or “what is this?” He's small, he doesn't know, he just asks. 
C: PCP response: Tell me about the person who sees your child for medical care. Help with a difficult problem ID494:Mother:35:W:NH:English 
  We really haven’t had any difficult problems with her where [my child’s doctor] been able to help. 
  ID541:Father:32:W:NH:English 
  She’s cried when he gave her a shot and then helps to make her feel better afterward. Besides that I don’t really have any examples… 
  ID336:Mother:27:W:H:English 
  Just seeing her about diabetes, giving us information on how to change his diet, more things to do. I can call her any time if I have any questions, anything; she just gives me so much information that’s helpful. You know, like explaining like his blood work to me and what this is or what she tested for. 
  ID514:Father:31:W:NH:English 
  [My son] was having problems going to the bathroom…It was like 2:30 or 3 o’clock in the morning. [My son’s doctor] helped us with everything. We ended up going over and getting some blood tests done at [the hospital]. He kept us in the loop every minute that the tests were going on. 
  ID5:Mother:41:W:NH:English 
  [My son] had started being very depressed, very closed off, very angry, very always wanting to be alone. So I took him to the doctor and they got concerned about depression, and how there was nothing enjoyable to him anymore. So they put him on antidepressants and we did weekly check-ins to make sure that the antidepressant wasn’t going to cause any suicidal thoughts or anything like that…his doctor would always have me leave the room and ask [my son], “How are you doing? Your mom isn’t in here. You don’t have to worry about hurting her feelings or worrying her. How are you doing?” 
 Support after CPS involvement ID28000:Mother:33:W:H:Spanish 
  He has been my doctor since I was pregnant. And when my son was born, he was ill for 1 month. He had pneumonia and he got very sick. And [the doctor] was, really, well aware of my son. And I think that is how he has helped me, in that my child is well. Then regularly, he has continued to see him when he goes to his vaccination appointments and…I feel confident in them. Because my son was very sick since he was little. They gave me confidence that everything would be fine. 
  ID209:Mother:32:W:NH:English 
  [The doctor] always said, if you have a problem bring [your son] in to me and I will do whatever I can to help you. He reminds me every time we see him, even if it is an appointment for one of my other kids. He knows that there is that history for my son, but he has also said that in regards to my other kids. It is comforting to know that he has been so supportive. 
  ID292:Mother:29:W:H:English 
  So we always talk and I told [the doctor] [about the abuse], and he was concerned…I was like 16 when I had my first son. I was just a small kid taking my baby to him and with no support. So he seen me go through a lot, and I would always talk to him. And he would just tell me there's always help. 
 Imagining the unknown ID328:Mother:29:AI/AN:NH:English 
  I think [the doctor] probably would be really concerned to make sure [my daughter] is getting the help she needs to overcome it. Like therapy, she’d probably ask to make sure she’s eating well and suggesting things in a good manner. 
  ID48000:Mother:30:W:H:Spanish: 
  He is a good pediatrician, pediatrician; he is one of those doctors who not only goes to the office and sees you and remembers you. He is one of the doctors that if he sees you in the street, he… will greet you and remember you by name and asks me about my son, my children. And if I have not taken them to the check-up, he is on the lookout and says, “Hey, you have not taken the children to the pediatrician, to have them checked. You need to make an appointment” and so on. [But]…I hardly comment much on [CPS involvement] to him. Simply, when I go to visit him, he begins to talk about the changes in his body, in the way that he should not let anyone touch him unless his mother is there, so that's it. 
  ID396:Mother:24:W:H:English 
  I don’t know what [the doctor’s] reaction would be. I really don’t know. I’d hope she doesn’t judge. 
  ID268:Mother:28:AI/AN:NH:English 
  I think that [the doctor] would be a little more understanding with [my child]. I think he’d slow down and take more time and I guess he’d be more understanding, and a little more attentive. 

AI/AN, American Indian/Alasanka Alaska Native; H, Hispanic; ID, subject identifier; NH, non-Hispanic; W, white.

a

Comparison P ≤ .001.

Surveyed caregivers reported a mean HRQoL of 76.6 (±15.4) for children with a recent history of physical abuse, 4.7 points lower than published norms (P = .001) and comparable to CSHCN (Tables 3 and 4). This reduction in total HRQoL was entirely attributable to low psychosocial health. Although physical HRQoL for the surveyed population was 6.7 points higher than described in a general population, psychosocial HRQoL was 8.1 points lower (both P < .001).22 

TABLE 3

Parent-Reported HRQoL Among Children With Recent CPS Involvement for Child Physical Abuse Compared to HRQoL in a General Pediatric Population

HRQoL Scores in CPS-Involved Children Versus General Pediatric PopulationcClinically Important DifferenceaGeneral PopulationCPS-Involved SampleDifference: CPS-Involved Versus Population Norms
 Total HRQoL 4.5 81.3 (±15.9) 76.6 (±15.4) −4.7b 
  Physical HRQoL 6.9 83.3 (±20.0) 89.9 (±13.5) +6.7b 
  Psychosocial HRQoL 5.5 80.2 (±15.8) 72.1 (±17.8) −8.1b 
HRQoL Scores in CPS-Involved Children Versus General Pediatric PopulationcClinically Important DifferenceaGeneral PopulationCPS-Involved SampleDifference: CPS-Involved Versus Population Norms
 Total HRQoL 4.5 81.3 (±15.9) 76.6 (±15.4) −4.7b 
  Physical HRQoL 6.9 83.3 (±20.0) 89.9 (±13.5) +6.7b 
  Psychosocial HRQoL 5.5 80.2 (±15.8) 72.1 (±17.8) −8.1b 
a

Child well-being reflected as parent-reported HRQoL measured with the PedsQL4.0, a 23-item survey of physical and psychosocial health that provides total and subscale scores between 0–100. Higher scores reflect better HRQoL.

b

The minimal clinically important difference reflects the smallest difference that a patient perceives as beneficial and would support a change in patient management.22

c

Comparison P ≤ .001.

TABLE 4

Parent-reported HRQoL Among Children With Recent CPS Involvement for Child Physical Abuse Compared to HRQoL in a General Pediatric Population, Stratified by Child Health Status

HRQoL Scores in CPS-Involved Children Versus General Pediatric Population Stratified on Child Health StatusaChildren in Good HealthChildren With Chronic IllnessbCPS-Involved SampleDifference: Good HealthDifference: Chronic Illness
 Total HRQoL 87.6 (±12.3) 74.2 (±18.4) 76.6 (±15.4) −11.0c +2.4 
  Physical HRQoL 89.3 (±16.4) 73.3 (±27.0) 89.9 (±13.5) 0.6 +16.6c 
  Psychosocial HRQoL 86.6 (±12.8) 74.8 (±18.2) 72.1 (±17.8) −14.5c −2.8 
HRQoL Scores in CPS-Involved Children Versus General Pediatric Population Stratified on Child Health StatusaChildren in Good HealthChildren With Chronic IllnessbCPS-Involved SampleDifference: Good HealthDifference: Chronic Illness
 Total HRQoL 87.6 (±12.3) 74.2 (±18.4) 76.6 (±15.4) −11.0c +2.4 
  Physical HRQoL 89.3 (±16.4) 73.3 (±27.0) 89.9 (±13.5) 0.6 +16.6c 
  Psychosocial HRQoL 86.6 (±12.8) 74.8 (±18.2) 72.1 (±17.8) −14.5c −2.8 
a

Child well-being reflected as parent-reported HRQoL measured with the PedsQL4.0, a 23-item survey of physical and psychosocial health that provides total and subscale scores between 0–100. Higher scores reflect better HRQoL.

b

Total and domain scores among children with chronic illnesses, including diabetes, asthma, and attention deficit disorder.23,29

c

Comparison P ≤ .001.

TABLE 5

Parent-Reported HRQoL Among Children With Recent CPS Involvement for Child Physical Abuse Stratified by Number of Parent-Reported ACEs

HRQoL Scores in CPS-Involved Children With Low, Moderate, and High ACE Exposuresa,bLow ACEs (0–3)Mod ACEs (4–7)High ACEs (8–17)Difference: CPS-Involved With High Versus Low ACEs
 Total HRQoL 84.5 (±14.1) 75.4 (±14.8) 70.1 (±14.2) −14.5c 
  Physical HRQoL 92.1 (±15.7) 89.6 (±12.6) 88.0 (±12.5) −4.1 
  Psychosocial HRQoL 81.8 (±15.5) 70.5 (±17.0) 64.1 (±16.7) −17.9c 
HRQoL Scores in CPS-Involved Children With Low, Moderate, and High ACE Exposuresa,bLow ACEs (0–3)Mod ACEs (4–7)High ACEs (8–17)Difference: CPS-Involved With High Versus Low ACEs
 Total HRQoL 84.5 (±14.1) 75.4 (±14.8) 70.1 (±14.2) −14.5c 
  Physical HRQoL 92.1 (±15.7) 89.6 (±12.6) 88.0 (±12.5) −4.1 
  Psychosocial HRQoL 81.8 (±15.5) 70.5 (±17.0) 64.1 (±16.7) −17.9c 
a

Child well-being reflected as parent-reported HRQoL measured with the PedsQL4.0, a 23-item survey of physical and psychosocial health that provides total and subscale scores between 0–100. Higher scores reflect better HRQoL.

b

ACE score (0–17) reflects parent report of 10 traditional ACEs and 7 additional ACEs drawn from the literature.2,18,19 Low, moderate, and high exposures defined by tertiles within study sample.

c

Comparison P ≤ .001.

We identified a significant, stepwise reduction in HRQoL between children with low, moderate, and high ACEs exposures (Table 5). Children with high ACEs had HRQoL 14.5 points lower (95% confidence interval [CI]: −20.1 to −8.9) than children with low ACEs. Stepwise reductions in physical HRQoL (−4.1 points, 95% CI: −9.4 to 1.1) and psychosocial HRQoL (−17.9 points, 95% CI: −24.3 to −11.4) were seen with rising ACEs.

In unadjusted linear regression, each reported ACE was associated with a 2.0-point (95%CI 1.4 to 2.6) reduction in total HRQoL (Fig 2). In a fully adjusted model, this association persisted with attenuated strength, with each reported ACE associated with a 1.3-point (95% CI: 0.7 to 2.0) reduction in HRQoL (Tables 3 through 5).

FIGURE 2

Child HRQoL by total ACEs.

FIGURE 2

Child HRQoL by total ACEs.

Consistent with these quantitative findings, interviewed caregivers often voiced concerns for the emotional or behavioral health of their children. Although few identified any association between ACEs and physical health, many made clear connections between these experiences and the emotional well-being of their children (Table 2B).

Ninety percent of caregivers identified a PCP for their child; 83.1% reported ≥1 visit with this PCP in the previous year. Of this sample, 29.9% met PCMH criteria.24  In bivariate analysis, a PCMH was associated with a significantly lower HRQoL (−9.1 points, 95% CI: −14.6 to −3.6). No association was identified in a model accounting for special health care needs (−0.8 points, 95% CI: −5.7 to +4.6) (Table 6).

The absence of any moderating effect of a PCMH was explored through qualitative interviews. Few caregivers spontaneously identified ACEs as a “difficult problem” that a PCP had helped address, focusing instead on specific medical events such as diabetes management, constipation, and immunizations (Table 2C). To overcome this, caregivers were asked to consider the role of a PCP in response to recent CPS involvement. With this prompt, some caregivers described very positive conversations with PCPs related to CPS involvement. Those reporting that a PCP was unaware of CPS involvement offered opinions about the provider’s likely response to such information. We noted that although English-speaking caregivers shared uniformly positive experiences with PCPs, Spanish-speaking caregivers often described neutral or confusing experiences.

Survey responses mirrored these interview findings. Although 86.5% of caregivers reported comfort with talking to their child’s PCP “about problems with violence or abuse in the home,” just 48.1% recalled such conversations and only 37.2% believed that their child’s PCP was aware of the recent CPS involvement. Language differences again surfaced in survey responses. Just 71.4% of Spanish-speaking caregivers felt comfortable talking with a child’s PCP about violence in the home compared with 88.7% of English-speaking caregivers (P < .001); 7.1% of Spanish-speaking caregivers believed that a child’s PCP knew of CPS involvement compared with 40.6% of English-speaking caregivers (P = .05).

TABLE 6

Association Between Child HRQoL With ACEs

Model 1 Total HRQoLModel 2 Physical HRQoLModel 3 Psychosocial HRQoL
ACEs, unadjusted β (95% CI), 0–17 −2.0 (−2.7 to −1.3) −0.6 (−1.3 to −0.04) −2.4 (−3.2 to −1.7) 
Child, adjusted β (95% CI)  
 ACEs, 0–17 -1.3 (−2.0 to −0.6) −0.7 (−1.3 to +0.02) −1.5 (−2.3 to −0.7) 
 Special health care needs −11.1 (−15.5 to −6.8) −6.6 (−6.9 to +6.1) −12.4 (−17.5 to −7.3) 
 Age, 2–12 y −0.7 (−1.5 to +0.13) +0.4 (−0.5 to +1.2) −1.0 (−2.0 to −0.02) 
 Female sex +2.4 (−1.7 to +6.5) +1.2 (−2.8 to +5.2) +2.9 (−1.9 to +7.7) 
 Minority race and ethnicity −3.5 (−7.4 to +0.4) −2.1 (−5.9 to +1.8) −4.0 (−8.5 to +0.6) 
 Medicaid +1.2 (−3.4 to +5.9) +1.1 (−3.4 to +5.6) +1.4 (−4.0 to +6.8) 
 Uninsured +2.0 (−4.7 to +8.7) −0.4 (−6.9 to +6.1) +2.9 (−4.9 to +10.8) 
Caregiver, adjusted β (95% CI)  
 Maternal caregiver +0.5 (−1.9 to +0.6.2) +2.4 (−3.1 to +8.0) −0.05 (−6.7 to +6.6) 
 No high school degree +1.4 (−4.1 to +6.9) −4.8 (−10.2 to +0.5) +3.4 (−3.0 to +9.9) 
 Below federal poverty level −0.8 (−5.4 to +3.7) −1.5 (−6.0 to +2.9) −0.5 (−5.8 to +4.8) 
 Low self-efficacy −3.4 (−8.8 to +2.0) −4.6 (−9.9 to +0.6) −3.3 (−9.6 to +3.0) 
 Depressive symptoms −0.6 (−6.3 to +5.1) +2.3 (−3.3 to +7.8) −1.6 (−8.2 to +5.0) 
Model 1 Total HRQoLModel 2 Physical HRQoLModel 3 Psychosocial HRQoL
ACEs, unadjusted β (95% CI), 0–17 −2.0 (−2.7 to −1.3) −0.6 (−1.3 to −0.04) −2.4 (−3.2 to −1.7) 
Child, adjusted β (95% CI)  
 ACEs, 0–17 -1.3 (−2.0 to −0.6) −0.7 (−1.3 to +0.02) −1.5 (−2.3 to −0.7) 
 Special health care needs −11.1 (−15.5 to −6.8) −6.6 (−6.9 to +6.1) −12.4 (−17.5 to −7.3) 
 Age, 2–12 y −0.7 (−1.5 to +0.13) +0.4 (−0.5 to +1.2) −1.0 (−2.0 to −0.02) 
 Female sex +2.4 (−1.7 to +6.5) +1.2 (−2.8 to +5.2) +2.9 (−1.9 to +7.7) 
 Minority race and ethnicity −3.5 (−7.4 to +0.4) −2.1 (−5.9 to +1.8) −4.0 (−8.5 to +0.6) 
 Medicaid +1.2 (−3.4 to +5.9) +1.1 (−3.4 to +5.6) +1.4 (−4.0 to +6.8) 
 Uninsured +2.0 (−4.7 to +8.7) −0.4 (−6.9 to +6.1) +2.9 (−4.9 to +10.8) 
Caregiver, adjusted β (95% CI)  
 Maternal caregiver +0.5 (−1.9 to +0.6.2) +2.4 (−3.1 to +8.0) −0.05 (−6.7 to +6.6) 
 No high school degree +1.4 (−4.1 to +6.9) −4.8 (−10.2 to +0.5) +3.4 (−3.0 to +9.9) 
 Below federal poverty level −0.8 (−5.4 to +3.7) −1.5 (−6.0 to +2.9) −0.5 (−5.8 to +4.8) 
 Low self-efficacy −3.4 (−8.8 to +2.0) −4.6 (−9.9 to +0.6) −3.3 (−9.6 to +3.0) 
 Depressive symptoms −0.6 (−6.3 to +5.1) +2.3 (−3.3 to +7.8) −1.6 (−8.2 to +5.0) 

Values reflect reduction in HRQoL for each additional ACE exposure in model adjusted for child and caregiver characteristics. Significant reductions in total and psychosocial HRQoL are associated with increasing ACEs and presence of special health care needs. Significant reductions in psychosocial HRQoL are also associated with increasing child age.

Children involved with child welfare often have histories of adversity far beyond those identified in a single CPS investigation. In our study, we find that the accumulation of ACEs in this high-risk population is strongly associated with clinically important reductions in parent-reported total and psychosocial HRQoL. Caregivers recognize the relationship between ACEs and their child’s emotional health but commonly identify ACEs other than the known abuse to be the most influential for their child’s health and well-being. Finally, we found that the PCMH is often an untapped resource in supporting child health and well-being after adversity.

Researchers in previous studies describe lower unidimensional health among children with a history of child welfare intervention and lower multidimensional HRQoL among children in foster care.3134  To our knowledge, our study is the first to in which multidimensional HRQoL were measured among children remaining at home after CPS involvement for abuse. Overall, HRQoL among children with this history is significantly lower than general population norms and is comparable to CSHCN. With this finding, we support previous recommendations that children with a history of abuse be included within an expanded definition of CSHCN.12  We also take a hopeful lesson from our findings. Although children with a history of abuse and high cumulative ACE exposures have total and psychosocial HRQoL comparable to children with ADHD, asthma, diabetes, or depression, those children with a history of abuse but few additional ACEs have HRQoL at or above that reported for healthy children.21,22,29  These findings highlight the need to reduce ongoing exposure to childhood adversity after abuse.

We were encouraged to find that 90% of caregivers of children with recent CPS involvement identify a known PCP for their child, with many describing trusted longitudinal relationships with these providers. Caregivers who reported sharing experiences of adversity and abuse with a PCP described feeling supported by careful evaluation of a child’s emotional well-being, the assurance of close follow-up, and an “open door” for future conversations. Despite this, we did not find that these relationships were associated with higher HRQoL results. We suggest that interactions between a child’s caregiver and a trusted PCP too often fail to directly address those factors most relevant to HRQoL among children with a history of abuse. Despite calls by primary care pediatricians for increased sharing of child welfare information related to their patients and surging academic efforts to address social risk and toxic stress in primary care settings, caregivers in this high-risk population told us that conversations with a PCP about violence, abuse, or other social risks were unusual.14,15,35,36  Most believed that PCPs were unaware of a recent history of CPS involvement with their child. Nonetheless, many interviewed caregivers felt that their child’s PCP could be helpful in identifying resources to help a child struggling after a traumatic experience.

There are important practical and policy barriers to initiating these difficult conversations. Caregivers reported a reluctance to bring up subjects of violence and abuse, even if they felt that a PCP might be helpful in addressing these issues. Although it was not studied in this article, PCPs may feel similarly uncomfortable. Previous research highlights policies and practices that prevent CPS agencies from sharing information with PCPs related to investigations.35,37  Our findings support efforts to screen for social needs and traumatic stress in primary care settings, to improve collaboration between child welfare and child health care, and to encourage PCPs to initiate difficult conversations with caregivers of children struggling with emotional and behavioral health problems.

The unexpected finding of differences in PCP relationships based on caregiver language preference is supported by previous research and deserves attention in current practice and research.38,39  Discomfort with conversations regarding violence or abuse among Spanish-speaking caregivers is troubling, and may reflect long-standing cultural tradition or more immediate political circumstances. Regardless, cultural competency and compassion within the PCMH is critical to assuring equity in access to services for children of Spanish-speaking caregivers with a history of abuse.

Our findings must be considered in light of important limitations. Our methodology does not allow us to determine causality in the association between cumulative ACEs and HRQoL. We attempted to address these limitations through quantitative models adjusting for known confounders and qualitative interviews to explore parental perceptions and attributions. These mixed-method findings support but cannot confirm a causal relationship between cumulative ACEs and lower psychosocial HRQoL.

Our findings may be limited to children with a history of physical abuse. Our focus on children with recent CPS involvement is rooted in the belief that state involvement by CPS opens a window of opportunity for interventions to improve outcomes for children after abuse. Our focus on children with a history of physical abuse grew from the understanding that a PCP may be more aware of cases of physical abuse than other types of maltreatment. We recognize that physical abuse may not, as demonstrated by our findings, be the most significant traumatic experience for children with this history. Further research is needed to understand if our findings are generalizable to other at-risk populations.

Our results may be influenced by participation bias. Eligible caregivers with the most substantial CPS involvement were the least likely to participate. This bias suggests that our findings are likely to underestimate ACEs and overestimate HRQoL among children with a history of physical abuse. Finally, our results may be influenced by response bias. Caregivers may provide more positive or negative answers to questions related to child health, ACEs exposures, or personal history for any number of reasons. Although we cannot correct for this, triangulation between qualitative and quantitative observations suggests robustness in our primary conclusions.

Many children remaining at home after CPS involvement for physical abuse have ACEs exposures beyond those that bring them to the attention of child welfare. These accumulated ACEs are associated with HRQoL comparable to children with ADHD, asthma, and diabetes. Nine in 10 of these children has an identified PCP, but these PCPs are often unaware of a history of abuse or violence in the home. Many caregivers feel that a trusted PCP could be a source of support in helping their children after traumatic experiences, yet are uncomfortable initiating this conversation. PCPs should consider children with a history of abuse as a distinct population of CSHCN and be willing to initiate difficult conversations about social risk, emotional trauma, and household violence to support child well-being after abuse.

We thank the Utah DCFS for their willingness to serve as partners in this project. Thanks also to the Qualitative, Survey and Research Core of the University of Utah Center for Clinical and Translational Sciences for support in qualitative analysis. Finally, we thank the many caregivers who were willing to participate in our surveys and interviews for this project.

Dr Campbell conceptualized and designed the study, designed the data collection instruments, coordinated and supervised data collection, conducted analyses, drafted the initial manuscript, and reviewed and revised the manuscript; Ms Gamarra designed the data collection instruments, coordinated and collected data, conducted initial analysis, and reviewed and revised the manuscript; Drs Keenan and Frost conceptualized and designed the study and critically reviewed the manuscript for important intellectual content; Ms Choi conducted initial analysis and critically reviewed the manuscript for important intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Ms Gamarra’s current affiliation is the International Christian University, Tokyo, Japan. Ms Choi's current affiliation is Pennsylvania College of Optometry, Salus University, Elkins Park, Pennsylvania.

FUNDING: Funded in part by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health under award K24 HD072984 (PI Keenan). Qualitative analysis was funded in part by Interdisciplinary Research Leaders, a program supported by the Robert Wood Johnson Foundation (MPI Campbell). The REDCap platform is supported by Center for Clinical and Translational Sciences grant support (8UL1TR000105 [formerly UL1RR025764] National Center for Advancing Translational Sciences/NIH). Funded by the National Institutes of Health (NIH).

     
  • ACE

    adverse childhood experience

  •  
  • CI

    confidence interval

  •  
  • CPS

    Child Protective Services

  •  
  • CSHCN

    Children with Special Health Care Needs

  •  
  • DCFS

    Division of Child and Family Services

  •  
  • HRQoL

    health-related quality of life

  •  
  • PCMH

    patient-centered medical home

  •  
  • PCP

    primary care provider

1
U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau
. Child Maltreatment 2018.
2020
. Available at: https://www.acf.hhs.gov/cb/research-data-technology/statistics-research/child-maltreatment. Accessed February 20, 2020
2
Felitti
VJ
,
Anda
RF
,
Nordenberg
D
, et al
.
Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study
.
Am J Prev Med
.
1998
;
14
(
4
):
245
258
3
Widom
CS
,
Czaja
SJ
,
Bentley
T
,
Johnson
MS
.
A prospective investigation of physical health outcomes in abused and neglected children: new findings from a 30-year follow-up
.
Am J Public Health
.
2012
;
102
(
6
):
1135
1144
4
Jonson-Reid
M
,
Kohl
PL
,
Drake
B
.
Child and adult outcomes of chronic child maltreatment
.
Pediatrics
.
2012
;
129
(
5
):
839
845
5
Corso
PS
,
Edwards
VJ
,
Fang
X
,
Mercy
JA
.
Health-related quality of life among adults who experienced maltreatment during childhood
.
Am J Public Health
.
2008
;
98
(
6
):
1094
1100
6
Dube
SR
,
Felitti
VJ
,
Dong
M
,
Giles
WH
,
Anda
RF
.
The impact of adverse childhood experiences on health problems: evidence from four birth cohorts dating back to 1900
.
Prev Med
.
2003
;
37
(
3
):
268
277
7
Campbell
KA
,
Thomas
AM
,
Cook
LJ
,
Keenan
HT
.
Resolution of intimate partner violence and child behavior problems after investigation for suspected child maltreatment
.
JAMA Pediatr
.
2013
;
167
(
3
):
236
242
8
Macmillan
HL
,
Wathen
CN
,
Barlow
J
,
Fergusson
DM
,
Leventhal
JM
,
Taussig
HN
.
Interventions to prevent child maltreatment and associated impairment
.
Lancet
.
2009
;
373
(
9659
):
250
266
9
Medical Home Initiatives for Children With Special Needs Project Advisory Committee, American Academy of Pediatrics
.
The medical home
.
Pediatrics
.
2002
;
110
(
1, pt 1
):
184
186
10
Sia
C
,
Tonniges
TF
,
Osterhus
E
,
Taba
S
.
History of the medical home concept
.
Pediatrics
.
2004
;
113
(
5,
suppl
):
1473
1478
11
Long
WE
,
Bauchner
H
,
Sege
RD
,
Cabral
HJ
,
Garg
A
.
The value of the medical home for children without special health care needs
.
Pediatrics
.
2012
;
129
(
1
):
87
98
12
Fuentes
M
,
Coker
TR
.
Social complexity as a special health care need in the medical home model
.
Pediatrics
.
2018
;
142
(
6
):
e20182594
13
Campbell
KA
,
Olson
LM
,
Keenan
HT
,
Morrow
SL
.
What happened next: interviews with mothers after a finding of child maltreatment in the household
.
Qual Health Res
.
2017
;
27
(
2
):
155
169
14
Dubowitz
H
,
Feigelman
S
,
Lane
W
,
Kim
J
.
Pediatric primary care to help prevent child maltreatment: the Safe Environment for Every Kid (SEEK) Model
.
Pediatrics
.
2009
;
123
(
3
):
858
864
15
Garg
A
,
Toy
S
,
Tripodis
Y
,
Silverstein
M
,
Freeman
E
.
Addressing social determinants of health at well child care visits: a cluster RCT
.
Pediatrics
.
2015
;
135
(
2
).
16
Garner
AS
,
Shonkoff
JP
;
Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; Section on Developmental and Behavioral Pediatrics
.
Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health
.
Pediatrics
.
2012
;
129
(
1
).
17
Creswell
JW
,
Clark
VLP
.
Designing and Conducting Mixed Methods Research
, 2nd ed.
Thousand Oaks, CA
:
SAGE publishers
;
2011
18
Finkelhor
D
,
Shattuck
A
,
Turner
H
,
Hamby
S
.
Improving the adverse childhood experiences study scale
.
JAMA Pediatr
.
2013
;
167
(
1
):
70
75
19
Ghosh-Ippen
C
,
Ford
J
,
Racusin
R
, et al
.
Trauma Events Screening Inventory-Parent Report Revised
.
San Francisco, CA
:
The Child Trauma Research Project of the Early Trauma Network and The National Center for PTSD Dartmouth Child Trauma Research Group
;
2002
20
Creswell
JW
.
Qualitative Inquiry and Research Design: Choosing Among Five Approaches
, 3rd ed.
Thousand Oaks, CA
:
SAGE Publications
;
2013
21
Varni
JW
,
Seid
M
,
Kurtin
PS
.
PedsQL 4.0: reliability and validity of the Pediatric Quality of Life Inventory version 4.0 generic core scales in healthy and patient populations
.
Med Care
.
2001
;
39
(
8
):
800
812
22
Varni
JW
,
Burwinkle
TM
,
Seid
M
,
Skarr
D
.
The PedsQL 4.0 as a pediatric population health measure: feasibility, reliability, and validity
.
Ambul Pediatr
.
2003
;
3
(
6
):
329
341
23
Varni
JW
,
Limbers
CA
,
Burwinkle
TM
.
Parent proxy-report of their children’s health-related quality of life: an analysis of 13,878 parents’ reliability and validity across age subgroups using the PedsQL 4.0 Generic Core Scales
.
Health Qual Life Outcomes
.
2007
;
5
:
2
24
Agency for Healthcare Research and Quality
.
CAHPS clinician & group 12-month survey 2.0. 2017. Available at: https://www.ahrq.gov/cahps/surveys-guidance/cg/12-month/index.html. Accessed February 2, 2020
25
Bethell
CD
,
Read
D
,
Stein
REK
,
Blumberg
SJ
,
Wells
N
,
Newacheck
PW
.
Identifying children with special health care needs: development and evaluation of a short screening instrument
.
Ambul Pediatr
.
2002
;
2
(
1
):
38
48
26
Bethell
CD
,
Read
D
,
Neff
J
, et al
.
Comparison of the children with special health care needs screener to the questionnaire for identifying children with chronic conditions–revised
.
Ambul Pediatr
.
2002
;
2
(
1
):
49
57
27
Scherbaum
CA
,
Cohen-Charash
Y
,
Kern
MJ
.
Measuring general self-efficacy
.
Educ Psychol Meas
.
2006
;
66
(
6
):
1047
1063
28
Löwe
B
,
Wahl
I
,
Rose
M
, et al
.
A 4-item measure of depression and anxiety: validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population
.
J Affect Disord
.
2010
;
122
(
1–2
):
86
95
29
Varni
JW
,
Burwinkle
TM
.
The PedsQL as a patient-reported outcome in children and adolescents with Attention-Deficit/Hyperactivity Disorder: a population-based study
.
Health Qual Life Outcomes
.
2006
;
4
(
1
):
26
30
Fetters
MD
,
Curry
LA
,
Creswell
JW
.
Achieving integration in mixed methods designs-principles and practices
.
Health Serv Res
.
2013
;
48
(
6, pt 2
):
2134
2156
31
Flaherty
EG
,
Thompson
R
,
Litrownik
AJ
, et al
.
Effect of early childhood adversity on child health
.
Arch Pediatr Adolesc Med
.
2006
;
160
(
12
):
1232
1238
32
Lanier
P
,
Kohl
PL
,
Raghavan
R
,
Auslander
W
.
A preliminary examination of child well-being of physically abused and neglected children compared to a normative pediatric population
.
Child Maltreat
.
2015
;
20
(
1
):
72
79
33
Flaherty
EG
,
Thompson
R
,
Litrownik
AJ
, et al
.
Adverse childhood exposures and reported child health at age 12
.
Acad Pediatr
.
2009
;
9
(
3
):
150
156
34
Stein
RE
,
Hurlburt
MS
,
Heneghan
AM
, et al
.
Chronic conditions among children investigated by child welfare: a national sample
.
Pediatrics
.
2013
;
131
(
3
):
455
462
35
Campbell
KA
,
Wuthrich
A
,
Norlin
C
.
We have all been working in our own little silos forever: exploring a cross-sector response to child maltreatment
.
Acad Pediatr
.
2020
;
20
(
1
):
46
54
36
Flaherty
EG
,
Sege
RD
,
Griffith
J
, et al;
PROS network
;
NMAPedsNet
.
From suspicion of physical child abuse to reporting: primary care clinician decision-making
.
Pediatrics
.
2008
;
122
(
3
):
611
619
37
Flaherty
EG
,
Jones
R
,
Sege
R
;
Child Abuse Recognition Experience Study Research Group
.
Telling their stories: primary care practitioners’ experience evaluating and reporting injuries caused by child abuse
.
Child Abuse Negl
.
2004
;
28
(
9
):
939
945
38
Coker
TR
,
Rodriguez
MA
,
Flores
G
.
Family-centered care for US children with special health care needs: who gets it and why?
Pediatrics
.
2010
;
125
(
6
):
1159
1167
39
Lichstein
JC
,
Ghandour
RM
,
Mann
MY
.
Access to the medical home among children with and without special health care needs
.
Pediatrics
.
2018
;
142
(
6
):
e20181795

Competing Interests

POTENTIAL CONFLICT OF INTEREST: Dr Campbell’s institution receives financial compensation for expert witness testimony provided in cases of suspected child abuse for which she is subpoenaed to testify; the other authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

Supplementary data