Background & Aims

The World Health Organization describes adverse childhood experiences (ACEs) including abuse, neglect, and household dysfunction, as the commonest and most intense childhood stressors1. Despite growing evidence that those exposed to ACEs are more likely to develop severe health problems later in life, including chronic pain, misuse of pain medications and polysubstance dependence2–5, there is no agreement on a standardised assessment of ACEs in either research or clinical practice. Most questionnaires assessing ACEs have been created without the involvement of people with lived experience nor a guiding theoretical framework, thereby leading to inconsistency in their content and lack of sensitivity. Consequently, the aim of the current systematic review is to identify all ACEs questionnaires used in adult population, assess their psychometric quality using standardised, comprehensive guidelines and input from people with lived experiences.

Methods

Searches run between March 2022 and June 2023 according to PRISMA guidelines in the following databases: MEDLINE, PubMed, PsycINFO, Web of Science, EMBASE, Scopus, CENTRAL and CINAHL. A two-stage search strategy was employed with the 1st stage involving title and abstract screening using the following inclusion criteria: 1) ACEs were assessed by means of a self-reported questionnaire, 2) respondents’ age was 16+, 3) papers assessed more than one ACE, and 4) publication was in English. The 2nd stage focused on screening all remaining abstracts, followed by full text screening, to only retain articles assessing psychometrical qualities (e.g., validity and reliability) of ACE questionnaires. Quality assessment involved 1) the Cohen6 criteria for evidence-based assessments, 2) the COSMIN7 checklist for psychometrical qualities of questionnaires, and 3) an evaluation form, co-designed with the chronic pain advisory group (CPAG). The protocol was registered on PROSPERO (CRD42022299435).

Results

The search strategy identified 14,350 articles, of which 95 articles (covering 29 ACE questionnaires) were retained after the screening process. These questionnaires were not specific to or validated for adults with chronic pain and 17 had only one publication with psychometric qualities. The Childhood Trauma Questionnaire (CTQ) was most frequently evaluated (36 publications). Nine questionnaires fell in the “well-established” category of the Cohen’s criteria. Psychometric tests were highly variable across studies and no questionnaire achieved a rating of “sufficient” quality across all the relevant COSMIN categories. The original ACE measure by Felitti et al., (1998)8 had the highest number of psychometric criteria rated as sufficient; whereas the CTQ- Short Form was the only one to receive ratings of “insufficient” in all psychometric categories. High content validity was scored by the CPAG for the Traumatic Experiences Checklist and low for the ISPCAN Child Abuse Screening Tools.

Conclusions

A wide range of questionnaires exist to retrospectively assess ACEs in adults; however, the psychometrical qualities of the questionnaires vary widely, with not a single questionnaire receiving a good rating across all relevant psychometrical qualities. No conclusions can be drawn on the applicability of the measures to people with chronic pain as none of the measures were validated in adults with chronic pain. To our knowledge, this is the first systematic review of ACE questionnaires which had people with lived experiences (PWLE) contribute to the quality assessment. This approach empowered PWLE to make critical evaluations about how childhood trauma can be assessed a trauma-informed and sensitive way. Interestingly, the evaluations of the PWLE did not align with the psychometrical qualities of the questionnaires. Future research should focus on co-developing a questionnaire with PWLE that can meet essential psychometric quality indicators such as reliability and validity.

References

1.World Heal Organization (WHO). Violence against children. (2022). Available at: https://www.who.int/news-room/fact-sheets/detail/violence-against-children.
2.Burke, N. N., Finn, D. P., McGuire, B. E. & Roche, M. Psychological stress in early life as a predisposing factor for the development of chronic pain: Clinical and preclinical evidence and neurobiological mechanisms. J. Neurosci. Res. 95, 1257–1270 (2017).
3.Hughes, L. S., Clark, J., Colclough, J. A., Dale, E. & McMillan, D. Acceptance and Commitment Therapy (ACT) for Chronic Pain: A Systematic Review and Meta-Analyses. Clin. J. Pain 33, 552–568 (2017).
4.Quinn, K. et al. Internalizing and externalizing factors on the pathway from adverse experiences in childhood to non-medical prescription opioid use in adulthood. Drug Alcohol Depend. 197, 212–219 (2019).
5.Nelson, C. A. et al. Adversity in childhood is linked to mental and physical health throughout life. BMJ 371, m3048 (2020).
6.Cohen, L. L. et al. Introduction to Special Issue: Evidence-based Assessment in Pediatric Psychology. J. Pediatr. Psychol. 33, 911–915 (2006).
7.Prinsen, C. A. C. et al. COSMIN guideline for systematic reviews of patient-reported outcome measures. Qual. life Res. 27, 1147–1157 (2018).
8.Felitti, V. J. 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. 14, 245–258 (1998).

Presenting Author

Aikaterini Christogianni

Poster Authors

Aikaterini Christogianni

PhD

University of Dundee

Lead Author

E-mail

Line Caes

University of Stirling

Lead Author

E-mail

Franziska Mosler

University of Dundee

Lead Author

E-mail

Samuel Singleton

PhD

University of Dundee

Lead Author

E-mail

Janine Rennie

BSc

University of Dundee

Lead Author

E-mail

Tim Hales

University Of Dundee

Lead Author

E-mail

Lesley Colvin

University of Dundee

Lead Author

E-mail

Topics

  • Evidence, Clinical Trials, Systematic Review, Guidelines, and Implementation Science