Mitigating Adverse Childhood Experiences (ACEs) in Pediatric Primary Care
We aim to change practice and policy in pediatric primary care related to addressing adverse childhood experiences (ACEs).
Updates: How has your idea changed or evolved throughout the Prize? What updates have you made to this submission? (1500 characters)
Our idea has evolved throughout the editing period, primarily due to feedback from my mentor Laura Scharphorn. Laura's input had a major influence on our application. Laura's insightful feedback prompted me to expand my idea from a focus only on research to also include a focus on development and distribution. My original application described what I know I can accomplish, conducting and publishing clinical research. Certainly, research is crucial because practitioners and insurance companies seek to implement interventions that are evidence-based. However, the research database is already deep enough to make a strong argument to proceed with assessing and mitigating ACEs in pediatric primary care. Furthermore, research is not going to be implemented in practice unless there are efforts to enhance the innovations (i.e. development) and inform others of the effectiveness of the innovations (i.e. distribution). On average, it takes 17 years for research to change practice. Our research will smolder on the academic shelf unless there are efforts to increase awareness of our innovations among practitioners, health policy leaders, and educators.
Another enhancement of our idea has been through adding images to our application. The images illustrate important concepts such as the definition of ACEs, a framework for how ACEs cause health problems, and how our project is going to disrupt the standard of care related to addressing ACEs in pediatric primary care. Other images allow the reviewer to have a clearer understanding of our ACEs screening tool and our parenting intervention. Finally, images added to our proposal provide illustrations of data related to testing the Parenting and Childhood Stressors (PCS) survey and Play Nicely with hundreds of low-income parents.
Pediatric practice will change more rapidly if research is coupled with efforts to further develop and distribute resources. Practice will change more rapidly if the reasons for a new approach can be conveyed in both words and illustrations. Our application has been greatly strengthened by expanding beyond research and including images.
Name or Organization
Vanderbilt University Medical Center
What is your stage of development?
Advanced Innovator with 3 to 10+ years of experience in ECD
What is the stage of your proposal?
Piloting: I have started to implement my solution as a whole with a first set of real users.
Image 1. Our long-term goal is to change policy and practice in pediatric primary care related to screening and intervening for adverse childhood experiences (ACEs). We have prototypes for screening (PCS survey) and intervention (Play Nicely). ACEs screening will be performed at least annually (blue arrows) until ACEs scores become low ("low to be determined). The PCS has 12 questions that assess for unhealthy parenting strategies. Our long term goal is disease prevention.
Image 2. Adverse childhood experiences (ACEs) are typically divided into abuse and household dysfunction. ACEs are social determinants of health because they are associated with many health problems including lung disease, liver disease, alcoholism, smoking, drug use, obesity, depression, school problems, teen pregnancy, and violence. In our project, we will assess and mitigate ACEs with a focus on parenting-related ACEs (PRACEs).
Image 3. In the original ACEs study, 17,000 adults in California were asked about their exposure to adverse childhood experiences before age 18. Five ACEs were categorized as abuse/neglect and five ACEs were categorized as household dysfunction. Over 60% of adults had at least one ACE and 12% had at least 4 ACEs. Other ACEs have been added to this list over the years (e.g. exposure to community violence, bullying, poverty, food insecurity, racism).
Image 4. ACEs have been found to be associated with dozens of health problems, some of which are listed in this image.
Image 5. The more ACEs someone is exposed to, the higher the likelihood of problems. As just one example, if someone has over 3 ACEs, they are much more likely (>4 times) to use illicit drugs compared to someone who has no ACEs.
Image 6. ACEs cause health problems through multiple mechanisms. ACEs cause toxic stress, leading to unhealthy coping habits (e.g. smoking, eating, drug use). Toxic stress can turn genes on or off that affect health (i.e. epigenetic changes). In infants and young children, toxic stress affects brain architecture and steroid levels. To improve public health, efforts are needed to decrease exposure to toxic stress and increase exposure to protective factors, including healthy parenting.
Image 7. Health care providers need a validated ACEs screening tool. This image is the newly developed Parenting and Childhood Stressors (PCS) survey. The first 12 questions assess parenting behaviors of caregivers, the first ACEs screening tool to do this, and questions 13-23 assess other childhood stressors. In 2017, the survey was tested with over 700 parents of young children in the Vanderbilt Pediatric Clinic (results presented later in application).
Image 8. This image illustrates the 20 options page of the Play Nicely handbook, available in English, Spanish, and Arabic. Professionals can introduce the intervention in one minute by saying, "We would like all parents to learn healthy ways to discipline young children. Assume you see one young child hit another. What are you going to do? Consider these 20 options. Choose one, and then turn to the tabbed page to learn if your choice is great, good, or not recommended. Please review at home."
Image 9. This image illustrates the 20-options page of the Play Nicely multimedia intervention. Parents are asked to respond to the hypothetical situation of one young child hurting another. By clicking on the different options, parents learn healthy parenting strategies. The program has been tested with thousands of parents (see www.playnicely.org). Professionals can introduce the program in less than one minute and parents can view the program in the clinic or at home.
Image 10. The Play Nicely program teaches parents that they do not to need spank or yell at their children because there are much better options. Parents reported that the program helped to change their attitudes about spanking because it offers alternatives.
Describe how your solution could be a game-changer for your selected Opportunity Area (600 characters)
Our goal is to change policy and practice in pediatric primary care related to assessing and mitigating adverse childhood experiences (ACEs). Our plan has the potential to prevent diseases in millions of people by taking two evidence-based innovations to scale in pediatric primary care (Image 1). The first innovation is the Parent and Childhood Stressors (PCS) survey, a screening tool that assesses adverse childhood experiences (ACEs) with a focus on parenting-related ACEs. The second innovation is an intervention that educates parents about healthy discipline strategies.
Select an Innovation Target
System design: Solutions that target changing larger systems.
Tell us more about your innovation (1500 characters)
We have developed two effective and efficient innovations that, if taken to scale, will change practice and policy in pediatric primary care (Image 1).
The first innovation is the PCS, a 2-minute screening tool to identify children exposed to adverse childhood experiences (ACEs) with a focus on parenting-related ACEs. We define parenting-related adverse childhood experiences (PRACEs) as unhealthy parenting behaviors such as spanking, threatening, yelling, and humiliation. For adults in the original ACEs study, it was exposure to these behaviors that led to the categorization of child abuse/neglect and that were associated with heart disease, obesity, depression, smoking, drug use, violence, and many other problems. The first part of the survey is a 12 item, yes/no, parenting survey. The second part of the survey is 13 questions that assess other childhood stressors (Image 7).
The second innovation is Play Nicely, a multimedia program and handbook designed to educate parents about healthy discipline strategies (Images 8-10). We have published over a dozen articles attesting to the program's efficacy (see http://www.playnicely.org). Many effective parenting programs have been developed but limitations prevent them from being used in pediatric primary care. Play Nicely is different from other parenting program in that it can be introduced in one minute, results are obtained in 5-10 minutes, and has been tested in pediatric primary care using a population-based approach.
What problem are you aiming to solve? (3 sentences)
At least 45% of US children are exposed to ACEs, some of which include unhealthy parenting behaviors (e.g. spanking, humiliation, threatening, yelling). The health care system is an ideal setting to screen and intervene for ACEs and unhealthy parenting, but, unfortunately, health care providers do not know which children are being exposed. Health care providers need inexpensive, evidence-based ACEs screening tools and interventions to respond to high ACE scores.
Explain your idea (5000 characters)
To be sustainable, integration of ACEs screening and discipline education into the pediatric well child visit at a national level will require a multi-pronged approach. Research is crucial because physicians and insurance companies will not implement a health care service that has not been proven to be effective, culturally sensitive, and scalable. Efforts are also needed in program development. Although we have working prototypes of the PCS screening tool and the educational intervention, funds are needed to enhance the innovations. Finally, even effective and attractive programs will sit on the academic shelf without work in the areas of marketing and distribution. To scale-up our screening and intervention prototypes, here is an outline of work that is needed in the areas of research, development, and distribution.
Overview: Using a randomized controlled trial study design, we will integrate the new ACEs screening tool and parenting intervention into the primary care visit for parents of children between the ages of 6 months and 2 years. We will determine if the parenting intervention can affect parenting behavior and parents’ attitudes about corporal punishment in an intervention group compared to a control group.
Recruitment: We plan to enroll over 1000 low-income parents in a randomized controlled trial. The setting will be the Vanderbilt Pediatric Primary Care Clinic which serves approximately 17,000 children and their families. The majority (>80%) of the families in the clinic are on TennCare, a government sponsored health insurance similar to Medicaid. Services are provided by pediatric residents, nurse practitioners, and faculty members. The clinic has a social worker to help families who have social stressors.
Eligibility: We will screen parents of 6-24 month old with the PCS and a scale that assesses parents’ attitudes about spanking.
Randomization: Parents will be randomized into an intervention group or control group.
Intervention Group: Parents in the intervention group will be instructed to view at least 2 discipline options in the Play Nicely multimedia program online and will receive a copy of the Healthy Discipline Handbook. Parents will be encouraged to share the handbook with other caregivers to help families with caregivers who are using disparate, inconsistent discipline strategies.
Control Group: Parents in the Control Group will receive routine clinic care.
Short-term outcomes: When the child returns for follow up well visits, we will complete follow-up surveys in clinic every 3-6 months until the child reaches 3 years of age. Parents in the intervention group with persistently elevated parenting scores will receive booster educational sessions about healthy discipline and, as indicated, will be evaluated by our clinic social worker.
Long-term outcomes. We will perform chart reviews every 1-2 years to assess for long-term outcomes including: behavior problems, child maltreatment, referral to a mental health provider, referral to a social worker, admission to the psychiatric hospital, and school problems.
Currently, the PCS screening tool is available online for free in English, Spanish, and Arabic. Funding is requested to translate the screening tool into other languages.
The Play Nicely multimedia program, currently in its 3rd edition, is available in English and Spanish. The Play Nicely handbook, mirroring the 3rd edition multimedia content, is available in English, Spanish, and Arabic. Funding is requested to further develop the program. Development plans include creating an updated 4th edition of the digital Play Nicely program (e.g. a Play Nicely app), developing new videos to embed in the multimedia program, and revising the handbook in multiple languages.
Parents who are in greatest need of parenting screening and intervention are, in general, least likely to pay for it. Also, pediatricians are unlikely to implement a population-based screening tool (i.e. the PCS) that must be purchased. Thus, our ongoing goal is to distribute the PCS and the parenting intervention as inexpensively as possible.
The PCS screening tool is available for free at: http://www.childrenshospital.vanderbilt.org/services.php?mid=13003.
The Play Nicely multimedia program and handbook are both available through Vanderbilt University; see http://www.playnicely.org . The multimedia program is online and free. The Play Nicely Handbook available at cost ($10/handbook for bulk purchases).
To increase awareness of the innovations, we are seeking funding to increase distribution through activities such as mailing the ACEs screening tool and Play Nicely Handbook to physicians, educators, policy makers, and potential publishers.
Through implementation research, development, marketing, and distribution, our idea is to have ACEs screening and intervention be part of the pediatric primary care visit.
Who benefits? (1500 characters)
The most important beneficiaries of the program will be young children and their siblings because the innovations will result in more screening of parenting behaviors and parenting education, decreasing the likelihood that children and their siblings will be exposed to unhealthy discipline strategies such as corporal punishment.
Parents will benefit as it is recognized that most parents want to receive education about discipline from their pediatrician. Play Nicely has been studied with hundreds of low-income parents. In one study, parents reported that the program is valuable because it is educational, it reinforced their parenting, and/or it facilitated a discussion with their physician; see https://www.ncbi.nlm.nih.gov/pubmed/22496174.
Through research and distribution of the resources, leaders in health care will benefit. Practitioners, educators, and health policy makers are searching for evidenced-based, inexpensive solutions to address ACEs. Regarding discipline education, many pediatricians are reluctant to discuss parenting because it can be a time-consuming and emotionally charged experience. On a regular basis, Dr. Scholer uses the Play Nicely Handbook to educate Vanderbilt medical students and pediatric residents about how to counsel parents about healthy discipline options. The response to the handbook is uniformly positive. Through research and anecdotal experiences, we are convinced that both families and professionals benefit from our innovations.
What kind of impact will your idea have? (1500 characters)
Recognizing that parents need more support during the early childhood years, this project is designed to change policy and practice in pediatric health care around parenting-related ACEs. Specifically, results of the project could lead to ACEs screening and parenting education being routinely incorporated into well child visits across the nation. We believe the innovations will improve parenting practices and decrease associated adverse outcomes such as depression, teenage pregnancy, drug use, smoking, child abuse, and youth violence.
Our 5-year goals are: (1) 90% of pediatric health care providers to be aware of our effective, value-based innovations to screen for parenting behaviors and educate parents about discipline; (2) over 75% of parents to be screened for parenting behaviors as part of their child’s well visit.
In the interim, funding of this project will prompt additional research and implementation projects. Current examples include:
1. Dr. Kim Burkhart conducted a study of Play Nicely's affect on discipline counseling for pediatric residents; see https://www.ncbi.nlm.nih.gov/pubmed/27582490.
2. Dr. Cathy Taylor, Tulane University, obtained a grant from the Center for Disease Control to study the Play Nicely program in WIC clinics in New Orleans.
3. Kristen Rector, President and CEO of Prevent Child Abuse Tennessee, is studying the Play Nicely program in a large home visiting program.
How does or how could your idea impact low-income children? (1500 characters)
Low-income children will be impacted because experiencing poverty is considered an ACE. The 2016 National Survey of Children's Health found that 45% of US children had been exposed to at least one ACE, but the rate of exposure was higher for Black (61%) and Hispanic (51%) children. Low-income children are more likely to be spanked.
Our innovations have been tested with hundreds of low-income parents on Tenncare (a government insurance program) with promising results. Low-income parents who have viewed the Play Nicely multimedia program were asked what they planned to do differently to discipline their children. Quotes from parents include the following:
“Not spank. Limit time-out. Will not yell or show anger.”
“Redirecting. Spanking – will try not to use it.”
“Try not to spank. Saying “No” less often. Redirecting.”
“No spanking. No yelling.”
“Limit “No”. Redirect more.”
“Less time out. Use all other options. Talking. Setting the rule. Redirecting.”
Several months after low-income parents received the Play Nicely Handbook in clinic, parents were asked what they are doing differently to discipline their children because of the handbook. Parents provided the following quotes:
“Talk and explain more, reduced yelling and avoided spanking.”
“More talking, less yelling and spanking.”
“I try to avoid timeout and talk to her more.”
“I try not to yell.”
“I can explain things to them. I am not just yelling and spanking all the time.”
Innovation: What makes your concept innovative? (5000 characters)
We have developed prototypes to screen and intervene for ACEs that, if taken to scale, could have a tremendous impact on people’s health. There are other ACEs screening tools, but they have limitations (e.g., they’re geared for adults or lack questions about parenting-related ACEs). There are dozens of parenting interventions, but they also have limitations (e.g., lengthy program or inability to scale the intervention to the pediatric primary care visit). Furthermore, most studies of parenting classes recruited volunteers, resulting in a selection bias and inability to generalize the results to a larger population.
The PCS is an original, disruptive innovation for the following reasons:
1. In the PCS, we are including known family stressors such as incarceration, mental illness, substance abuse, bullying, and community violence. However, the PCS has a special focus on what we are calling “parenting-related ACEs”. The PCS is the first ACEs screening tool to assess parenting behaviors of the parent presenting to clinic and the first to assess the parenting behaviors of other parents (Image 7). Based upon our experience and preliminary data, we are convinced that assessing parenting is a more viable approach than assessing for child abuse. Certainly, child abuse is an ACE; many adults in the original ACEs study were categorized as having been abused or neglected. However, if a pediatrician insinuates that a parent is abusing their child, the parent will likely not return to the clinic out of either resentment or fear of being reported to the Department of Children's Services. Our screening tool taps into the domain of child abuse without offending parents because parents are very willing to discuss discipline strategies with their pediatrician.
2. The questions on the PCS have a child focus rather than an adult focus. In the original ACEs study, adults were questioned about their childhood. The questions were not designed to assess ACEs of children in pediatric clinics. To reflect the perspective of children, the ACEs questions in the PCS have been modified.
3. The PCS has already been tested with over 700 low-income parents of 2-10 year old children presenting for a well child visit. The survey has been well-received. Parents, many with less than a high school education, have not had any difficulty understanding the questions and no parent has expressed offense at the survey's questions.
4. We found that high PCS scores are associated with health problems. As would be expected if the PCS screening tool were able to identify parents who are using unhealthy discipline strategies, our preliminary analyses demonstrate a significant association between unhealthy parenting strategies (questions 1-12 on the PCS) and childhood behavior problems, as assessed by the Strength and Difficulties Questionnaire, a validated child behavior screening tool.
5. Many surveys and screening tools must be purchased. The PCS is free; seehttp://www.childrenshospital.vanderbilt.org/services.php?mid=13003.
The Play Nicely program is innovative for several reasons.
1. Play Nicely is the first brief parenting program that has been tested in a pediatric primary care clinic setting using a population-based approach. Reductions in child maltreatment have been documented in numerous parenting programs, including Child-Parent Centers (52% decrease), Durham Family Initiative (57% decrease), Nurse Family Partnership (48% decrease), Parent Child Interaction Therapy (19% decrease), Triple P (22% decrease), and Safe Environment for Every Kid (30% decrease). However, these programs are, in general, lengthy and enroll volunteers, resulting in issues with scalability for primary care and selection bias. In contrast to other parenting programs, Play Nicely has been tested with consecutive parents in a real-world clinic setting.
2. Play Nicely can be introduced in 1 minute and results can be appreciated in 5-10 minutes. In one study we found that over 80% of parents who viewed at least 4 discipline options (5 minutes) in Play Nicely planned to change how they discipline (Image 15). Most other parenting program last dozens of hours.
3. In contrast to other parenting programs that require a trained educator, the person who introduces Play Nicely program does not require any formal education in child health or development. We found significant results when the program was introduced to parents by a high-school student, untrained in pediatric health, who served as a research assistant. (see Image 15).
4. The Play Nicely multimedia program is free and the handbook is available at cost ($10/handbook with bulk purchases). In addition to the cost of training an educator, other parenting programs can be expensive because of the cost of materials. See http://www.playnicely.org.
Scale: Describe how your idea could reach a significant number of end-users. (1500 characters)
Our idea is to scale up a population-based approach to screen for ACEs and intervene with parents who have elevated scores. We know that our prototypes of the PCS and the Play Nicely program work at Vanderbilt. The innovations are either free (PCS and Play Nicely multimedia program) or inexpensive ($10 for the Play Nicely Handbook). The PCS takes 2 minutes to complete. The Play Nicely program can be introduced in 1 minute and results can be appreciated in 5-10 minutes; the program can be viewed in clinic or at home. If these prototypes can be further studied, developed, and distributed, there is potential for this project to reach many end-users.
Rationale: There are approximately 4 million births in the US each year. Most children in the U.S. are seen by a health care provider multiple times in the first few years of life. The American Academy of Pediatrics recommends that infants and young children are seen at the following ages: 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 24 months, 30 months, and 36 months. It is recognized that pediatricians want to screen for ACEs and provide education about discipline to parents in clinic but physicians’ awareness of evidence-based resources is limited. Therefore, the results of our project, if taken to scale, would reach a large proportion of U.S. children and their families, easily numbering in the millions.
Feasibility: Where are you with understanding the feasibility of your idea? Describe what you’ve done so far and your plans. (3000 characters)
Funding from this application will be used for research and validation, development, and distribution of the innovations. There is strong evidence that our idea is feasible within the context of these priority areas.
Our request for funding builds on projects that have tested how to integrate a brief parenting screen into the well child visit. With Tennessee State funding, we tested the PCS in 2017 with over 700 English-, Spanish-, and Arabic-speaking parents of 2-10 year old children. The pediatric ACEs screening tool worked very well to identify children who have been exposed to a range of unhealthy parenting strategies (see Image 11). As would be expected, unhealthy parenting, as measured by the PCS (questions 1-12), is associated with child behavior problems such as conduct disorder and hyperactivity.
With over a dozen publications in peer-reviewed journals, we have demonstrated that a brief parent training intervention, Play Nicely (see http://www.playnicely.org/), can educate parents about healthy discipline strategies in 5-10 minutes in a way that is culturally sensitive.
We will extend a study that is being funded by the State of TN Department of Health; funding ends June 30, 2018. In this study we are enrolling parents of younger children between the ages of 6 months and 2 years because it is known that parenting styles develop in the early months/years when children are vulnerable to toxic stress. This project is working but it takes longer than anticipated to recruit parents and there are important outcomes that require follow up. A long-term vision is needed to enroll and follow up enough parents to detect meaningful differences in important outcomes. Our goal is to enroll over 1000 parents of young children and follow the parent/child dyads in clinic for 1-2 years, providing booster educational sessions to parents who continue to use unhealthy discipline strategies.
There is much evidence that speaks not only to the feasibility to further develop the PCS survey and the Play Nicely innovation, but also our commitment to the innovations. For example, the Play Nicely multimedia program is in its 3rd Edition. We have developed a separate smart phone/tablet version of Play Nicely. The Play Nicely multimedia program, the Play Nicely Handbook, and the PCS are available in multiple languages. Still, much more could be accomplished in development.
We have made progress with distribution through the Vanderbilt University Center for Technology Transfer and Commercialization. Both the PCS and Play Nicely can be accessed at www.playnicely.org. The Play Nicely multimedia program can be viewed online by anyone for free. The handbook is available to purchase on the website. The PCS can be downloaded at no cost. Future plans include more efforts to distribute and market the innovations to practitioners and health care leaders. We also aim to identify a publisher for the handbook.
Business Viability: How viable is your business model? (5000 characters)
We acknowledge that there are potential barriers that could hinder the successful integration of our innovations into the pediatric primary care visit, including time constraints and lack of reimbursement. The pediatric primary care visit is, on average, 20 minutes in duration and requires disease screening and intervention, a physical examination, anticipatory guidance, education, and immunizations. Typically, physicians are reimbursed for a bundle of services that is negotiated between providers and payers (i.e., insurance companies).
Despite these barriers, there are several reasons why our business model is viable.
1. Our innovations address recognized gaps in pediatric services by the American Academy of Pediatrics, a leading organization. Most pediatric health care providers are members of the AAP. The AAP recommends that pediatricians screen for social determinants of health and counsel parents about discipline during the well child visits. Dr. Scholer understands the role of the AAP in establishing/changing the schedule of services for children.
2. There are many precedents for health screening and interventions in pediatric primary care that are on the AAP’s schedule of services. Examples include validated surveys to screen for hypercholesterolemia, tuberculosis, lead toxicity, food insecurity, and autism. Depending upon the results of screening questions, providers intervene accordingly.
3. Our innovations are evidence-based. Given the already packed well child visit, new services that screen for important diseases and intervene as needed will not be accepted without evidence that they are effective; fortunately, ours are proven effective.
4. Our innovations are population-based. Other ACEs tools and parenting programs are limited in that most have studied volunteers, introducing a selection bias. In contrast, the PCS and the Play Nicely program have been tested with consecutive parents in a real-world clinic setting, avoiding selection bias and stigmatization.
5. Our innovations are excellent examples of value-based care. Interventions in the pediatric primary care visit are unlikely to be introduced readily if they are expensive. The US spends approximately 17% of its GDP on health care related expenditures. The Department of Health and Human Services is committed to focus on value-based services. Our innovations exemplify value-based care as the PCS and the Play Nicely multimedia program are free. In less than a minute, heath care providers can review the PCS and introduce an effective parenting intervention.
Another potential obstacle – but one where today’s internet and social media landscape may offer a solution and great opportunity – is the research-practice gap (aka the knowing-doing gap), which is the amount of time between the publication of research and practice change. On average, it takes 17 years for research to result in changes in actual clinical practice. With our project, we will strive to decrease the research-practice gap by focusing on implementation strategies that promote the exchange, transfer, diffusion, and dissemination of the PCS and Play Nicely, as well as the research results that support their use. We will use the efficiency and economy of the internet and social media platforms to help with distribution. Similar to the innovative nature of this opportunity provided by Gary Community Investments and OpenIDEO, we hope to leverage similar networks and resources to promote this important intervention for the benefit of young children and parents in need of support.
HCD: How have you used human centered design to build or refine your concept? (5000 characters)
We have used a human centered designed to develop our prototypes of the ACEs screening survey and the Play Nicely program. We have tested both innovations with hundreds of parents of young children in the pediatric clinic, using population-based approaches to avoid selection bias and stigmatization.
Testing of the ACEs screening tool (Images 11-14).
In 2017, we tested the PCS with over 700 parents in the pediatric clinic. Parents received the survey well and none expressed offense with the survey. We found that 36% of children had parenting-related ACEs scores of over 4 and that 11% of children had at least 2 childhood stressors.
Testing of the Play Nicely program.
The Play Nicely program has been reviewed by parents, health care providers, psychologists and teachers. We have been diligently focused on obtaining data from parents and health care professionals after they have viewed the Play Nicely program. We have studied English, Spanish, and, most recently Arabic speaking parents. These studies document that our parenting intervention works to change behavior by empowering parents with knowledge about healthy discipline strategies. These studies highlight this human centered design.
1. In 2010, we published a study of 259 parents of 1-5 year old children presenting for a well visit. Parents were randomized to an intervention or control group. Parents in the intervention group were instructed to view at least 4 of the strategies in the Play Nicely program (approximately 1 minute per strategy) and parents in the control group were provided with routine primary care. After the clinic visit, all parents were asked to participate in a 2-minute survey in which the key question was, "What, if anything, do you plan to do differently to discipline your child at home?" We found that over 80% of parents in the intervention group planned to change how they discipline compared to only 7% in the control group (see Image 15 and https://www.ncbi.nlm.nih.gov/pubmed/20083523). A notable strength of the study is that we recruited consecutive parents, indicating the promise for a population-based approach to parenting education.
2. Parents should not use coercive forms of discipline such as spanking because spanking is associated with long term problems (i.e. spanking is recognized as an ACE). Play Nicely can shift parents' attitudes about physical punishment. See https://www.ncbi.nlm.nih.gov/pubmed/23859768.
3. In 2016, we published a study which found that the Play Nicely program was culturally sensitive to parents from different ethnic backgrounds and races. This study is important as it demonstrated that a standard approach to discipline education is feasible regardless of parents' backgrounds. See https://www.ncbi.nlm.nih.gov/pubmed/27423240. As another example of how the content can cross ethnic/racial boundaries, a study found that Samoan parents in New Zealand responded favorably to the Play Nicely program (see http://researcharchive.vuw.ac.nz/handle/10063/2815).
4. In 2018, we published a study examining how the Play Nicely program works to shift parents' attitudes about corporal punishment. Parents of 1-5 year old children reported that the program shifted their attitudes about spanking by providing them with alternatives. See https://www.ncbi.nlm.nih.gov/pubmed/28952320.
5. Play Nicely has also been tested with health care professionals in training. Students and residents who viewed the program felt more comfortable counseling parents about discipline and shifted their attitudes away from using corporal punishment (see https://www.ncbi.nlm.nih.gov/pubmed/27582490).
Another way in which we have used a human-centered design is by addressing a problem that affects a large proportion of the population and is associated with a tremendous disease burden (Images 1-4). Examining our PCS data, 46% of children had at least one stressor/ACE and 36% of children had over 4 parenting-related ACEs. In a national study conducted in 2016, 45% of children younger than 18 had been exposed to at least one ACE (see https://www.childtrends.org/publications/prevalence-adverse-childhood-experiences-nationally-state-race-ethnicity/). In this study, ACEs were assessed from parent report and focused on 8 household/community exposures. A limitation of this study is that there was no assessment of either child abuse or parenting behaviors, resulting in 45% being an underestimate of actual ACEs exposure.
To summarize our human-centered approach, at least 45% of children are impacted by ACEs which contribute to disease in adulthood. Our 2-minute screening can quickly and easily detect PRACEs during well child visits and the Play Nicely intervention can reduce PRACEs. This has implications for improving the human condition through disease prevention, reducing later health costs, and the general positive development of children.
Image 11. The PCS was tested with over 700 parents in the Vanderbilt Pediatric Clinic. The bars to the right of the questions report the prevalence of at-risk responses. The first 12 questions of the PCS focus on parenting-related ACEs (e.g. spanking, threatening, humiliation). We also included a question about overuse of punitive parenting behaviors such as frequent use of saying "No", time-out, and taking away a privilege.
Image 12. For questions 1-12 of the PCS, scores ranged from 0-11 out of 12, with a median of 4 (IQR 2-7). 36% of parents had a score > 4. These data indicate that the PCS is able to identify a significant proportion of low-income parents who might benefit from parenting education.
Image 13. The PCS was tested with over 700 parents in the Vanderbilt Pediatric Clinic. The bars to the right of the questions report the prevalence of at-risk responses. Questions 13-22 focused on non-parenting-related childhood stressors such as household exposure to mental illness, incarceration, divorce.
Image 14. For questions 13-22, most children (56%) had no childhood stressors. Scores ranged from 0-8 out of 10, with a median of 0. 22% of children had at least 2 stressors.
Image 15. We randomized consecutive parents of 1-5 year old children to an intervention group or control group. The intervention group was asked to view at least 4 of the interactive options in Play Nicely and the control group received routine primary care. After the clinic visit, parents were asked what they planned to do differently to discipline their children. Over 80% of parents in the intervention group planned to change how they discipline compared with 7% in the control group.
Tell us more about you (3000 characters)
Dr. Scholer is a general pediatrician who is reminded on a daily basis that many health problems stem from people's environment. Dr. Scholer's research on the PCS and Play Nicely prototypes convince him that inexpensive solutions are available to solve the problem of how to assess and mitigate ACEs in pediatric primary care.
Here is a list of influential people in Dr. Scholer's academic life:
- Richard Tremblay: Dr. Tremblay, professor at University of Montreal, studies the trajectory of violence from early childhood through adulthood. Dr. Tremblay's work demonstrating that violence prevention should start in the early years was the inspiration that prompted Dr. Scholer to create the Play Nicely program.
- George Holden: Dr. Holden, professor at SMU, is a nationally recognized expert on parenting, discipline and family violence. His research projects have determined the timing of the establishment of parenting practices and attitudes about corporal punishment. On multiple occasions, Dr. Scholer has used Dr. Holden's validated Attitudes Toward Spanking scale to demonstrate that Play Nicely can shift parents' attitudes about corporal punishment.
- Elizabeth Gershoff: Dr. Gershoff, professor at University of Texas, studies negative outcomes associated with physical punishment. Dr. Gershoff's work has convinced Dr. Scholer that some parenting strategies (e.g. spanking) cause short and long term health problems.
- Vincent Felitti and Robert Anda: Dr. Felitti and Dr. Anda were the investigators who led the original ACEs study in California in the 1990s. Their work demonstrated that exposure to child abuse and household dysfunction is associated with dozens of health problems.
Dr. Scholer is passionate about early brain and child development. He feels that all parents should be asked the following question, "Assume you see one young child hit another. What are you going to do?" This question addresses early childhood aggression, one of the strongest risk factors for violence, and the question opens the door for discussion about discipline strategies that can be used for other challenging behaviors.
Dr. Scholer, professor of pediatrics, has worked as a clinician, educator and researcher at Vanderbilt since 1995. Dr. Scholer’s work would not be possible without collaboration and partnerships. Dr. Scholer has excellent working relationships with the American Academy of Pediatrics (AAP) and the TN Department of Health. He is an executive member of the AAP Council on Early Childhood. Dr. Scholer has received funding from the State of Tennessee to lay the foundation for the proposed project.
Dr. Scholer understands the balance that is needed to accomplish tasks such as disease screening, parent education, trainee education, clinical research, and pediatric clinic operations. Dr. Scholer has extensive experience with conducting similar projects, and will supervise all aspects of the program.
Image 16. Dr. Scholer's work is at the intersection of parenting and adverse childhood experiences. We refer to this overlapping area as parenting-related ACEs (PRACEs). Regardless of whether PRACEs represent unhealthy parenting or child abuse, it is known that exposure to some parenting strategies are associated with health problems. Dr. Scholer is excited to mitigate ACEs, especially parenting-related ACEs, in the context of the pediatric primary care visit.
Image 17. Dr. Scholer serves on the executive committee of the Council on Early Childhood of the American Academy of Pediatrics. The American Academy of Pediatrics is dedicated to improving children's health and has over 60,000 members.
Image 18. Dr. Scholer is a general pediatrician and professor of pediatrics at Vanderbilt University Medical Center.
Do you have the people and partners you need to do what you’ve described? (600 characters)
Yes, we have support to complete the work that we have described. We have the support of Vanderbilt University Medical Center, the Vanderbilt Center for Technology Transfer and Commercialization, and the Tennessee Department of Health. The Tennessee Department of Health has provided funding to test the ACEs-derived, parenting-related ACEs survey with hundreds of parents. Research on the PCS and the Play Nicely program is possible because of the contributions of many Vanderbilt University medical students, MPH students, and pediatric residents.
As you consider your next steps, what kinds of help could you use? Is there a type of expertise that would be most helpful? (1800 characters)
Help is needed in the areas of development and distribution. Although more research will be valuable, there is already enough research to proceed with development and distribution efforts. As examples, it is known that:
- toxic stressors such as ACEs can cause long term health problems.
- some parenting strategies (e.g. spanking, threatening, humiliating) are ACEs.
- we can identify parents who are using unhealthy discipline strategies with a 2-minute screening tool in pediatric primary care.
- parents can be educated about healthy discipline after a 1-minute introduction to an educational program in pediatric primary care.
While additional long-term studies will be useful, waiting years or decades for completion of that research would be a disservice to children’s health.
Dr. Scholer has expertise in conducting and publishing clinical research, but he has no specific training in the areas of development and distribution of innovations such as the PCS survey and Play Nicely. Innovations will smolder without efforts to improve the innovations and introduce the innovations to more end-users. Vanderbilt University owns the PCS and Play Nicely and, through Vanderbilt’s Center for Technology Transfer and Commercialization, would be eager to work with Gary Community Investments.
Would you like mentoring support?
If so, what type of mentoring support do you think you need? (1200 characters)
Mentoring support is sought to review our proposal and to provide feedback. We acknowledge the thoughtful insight of Dr. Laura Scharphorn as it greatly strengthened our application.
Are you willing to share your email contact information submitted on OpenIDEO with Gary Community Investments?
Yes, share my contact information
[Optional] Biography: Upload your biography. Please include links to relevant information (portfolio, LinkedIn profile, organization website, etc).
Dr. Seth Scholer is a professor of pediatrics at Vanderbilt University. Dr. Scholer completed medical school at Indiana University and a residency in pediatrics at Duke University. He obtained a master of public health at Indiana University. Since starting at Vanderbilt University in 1995, Dr. Scholer has been an active clinician, educator, and researcher. Dr. Scholer’s research has focused on how to improve pediatric services in the area of child maltreatment prevention.
Mentorship: How was your idea supported? (5000 characters)
I was matched with a mentor, Dr. Laura Scharphorn. Laura's feedback resulted in a major transformation of my application. Initially, my project focused only on research. Research is necessary if we are to change policy and practice in pediatric primary care. However, as Laura convinced me, practice transformation will require more than research. Because of Laura's input, I expanded our idea to included efforts to develop the innovations and, perhaps more importantly, to consider how to distribute and market the innovations. Laura's broader vision will result in more rapid integration of our ACEs screening and intervention into pediatric primary care practice.