Exposure to Community Violence and Adverse Childhood Experiences in the Emergency Department

Adverse childhood experiences (ACEs) and exposure to community violence are public health issues linked to negative mental and physical health outcomes. The emergency department (ED) can play a critical role in the care of patients with a history of trauma exposure. Unfortunately, patients' experiences often go unidentified, leading to missed opportunities to address and prevent further harm.

We administered a 22-question survey of trauma exposure in ED patients to 1) identify the prevalence of exposure to community violence and ACEs and resulting post-traumatic stress disorder (PTSD) symptoms, and 2) determine perceived social service needs. This self-administered survey study was conducted on a convenience sample of 267 adult patients at one academic hospital in Chicago, IL, between July 2018-December 2019. This ED sees approximately 70,000 patients annually. These were fluent English-speaking patients who were non-critically ill or altered and chosen randomly after being assigned to an ED room, typically during regular business hours based on research associate availability. They were not offered compensation for study participation. The survey included demographic information and questions modified from the Adverse Childhood Experiences Study questionnaire, the 54-item Survey of Exposure to Community Violence, and the Primary Care PTSD screen. Participants were also asked to identify resources to address their exposure to trauma.

Of 268 surveys, 267 were completed; 88% of participants endorsed exposure to ACEs or community violence (95% confidence interval [CI] 84.1-91.9%, p < 0.001 compared to general US population rate of 61%). A total of 53.6% of respondents endorsed exposure to at least one ACE (95% CI, 47.6-59.6%), and 15.7% were exposed to ≥4 ACE (95% CI, 11.3-20.1%). The most commonly endorsed categories of ACE were "emotional neglect" (30.3%, 95% CI 24.8%-35.8%); "emotional abuse" (25.8%, 95% CI 20.6%-31.1%); and "exposure to family substance use" (21%, 95% CI 16.1%-25.9%). When asked about personal experience with violence in the community, 47.9% said they had been shoved, kicked or punched (95% CI 41.9%-53.9%), 8% had been stabbed (95% CI 4.8%-11.3%), and 6.7% had been shot (95% CI 3.7%-9.7%). Among the survey participants, 26.2% said they had seen someone die from violence either in their home or in their neighborhood (95% CI 20.9%-31.5%). ZIP Code analysis indicates that most patients resided in neighborhoods near our ED and were likely to utilize it for medical care. Of respondents with exposure to trauma 38% asked for resources through their primary care clinic (95% CI 32.2%-43.8%), while 77.4% asked for resources through faith-based organizations (95% CI 72.4%-82.4%).

These findings suggest that most respondents in the ED have experienced trauma, and many are interested in community and clinical resources. These results demonstrate the need for trauma-informed screening in the ED and support for institutional and community-level interventions to address patient experiences.