The impact of positive childhood experiences on adult psychiatric disorder and symptoms: Protocol for a systematic review and meta-analysis of longitudinal cohort studies

Lisa H. Telford; Colm Healy; Éilis J O’Reilly; Mary C Clarke

doi:10.12688/hrbopenres.13833.1

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Study Protocol

The impact of positive childhood experiences on adult psychiatric disorder and symptoms: Protocol for a systematic review and meta-analysis of longitudinal cohort studies

[version 1; peer review: 1 approved, 1 approved with reservations]

Lisa H. Telford ¹, Colm Healy², Éilis J O’Reilly³, Mary C Clarke^4,5

PUBLISHED 18 Apr 2024

Author details Author details

¹ School of Population Health, Royal College of Surgeons in Ireland, Dublin, County Dublin, Ireland
² School of Medicine, University College Dublin, Dublin, County Dublin, Ireland
³ School of Public Health, University College Cork, Cork, County Cork, Ireland
⁴ Department of Health Psychology, Royal College of Surgeons in Ireland, Dublin, County Dublin, Ireland
⁵ Department of Psychiatry, Royal College of Surgeons in Ireland, Dublin, County Dublin, Ireland

Lisa H. Telford
Roles: Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing

Colm Healy
Roles: Supervision, Writing – Review & Editing

Éilis J O’Reilly
Roles: Supervision, Writing – Review & Editing

Mary C Clarke
Roles: Conceptualization, Project Administration, Supervision, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Background

Mental and substance use disorders are the leading cause of disability among young people worldwide. Early life environments and experiences have a significant influence on development with long-lasting implications for both physical and mental health. While the harmful effects of childhood adversity are well-documented, positive childhood experiences are less well-established and the degree of association with later mental health outcomes is currently undefined. The proposed systematic review will therefore examine the literature exploring associations between exposure to positive childhood experiences and the development of psychiatric disorder or symptoms in adulthood.

Methods and analysis

Studies examining associations between exposure to positive childhood experiences and risk of adult psychiatric disorder or symptoms will be systematically identified by searching Embase, APA PsycInfo, MEDLINE, and Scopus. Customised search strategies will be built for each database by combining key search terms relating to inclusion criteria. No restrictions on publication date will be applied, however searches will be restricted to the English language. Provided data are sufficient, a random-effects model at the 0.05 level of significance will be used to pool quantitative effect estimates. If meta-analysis is not possible, results will be summarised in tables and reported narratively. The Joanna Briggs Institute Critical Appraisal Checklist for Cohort Studies will be used for quality assessment of included studies and the overall strength of the body of evidence will be assessed using the Grading of Recommendations Assessment, Development, and Evaluation framework. Heterogeneity between included studies will be explored through visual inspection of forest plots and by assessing the I2 statistic. Reporting of this protocol has been guided by the standards of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols Statement.

Ethics and dissemination

Only published data will be used for this review therefore ethical approval is not required. Findings will be disseminated in a scientific peer-reviewed journal and results presented at conferences.

Keywords

positive childhood experiences, mental health, adult psychiatric disorder

Corresponding author: Lisa H. Telford

Competing interests: No competing interests were disclosed.

Grant information: Health Research Board (HRB) SPHeRE (Structured Population and Health-services Research Education) programme, SPHeRE2022-1.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Copyright: © 2024 Telford LH et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Telford LH, Healy C, O’Reilly ÉJ and Clarke MC. The impact of positive childhood experiences on adult psychiatric disorder and symptoms: Protocol for a systematic review and meta-analysis of longitudinal cohort studies [version 1; peer review: 1 approved, 1 approved with reservations]. HRB Open Res 2024, 7:17 (https://doi.org/10.12688/hrbopenres.13833.1) First published: 18 Apr 2024, 7:17 (https://doi.org/10.12688/hrbopenres.13833.1) Latest published: 18 Apr 2024, 7:17 (https://doi.org/10.12688/hrbopenres.13833.1)

Introduction

Mental and substance use disorders are the leading cause of disability among young people worldwide accounting for a quarter of years lost due to disability (YLDs) between 0 and 24 years of age¹. Since young people make up 41% of the global population, mental wellbeing among this age group is of significant public health concern². While the developmental origins of mental disorders are complex and varied, both nature and nurture are known to play a role³. Early life environments, including positive and negative childhood experiences, are particularly formative and provide the bedrock for development over the life course^4,5. Research showing the detrimental influence of childhood adversity on adult physical and mental health spans over two decades with the concept of adverse childhood experiences (ACEs) first proposed by Felitti and colleague’s (1998) seminal study⁶. Traumatic events experienced before the age of 18, such as neglect, physical, emotional or sexual abuse, family dysfunction and loss of a parent, are some well-known examples of ACEs⁷.

Less is known about positive childhood experiences (PCEs)⁸, although interest in and research on PCEs, has grown in recent years⁹. PCEs, also known as advantageous or benevolent childhood experiences¹⁰, have been described as protective or promotive factors which contribute to healthy development such as having a secure attachment with at least one parent or adult, living in a safe home environment, developing skills and talents through physical activities and hobbies, and having family routines¹¹. There is a considerable gap in the literature regarding studies which investigate the beneficial effects of PCEs and their ability to protect against the development of psychiatric disorder. To date, one study¹² has shown that PCEs reduced the risk for depression, with the highest exposure group having 72% lower odds of developing depression compared to the lowest exposure group after controlling for ACEs.

Studies which investigate the aetiology of adult psychiatric disorders typically present in the form of deficit models and often focus on the effects of negative experiences in childhood. While understanding the harmful developmental origins of psychiatric disorders and symptoms is crucial for prevention, early intervention, and effective treatment, avoiding childhood adversity is not always feasible. Positive childhood experiences which foster resilience and may ameliorate the effects of ACEs offer a more accessible means for early intervention and prevention strategies. To target interventions appropriately, more evidence is needed on the strength, nature, and direction of associations between different PCEs and adult psychiatric disorders or symptoms. In synthesising the literature, we hope to provide this essential information regarding the preventive potential of PCEs for future adverse mental health outcomes.

Objectives

The primary objective of this study is to conduct a systematic review and meta-analysis of published observational studies examining associations between exposure to PCEs within the first 18 years of life and risk of developing psychiatric disorder or symptoms in adulthood.

If feasible, the secondary objectives are to investigate possible differences between sex, age at exposure, and type of PCEs through subgroup analysis.

The proposed review will seek to address the following research questions:

What is the evidence for associations between exposure to positive childhood experiences and risk of psychiatric disorder or symptoms in adulthood?
What are the sex-specific, age-dependent, and PCE type-related variations in adult psychiatric outcomes associated with positive childhood experiences?

Methods

Protocol and registration

This protocol is reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) Statement¹³ and has been registered on PROSPERO under registration number CRD42023482969.

Eligibility criteria

Studies will be considered eligible for inclusion in accordance with the following criteria:

Study design

Prospective or retrospective cohort studies investigating associations between exposure to PCEs and development of psychiatric disorder (i.e., anxiety and mood, including major depressive, bipolar and psychotic disorders) or symptoms in adulthood will be eligible.

Population

All participants from the general population aged 18 or younger at the time of exposure.

Exposure

Exposure to positive childhood experiences (one safe caregiver, friends, comforting beliefs, school enjoyment, a caring teacher, good neighbours, an adult mentor, opportunities, positive self-image, home routines, community traditions, spiritual beliefs, education, school belonging, skills development, household safety, physical activity, and hobbies), within the first 18 years of life (≤ 18 years of age) and measured prior to the development of the specified outcome(s).

Comparison

We will compare risk for those who have had PCE exposure for psychiatric outcomes compared to risk in the unexposed population group.

Outcome

A clinical diagnosis of anxiety disorder, mood disorder, including major depressive disorder, bipolar disorder, and psychotic disorder according to Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) criteria or measurement of their symptoms using a validated instrument in adulthood (> 18 years of age).

Language

Literature searches will be limited to the English language.

Exclusions

Sources which do not report on or include data analysis such as review articles, book chapters or conference papers will not be eligible, nor will studies recording ‘lifetime’ diagnosis in adulthood, studies using clinical high-risk samples or studies examining the effect of PCEs on outcomes in childhood (measured before the age of 18).

Search strategy

Electronic literature searches of Embase (Elsevier platform), APA PsycInfo (EBSCO platform), MEDLINE (Ovid platform), and Scopus databases from inception will be systematically conducted to identify eligible studies. Search strategies will include a combination of search terms relating to exposure (e.g., positive childhood experiences), outcome (e.g., psychiatric disorder or symptoms) and study design (e.g., longitudinal) inclusion criteria. The search strategy has been developed with and validated by a librarian in the Royal College of Surgeons in Ireland (RCSI) and the full search strategy for MEDLINE is available on figshare, [https://doi.org/10.6084/m9.figshare.24551893.v1]¹⁴. Full text review will be limited to peer-reviewed articles, theses, and dissertations. Authors will be emailed to request full-text articles where the full-text is not available. Database searches will be re-run before the final analysis to check for any further eligible studies.

Other sources

Published reviews in the field as well as reference lists of included articles will be manually hand-searched to identify any additional studies.

Data management and selection process

One reviewer will execute the search strategy, and then import, manage, and delete duplicate records using Covidence software (https://www.covidence.org/). Two reviewers will independently screen the titles and abstracts of identified studies based on predefined screening criteria using Covidence. Any conflicts will be discussed with the assistance of a third reviewer until consensus is reached. For abstracts failing to provide sufficient information for exclusion, full-text manuscripts will be obtained and reviewed. Final inclusions will be decided based on independent full-text review by two reviewers, and agreement with a third reviewer in instances of conflict. The selection process and reasons for exclusion based on full-text review will be reported in a PRISMA flow chart.

Data collection and abstraction

A tailormade data extraction form will be piloted by two independent reviewers and any discrepancies or adjustments discussed and decided within the wider research team. One reviewer will extract predefined data items relating to the study objectives from each included study using the final data extraction form. A second reviewer will independently check the extracted data.

Data items. Proposed data items to be extracted from all included studies include:

Citation details: primary author, year of publication, journal
Study details: study design, study period, study aims/objectives, study setting/country, dataset used
Sample characteristics: sample size, sex (proportions), demographic details
Exposure information: type of exposure(s), exposure assessment method, timing of exposure
Outcome information: type of outcome(s), outcome assessment method, age at outcome assessment
Measures of effect information: effect estimate and corresponding 95% confidence interval (CI) or metrics which can be used to calculate an effect size, direction of association, adjustments
Details on mediators, moderators, and confounders

Any disagreements will be identified and discussed with a third reviewer until consensus.

Quality assessment

The quality of included studies will be assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Cohort Studies¹⁵. Heterogeneity between included studies will be explored through visual inspection of forest plots and by assessing the I² statistic. Potential sources of heterogeneity may include study setting, study sample, and outcome measures and will be investigated using meta-regression where necessary. Risk of bias will be assessed using sensitivity analyses and through visual examination of funnel plots. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework will be used to assess the overall strength of the body of evidence¹⁶.

Patient and public involvement

Patient and public involvement was not elicited in developing this study protocol.

Reporting and presenting results

Conducting Systematic Reviews and Meta-Analyses of Observational Studies of Etiology (COSMOS-E)¹⁷ guidance will be followed when performing the systematic review. Reporting of the systematic review will be guided by the standards of the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Statement¹⁸.

Qualitative synthesis

A description of included studies and their methodological quality will be presented graphically (tables/figures) and key findings reported narratively in text.

Quantitative synthesis (meta-analysis)

Using prospective and retrospective data collated from cohort studies, we intend to meta-analyse the robustness of the relationship between exposure to PCEs and adult psychiatric disorder or symptoms. Both significant and non-significant associations between PCEs and outcomes will be reported. Quantitative synthesis of effect estimates will be considered if there is sufficient overlap in the definition of exposures and outcomes reported and based on an examination of risk of bias assessment.

Given the expected diversity in sample and study characteristics, we anticipate performing a meta-analysis using random-effects statistical models. Where possible, pooled ratios and their corresponding 95% CIs for outcome/diagnosis data will be calculated and reported. If a meta-analysis is not be possible, results will be summarised and reported narratively. If sufficient data are available, subgroup analyses will be conducted for sex, age at exposure, and type of PCEs.

Ethics and dissemination

As this study will only use published data, ethical approval is not required. Evidence on the association between exposure to positive childhood experiences and development of psychiatric disorder or symptoms in adulthood will be generated by this study. Findings will be disseminated in a scientific peer-reviewed journal and results presented at conferences.

Discussion

Potential limitations

Paucity of data might prevent the pooling of effect estimates and planned subgroup analyses. We will cluster outcomes as ‘any psychiatric disorder’ and perform analyses on specific PCEs if data are limited. Additionally, we will cluster individual PCEs according to subscale categories as outlined in the Child and Youth Resilience Measure (CYRM-R)¹⁹ if necessary.

Deviations from the protocol

Any protocol amendments prior to or during conduct of the review will be documented in tabular format along with version history. All deviations will be described in the final review.

Study status

The literature search has been executed and title and abstract screening is in process at the time of this protocol publication.

Data availability

Underlying data

No data are associated with this article.

Reporting guidelines

Figshare: PRISMA-P checklist for “The impact of positive childhood experiences on adult psychiatric disorder and symptoms: Protocol for a systematic review and meta-analysis of longitudinal cohort studies”, https://doi.org/10.6084/m9.figshare.24553159.v1²⁰.

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Author contributions

Lisa H Telford: Project administration, writing – original draft preparation, writing – review & editing

Colm Healy: Supervision, Writing – review & editing

Éilis J O’Reilly: Supervision, Writing – review & editing

Mary C Clarke: Conceptualisation, project administration, supervision, writing – review & editing

Acknowledgements

We wish to thank Mr Killian Walsh from the RCSI library for assisting with the development of the search strategy for this study protocol.

Faculty Opinions recommended

References

1. Erskine HE, Moffitt TE, Copeland WE, et al.: A heavy burden on young minds: the global burden of mental and substance use disorders in children and youth. Psychol Med. 2015; 45(7): 1561–3. PubMed Abstract | Publisher Full Text | Free Full Text
2. United Nations: World population prospects 2022. Online Edition. Department of Economic and Social Affairs, Population Division; 2022. Reference Source
3. Tsuang MT, Bar JL, Stone WS, et al.: Gene-environment interactions in mental disorders. World Psychiatry. 2004; 3(2): 73–83. PubMed Abstract | Free Full Text
4. Cicchetti D, Toth SL: The past achievements and future promises of developmental psychopathology: the coming of age of a discipline. J Child Psychol Psychiatry. 2009; 50(1–2): 16–25. PubMed Abstract | Publisher Full Text | Free Full Text
5. Masten AS: Developmental psychopathology: pathways to the future. Int J Behav Dev. 2006; 30(1): 47–54. Publisher Full Text
6. 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): 245–58. PubMed Abstract | Publisher Full Text
7. Abbott M, Slack KS: Exploring the relationship between childhood adversity and adult depression: a risk versus strengths-oriented approach. Child Abus Negl. 2021; 120: 105207. PubMed Abstract | Publisher Full Text | Free Full Text
8. Morris AS, Hays-Grudo J: Protective and compensatory childhood experiences and their impact on adult mental health. World Psychiatry. 2023; 22(1): 150–1. PubMed Abstract | Publisher Full Text | Free Full Text
9. Han D, Dieujuste N, Doom JR, et al.: A systematic review of positive childhood experiences and adult outcomes: promotive and protective processes for resilience in the context of childhood adversity. Child Abus Negl. 2023; 144: 106346. PubMed Abstract | Publisher Full Text | Free Full Text
10. Rollins EM, Crandall A: Self-regulation and shame as mediators between childhood experiences and young adult health. Front Psychiatry. 2021; 12: 649911. PubMed Abstract | Publisher Full Text | Free Full Text
11. Hays-Grudo J, Morris AS: Adverse and protective childhood experiences: a developmental perspective. Baroody, T. Washington: American Psychological Association; 2020. Publisher Full Text
12. Bethell C, Jones J, Gombojav N, et al.: Positive childhood experiences and adult mental and relational health in a statewide sample. associations across adverse childhood experiences levels. JAMA Pediatr. 2019; 173(11): e193007. PubMed Abstract | Publisher Full Text | Free Full Text
13. Moher D, Shamseer L, Clarke M, et al.: Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015; 4(1): 1. PubMed Abstract | Publisher Full Text | Free Full Text
14. Telford L: Search strategy for MEDLINE (Ovid platform). figshare; 2023. Publisher Full Text
15. Barker TH, Stone JC, Sears K, et al.: Revising the JBI quantitative critical appraisal tools to improve their applicability: an overview of methods and the development process. JBI Evid Synth. 2023; 21(3): 478–93. PubMed Abstract | Publisher Full Text
16. Schünemann H, Brozek J, Guyatt G, et al.: Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach. The Cochrane Collaboration: Cochrane Training, 2013. Reference Source
17. Dekkers OM, Vandenbroucke JP, Cevallos M, et al.: COSMOS-E: Guidance on conducting systematic reviews and meta-analyses of observational studies of etiology. PLoS Med. 2019; 16(2): e1002742. PubMed Abstract | Publisher Full Text | Free Full Text
18. Page MJ, McKenzie JE, Bossuyt PM, et al.: The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021; 372: n71. PubMed Abstract | Publisher Full Text | Free Full Text
19. Jefferies P, McGarrigle L, Ungar M: The CYRM-R: A rasch-validated revision of the child and youth resilience measure. J Evid Based Soc Work (2019). 2019; 16(1): 70–92. PubMed Abstract | Publisher Full Text
20. Telford L: PRISMA-P checklist. figshare. 2023. http://www.doi.org/10.6084/m9.figshare.24553159.v1

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Version 1

VERSION 1 PUBLISHED 18 Apr 2024

Author details Author details

¹ School of Population Health, Royal College of Surgeons in Ireland, Dublin, County Dublin, Ireland
² School of Medicine, University College Dublin, Dublin, County Dublin, Ireland
³ School of Public Health, University College Cork, Cork, County Cork, Ireland
⁴ Department of Health Psychology, Royal College of Surgeons in Ireland, Dublin, County Dublin, Ireland
⁵ Department of Psychiatry, Royal College of Surgeons in Ireland, Dublin, County Dublin, Ireland

Lisa H. Telford
Roles: Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing

Colm Healy
Roles: Supervision, Writing – Review & Editing

Éilis J O’Reilly
Roles: Supervision, Writing – Review & Editing

Mary C Clarke
Roles: Conceptualization, Project Administration, Supervision, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

Health Research Board (HRB) SPHeRE (Structured Population and Health-services Research Education) programme, SPHeRE2022-1.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Article Versions (1)

version 1

Published: 18 Apr 2024, 7:17

https://doi.org/10.12688/hrbopenres.13833.1

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© 2024 Telford LH et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Telford LH, Healy C, O’Reilly ÉJ and Clarke MC. The impact of positive childhood experiences on adult psychiatric disorder and symptoms: Protocol for a systematic review and meta-analysis of longitudinal cohort studies [version 1; peer review: 1 approved, 1 approved with reservations]. HRB Open Res 2024, 7:17 (https://doi.org/10.12688/hrbopenres.13833.1)

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PUBLISHED 18 Apr 2024

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Reviewer Report 28 Dec 2024

Christina Bethell, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA

Approved with Reservations

https://doi.org/10.21956/hrbopenres.15157.r43708

Thank you for the opportunity to review the protocol paper for an upcoming study “The impact of positive childhood experiences on adult psychiatric disorder and symptoms: Protocol for a systematic review and meta-analysis of longitudinal cohort studies.” It is important ... Continue reading

Thank you for the opportunity to review the protocol paper for an upcoming study “The impact of positive childhood experiences on adult psychiatric disorder and symptoms: Protocol for a systematic review and meta-analysis of longitudinal cohort studies.” It is important to conduct a systematic review on the impact of PCEs to promote positive mental health (not assessed in this study) and to protect against negative mental health problems (the focus of this study). Other reviews have been conducted, though they may differ from that proposed here. It is key for authors to note how this review differs up front and I expected to see this in the protocol.
I have several comments for your consideration:

It is not well justified why are authors focused only on cohort/longitudinal studies. As with ACEs studies, adults report on their lived experience (which is the main focus, not any factual or third party objective assessment of whether the ACE occurred) when reporting their PCEs. It is the lived experience and “felt sense” or having had PCEs that is the key exposure? As such, cross-sectional studies of adults with data on both their mental health diagnoses and PCEs would seem to be relevant? The one study authors did cite that had been done (their reference 12) was a cross sectional study.
The definition of “Positive Childhood Experiences” (PCEs) in the paper is weak. There needs to be a careful delineation of variations in definition and qualifying “experiences”. The key focus should be on experiences related to safe, stable and nurturing experiences and not on the full range of “protective factors” that impact health (e.g. having sufficient food, opportunities for engaging in sports, etc.). Otherwise, PCEs are not distinct and the intent of the research is to assess lived experiences of feeling safe, supported, a sense of belonging and mattering, being cared about, etc. I suggest authors are much more clear about what qualifies as a PCE. Another example is the list “friends” as a PCE. Yet, it is not having friends only. It is feeling supported by friends when things were hard, etc. Authors do not note PCEs related to feeling a sense of belonging in school and enjoying participating in community traditions, etc. These are both core PCEs included in the study noted in the paper (#12).
I suggest authors consider refining research questions to distinguish effects of PCEs with and without adjustment for ACEs. Not all studies will have conducted this type of adjustment and aligning studies based on similarity of definition/measurement of PCEs and factors adjusted or stratified for is important.
Authors note that “outcomes” are diagnoses mental health conditions using validated screeners. Self report of whether a person had been told by a provider they had depression is also valid and authors should clarify intent. Do they mean that the studies needed to have directly diagnosed participants or will they allow for self report of the outcomes of interest.
It would be nice if authors considered positive mental health outcomes like flourishing since the absence of negative mental health does not infer positive mental health.
The search strategy for PCEs is important and is not clear enough.

Is the rationale for, and objectives of, the study clearly described?

Partly
Is the study design appropriate for the research question?

Partly
Are sufficient details of the methods provided to allow replication by others?

No
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Early life impacts on lifelong health, especially positive and adverse childhood experiences, social determinants and larger contextual factors. Intervention studies on early identification and mitigation of risk as well as proactive health promotion and positive health development. Systems transformation, quality improvement and policy research associated with these topics

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Reviewer Report 02 Jul 2024

Angus MacBeth, The University of Edinburgh, Edinburgh, Scotland, UK

Approved

https://doi.org/10.21956/hrbopenres.15157.r40449

The literature on PCEs (Positive Childhood ExperienceS), as opposed to ACEs (Adverse Childhood ExperienceS) is gradually increasing, and the authors are correct to articulate that this is an important to the ACEs literature, and could help identify preventative approaches for ... Continue reading

The literature on PCEs (Positive Childhood ExperienceS), as opposed to ACEs (Adverse Childhood ExperienceS) is gradually increasing, and the authors are correct to articulate that this is an important to the ACEs literature, and could help identify preventative approaches for mental health. The review is clearly outlined and there is an appropriate methodology for narrative synthesis and meta-analysis if sufficient papers. Whether the literature is detailed enough yet to support meta analysis is a key consideration.

Specific comments to improve the review further are as follows:

1. Which operationalised of PCEs is used in the current review? There is reference to the Bethell 2019 JAMA Paediatrics paper, which gives a good working definition. Is this what is being used? Or is it the CYRM-R, which is implied later.

2. This is also relevant to the proposed secondary analyses of sub-groups of PCEs, which will need further operationalization. Also, these are relatively broad items, so will they be grouped at all?

3.How will distinctions between prospective and retrospective measurement of PCEs be handled in both narrative and meta analytic reviews? This would potentially be a sub-grouping variable.

4. Also important to take into account how the PCEs have been reported - ACEs literature varies between use of ACEs as total score, or in broad domains. Something similar could be hypothesised to be relevant to PCEs (see above point also).

5. Presumably publication bias will be assessed if meta analysing?

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Clinical Psychology, mental health, evidence synthesis

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Christina Bethell, Johns Hopkins University Bloomberg School of Public Health, Baltimore, USA

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28 Dec 2024 | for Version 1

Christina Bethell, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA

13 Views Cite this report Responses(0)

Approved With Reservations

Thank you for the opportunity to review the protocol paper for an upcoming study “The impact of positive childhood experiences on adult psychiatric disorder and symptoms: Protocol for a systematic review and meta-analysis of longitudinal cohort studies.” It is important to conduct a systematic review on the impact of PCEs to promote positive mental health (not assessed in this study) and to protect against negative mental health problems (the focus of this study). Other reviews have been conducted, though they may differ from that proposed here. It is key for authors to note how this review differs up front and I expected to see this in the protocol.
I have several comments for your consideration:

It is not well justified why are authors focused only on cohort/longitudinal studies. As with ACEs studies, adults report on their lived experience (which is the main focus, not any factual or third party objective assessment of whether the ACE occurred) when reporting their PCEs. It is the lived experience and “felt sense” or having had PCEs that is the key exposure? As such, cross-sectional studies of adults with data on both their mental health diagnoses and PCEs would seem to be relevant? The one study authors did cite that had been done (their reference 12) was a cross sectional study.
The definition of “Positive Childhood Experiences” (PCEs) in the paper is weak. There needs to be a careful delineation of variations in definition and qualifying “experiences”. The key focus should be on experiences related to safe, stable and nurturing experiences and not on the full range of “protective factors” that impact health (e.g. having sufficient food, opportunities for engaging in sports, etc.). Otherwise, PCEs are not distinct and the intent of the research is to assess lived experiences of feeling safe, supported, a sense of belonging and mattering, being cared about, etc. I suggest authors are much more clear about what qualifies as a PCE. Another example is the list “friends” as a PCE. Yet, it is not having friends only. It is feeling supported by friends when things were hard, etc. Authors do not note PCEs related to feeling a sense of belonging in school and enjoying participating in community traditions, etc. These are both core PCEs included in the study noted in the paper (#12).
I suggest authors consider refining research questions to distinguish effects of PCEs with and without adjustment for ACEs. Not all studies will have conducted this type of adjustment and aligning studies based on similarity of definition/measurement of PCEs and factors adjusted or stratified for is important.
Authors note that “outcomes” are diagnoses mental health conditions using validated screeners. Self report of whether a person had been told by a provider they had depression is also valid and authors should clarify intent. Do they mean that the studies needed to have directly diagnosed participants or will they allow for self report of the outcomes of interest.
It would be nice if authors considered positive mental health outcomes like flourishing since the absence of negative mental health does not infer positive mental health.
The search strategy for PCEs is important and is not clear enough.

Is the rationale for, and objectives of, the study clearly described?

Partly
Is the study design appropriate for the research question?

Partly
Are sufficient details of the methods provided to allow replication by others?

No
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Early life impacts on lifelong health, especially positive and adverse childhood experiences, social determinants and larger contextual factors. Intervention studies on early identification and mitigation of risk as well as proactive health promotion and positive health development. Systems transformation, quality improvement and policy research associated with these topics

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Reviewer Report

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02 Jul 2024 | for Version 1

Angus MacBeth, The University of Edinburgh, Edinburgh, Scotland, UK

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Approved

The literature on PCEs (Positive Childhood ExperienceS), as opposed to ACEs (Adverse Childhood ExperienceS) is gradually increasing, and the authors are correct to articulate that this is an important to the ACEs literature, and could help identify preventative approaches for mental health. The review is clearly outlined and there is an appropriate methodology for narrative synthesis and meta-analysis if sufficient papers. Whether the literature is detailed enough yet to support meta analysis is a key consideration.

Specific comments to improve the review further are as follows:

1. Which operationalised of PCEs is used in the current review? There is reference to the Bethell 2019 JAMA Paediatrics paper, which gives a good working definition. Is this what is being used? Or is it the CYRM-R, which is implied later.

2. This is also relevant to the proposed secondary analyses of sub-groups of PCEs, which will need further operationalization. Also, these are relatively broad items, so will they be grouped at all?

3.How will distinctions between prospective and retrospective measurement of PCEs be handled in both narrative and meta analytic reviews? This would potentially be a sub-grouping variable.

4. Also important to take into account how the PCEs have been reported - ACEs literature varies between use of ACEs as total score, or in broad domains. Something similar could be hypothesised to be relevant to PCEs (see above point also).

5. Presumably publication bias will be assessed if meta analysing?

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Clinical Psychology, mental health, evidence synthesis

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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The impact of positive childhood experiences on adult psychiatric disorder and symptoms: Protocol for a systematic review and meta-analysis of longitudinal cohort studies

Abstract

Background

Methods and analysis

Ethics and dissemination

Keywords

Introduction

Objectives

Methods

Protocol and registration

Eligibility criteria

Study design

Population

Exposure

Comparison

Outcome

Language

Exclusions

Search strategy

Other sources

Data management and selection process

Data collection and abstraction

Quality assessment

Patient and public involvement

Reporting and presenting results

Qualitative synthesis

Quantitative synthesis (meta-analysis)

Ethics and dissemination

Discussion

Potential limitations

Deviations from the protocol

Study status

Data availability

Underlying data

Reporting guidelines

Author contributions

Acknowledgements

References

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