Adverse Childhood Experiences Have a Profound, Direct Effect on Health. So Why Aren't More Physicians Aware of Their Impact?
Public Health Feature — September 2017
Tex Med. 2017;113(9):53-57.
By Sean Price
By age 12, Sarah had been pregnant twice and had contracted a sexually transmitted disease. Medical staff at an Austin clinic referred her to the Austin Child Guidance Center for counseling. That's when the fuller picture behind her trauma came out.
Seanna Crosbie, director of program and trauma-informed services at Austin Child Guidance Center, interviewed both Sarah (whose identity has been changed to protect her privacy) and her mother. Those interviews revealed that Sarah had been abused for years by a family friend. But they also uncovered something important about the mother.
"The child's mom had her own trauma history as well," said Ms. Crosbie, who is also chair of the Trauma-Informed Care Consortium of Central Texas, which brings together professional groups to address trauma needs in families. "The mother herself had been removed from the home by Child Protective Services [when she was a child]. She'd been physically and sexually abused by her own parents, and that had resulted in [her] using drugs at a pretty young age. The mom was young, in her 40s, and she had already been diagnosed with lung cancer. She ended up passing away."
Houston pediatrician Angelo P. Giardino, MD, says a case like this is typical of adverse childhood experiences, or ACEs. This term covers a wide range of stressful childhood events, including abuse, neglect, and loss of parents (see "Types of ACEs"). Research has shown that ACEs can be ― as they quite likely were for the mother ― a contributing cause for health behaviors that may place the individual at risk for adult illnesses, like cancer. ACEs can also lead to other chronic conditions, such as diabetes, depression, and heart disease. (See "Mechanism by Which Adverse Childhood Experiences Influence Health and Well-Being Throughout the Lifetime."
"We frequently call this a two-generation or three-generation problem," said Dr. Giardino, who is a professor of pediatrics and section chief of academic general pediatrics at Baylor College of Medicine in Houston. "Because not only is the kid exposed to it, it's likely that the adult in their life has experienced adversity. When you do an intervention, you have to treat everyone ― the kids, the parents, and even the grandparents."
Despite the proven impact ACEs have on health, many physicians are still unaware of ― or only passingly familiar with ― the ways they influence health. Many medical schools don't teach the importance of ACEs, and many physicians practice without reference to what a former president of the American Academy of Pediatrics has called "the single-greatest unaddressed health threat facing our nation today."
Christopher Greeley, MD, vice chair of community health in pediatrics at Baylor College of Medicine, says knowledge about ACEs tends to be focused in certain subsets of doctors, like those who work in poorer communities, where childhood trauma tends to be more prevalent. But he says the impact of ACEs cuts across all socioeconomic, age, and racial groups.
"I think [the understanding about ACEs] is improving," he said. "I think when you ask about ACEs with pediatricians, many of them still don't know about it. But it's vastly more now than five or 10 years ago."
To that end, the TMA Fall Conference in Lost Pines on Sept. 15–16 will feature a presentation on ACEs led by Dr. Giardino. It is designed to help Texas physicians understand what ACEs are, how to identify them in daily practice, and how patients can be helped as they struggle with the fallout from childhood trauma.
"In my teaching, what I try to make clear is the physician has a role to play," Dr. Giardino said. "Physicians are passionate about helping their patients, but there's only so much time in a day. Some of these issues are really deep-seated community and societal and familial issues."
A Groundbreaking Study
ACEs first broke into public consciousness more than 20 years ago thanks to the work of Vincent Felitti, MD, and Robert Anda, MD. In the 1980s, Dr. Felitti worked in Kaiser Permanente's obesity clinic in San Diego. He found that many people could successfully take off weight, but they frequently put it back on. He conducted interviews to find out why and discovered that most of them had faced childhood sexual abuse.
Dr. Felitti teamed up with Dr. Anda, a researcher at the Centers for Disease Control and Prevention, to do a much larger study involving more than 17,000 people covered by Kaiser. About 70 percent were college-educated white people with well-paying jobs. Each was asked about 10 types of ACEs (see "Where to Start").
The study found that at least 67 percent of people questioned had at least one ACE, and 12.6 percent had four or more. More alarmingly, the study showed that the higher a patient's "ACE score," the worse their health outcomes tended to be. Those who had four or more were 2.5 times more likely to have chronic obstructive pulmonary disease. Those with six or more could expect to lose 20 years off their lives (see infographic).
"It was amazing," Dr. Giardino said about the results. "There was this staircase relationship between the number of ACEs and poorer and poorer health."
The correlation between childhood trauma and poor outcomes has since been confirmed by more than 70 other studies. Subsequent research also has shown that dramatic childhood trauma ― the kind produced by multiple ACEs ― causes physical changes in people that can shorten their lives and diminish quality of life.
The big problem is that ACEs create what has been labeled "toxic stress." Experiencing this kind of severe, prolonged stress in childhood has long been known to result in unhealthy choices such as smoking, drinking, or overeating. But research done since the original ACE study shows that toxic stress changes brain structure and chemistry. These changes make people more susceptible to both chronic and infectious diseases throughout their lifetime. This makes ACEs a major social determinant of health in more ways than one, Dr. Greeley says.
"If you have a bad childhood and a bad adolescence, it wears your system down," he said. "So when you do get a major illness, your body doesn't respond as well. Also, if I have a horrible childhood, I probably don't have as many friends, and I become isolated. If I do get sick, no one helps me. It's likely that I'll have more complications because I can't make my doctors' appointments."
What Physicians Can Do
Once physicians understand the importance of ACEs, they have to figure out how they are going address it in their practice, Dr. Giardino says.
"I think there's a general common sense that a tough childhood would lead to poorer adult outcomes," Dr. Giardino said. "But I think what's been the 'ah-ha' [for ACEs] is the toxic stress. If you want to intervene [as a physician], it's all about creating a safe, supportive environment for the child. So you have to do that. You have to start asking how you can mitigate that toxic stress."
Ms. Crosbie says the case of Sarah about a decade ago woke her up to the impact of ACEs. Since then, she's spoken with physicians about how they can help, namely, in screening patients to see if ACEs play a role in their health.
"Just in talking with doctors over the last eight years, there are two challenges that they have vocalized to me," she said. "One is the time factor, specifically how do you get all this information and still do the exam? And the other ― what do they do when they ask these questions and patients become upset or show their mental health problems while they're meeting with a physician?"
Dr. Giardino says it's vital that physicians not act as if people with high ACE scores are damaged goods. Research has shown that people respond differently to different types of stress, he says. For one person, enduring childhood abuse or a divorce might be a trauma that badly damages their health. For another, it might just be a hardship that they overcome with little lasting damage.
"This is not destiny," Dr. Giardino said. "It's not like if you had a bad childhood you can't overcome it. But what you have to do is mitigate that toxic stress with nurturing supportive experiences. … [The message from physicians] has to be delivered in an optimistic, nonjudgmental way, and not in a fatalistic, 'You've had six ACEs so you're off the cliff.'"
Dr. Giardino says physicians have three main tasks when it comes to ACEs: identify the problem through screening, encourage the patient to get help through community resources, and direct the patient to the correct services.
"Just by virtue of the physician raising the issue and encouraging the person to use the community resources, that has a lot of standing with a patient," Dr. Giardino said.
Ms. Crosbie says this type of screening might have saved Sarah from years of difficulty. The abuse she suffered from a family friend started at age 9 or 10. Long before her pregnancy or sexually transmitted disease, she had regular well-child visits with a pediatrician. But there had been no routine screening for ACEs.
"No one had ever asked her if she had been sexually abused," Ms. Crosbie said. "And when I asked her, she was open and told me."
Pediatricians are not the only doctors who need to be educated and proactive about ACEs, Dr. Greeley says. Family physicians and specialists see the illnesses caused by ACEs every day. Physicians also are likely to argue for more community involvement in combatting ACEs as awareness about them spreads, he says. That could mean sometimes using medical dollars for things that are not strictly medical. He cited a pilot program in New York that allowed homeless people to use Medicaid dollars to pay rent. The program showed that the number of emergency department visits and incarcerations dropped as a result.
"And as more physicians become aware of it, there's going to be greater turning toward leadership to say that these things are really important for our patients and our kids," Dr. Greeley said. "[People will be asking,] what's the best way to think through how to support this?"
Because many people see a physician but few see a mental health professional on a regular basis, doctors are the best front-line defense against ACEs, Ms. Crosbie says. But, she says, educating physicians will take time.
"This research came out about 20 years ago, but it takes a while for practice to catch up with research," Ms. Crosbie said. "I think the medical community is key in helping to identify illness as it relates to adverse childhood experiences."
Sean Price can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.
Types of ACES
These are the adverse childhood experiences (ACEs) explored in the original 1990s study by Vincent Felitti, MD, and Robert Anda, MD:
- Physical abuse,
- Sexual abuse,
- Emotional abuse,
- Physical neglect,
- Emotional neglect,
- Domestic violence,
- Substance abuse in the household,
- Mental illness in the household,
- Parental separation or divorce, and
- Family member incarcerated.
Is there a way of ranking ACEs by severity? Pediatrician Angelo P. Giardino, MD, says no, because people respond differently to different types of stress. "We don't really think one is worse than the other," he said. "But we do know some are more prevalent than others. The most common one is having someone in your house with a substance abuse problem. And the least common one is having someone in your house who's incarcerated. And the rest are distributed in between."
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Where to Start
Understanding adverse childhood experiences (ACEs) begins with understanding a 1990s study by Vincent Felitti, MD, and Robert Anda, MD, which directly linked higher "ACE scores" to worse health outcomes as adults. For example, patients with six or more ACEs could expect to lose 20 years off their lives. See an infographic explaining the study, or visit the Centers for Disease Control and Prevention website for more information. And take a look at the original questionnaire given to the 17,000 test subjects, which is still used for screening.
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Don't Miss the TMA Presentation on ACEs
The TMA Fall Conference at the Hyatt Regency Lost Pines Resort on Sept. 15–16 will feature a presentation on adverse childhood experiences (ACEs) led by Houston pediatrician Angelo P. Giardino, MD. It is designed to help you delve deeper into this fundamental public health problem and learn how your specialty can help patients address the root causes, and not just the symptoms, of seemingly anomalous health conditions.
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