Early adversity and trauma – also known as Adverse Childhood Experiences (ACEs) – have significant health effects that carry forward throughout life. ACEs, which include childhood abuse, neglect and household dysfunction, can disrupt the growing bodies and brains of children, leading to a higher risk of disease, disability, risky health behaviours and social problems later in life.
During my clinical training I have found myself wondering: how might the health issues of patients I have met be influenced by their childhood experiences? I am reminded of the middle-aged woman, sitting in the waiting room of the emergency department, following her first suicide attempt on a background of a chronic eating disorder. The refugee with a history of cocaine abuse presenting to the emergency psychiatry clinic. And the young man who came to his family doctor in crisis because of a worsening abusive relationship at home.
In my short discussions with each of these patients, I discovered they had all suffered a traumatic event at some point during childhood. These ranged from sexual or physical abuse at the hands of a loved one to living through a civil war in a developing country.
In 1998, the US Centers for Disease Control and Kaiser Permanente published a seminal study that first coined the term ACEs and has since explored the relationship between childhood adversity and health outcomes. Researchers surveyed more than 17,000 adult patients about their medical history and childhood exposure to ACEs. Exposures included physical, sexual and emotional abuse; emotional or physical neglect; as well as domestic violence, parental separation or divorce, and substance abuse, mental illness and incarceration of family members. Nearly two-thirds of respondents had at least one ACE, and one in eight had four or more.
The study found a powerful dose-response relationship between ACEs and health, suggesting that higher ACE scores lead to more disability, morbidity and mortality in adulthood. Having four or more ACEs was associated with a four- to 12-fold increased risk of alcoholism, drug abuse, depression and suicide attempts. ACEs have been linked to the development of cardiovascular disease, diabetes, cancer, chronic lung disease and hepatitis. Researchers hypothesize that ACEs may lead to poor health by disregulating the body’s normal stress responses.
Of course, the relationship between ACEs and poor health outcomes is multifactorial. ACEs make up just one part of a complex puzzle that are the social determinants of health – gender, income, food security and education being a few other examples. Many people with multiple ACEs thrive in adulthood. It is possible that ACEs could be balanced out by protective factors like caring adults outside the household, a supportive school environment or recreational programs.
So what can healthcare providers do? The jury is out on the value of systematic screening for ACEs in routine clinical encounters. More studies are needed to assess whether screening actually leads to better health outcomes down the road. In 2000, the Canadian Task Force on Preventive Health Care recommended against screening to identify those at risk of experiencing or committing child maltreatment. Although the US Preventive Services Task Force has not made recommendations on screening for ACEs specifically, it has concluded that current evidence is inadequate to evaluate the benefits versus harms of primary care interventions to prevent child maltreatment in asymptomatic children.
Despite this, physicians and other healthcare providers should still remain alert for signs and symptoms of child maltreatment, and other indications of childhood adversity and chronic stress. With a better understanding of ACEs, we can more readily determine key risk factors and address social challenges that may lead to poor health in patients known to have experienced trauma.
Healthcare providers can educate patients and caregivers of young patients about the basics of ACEs. Knowing how adversity affects health later in life may encourage some people with traumatic pasts to come forward to seek help. Physicians can identify those who might benefit from treatments like cognitive behavioral therapy or trauma-specific therapies like Eye Movement Desensitization and Reprocessing. When needed, patients can also be referred to support services and community benefits like home visits for new or expecting mothers; parental education for pregnant teenagers; income support programs for parents; and intimate partner violence prevention programs.
Discussing past traumas is not easy. When a patient discloses this information, they must trust that their physician will hear their story and extend a helping hand. A strong therapeutic relationship can lessen the risk that patients will feel abandoned.
We owe it to patients to push back against the shame and secrecy surrounding ACEs to expose their profound effects on health and wellbeing. Building an awareness of the powerful effects of ACEs, and developing evidence-based methods to prevent childhood adversity and treat its effects should be our next steps forward.
*An draft version of this story was erroneously published on March 29
at 7 a.m. It was replaced with the correct version at noon.*
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Hi Max, I am interested in where you are at today with this conversation and how we might collaborate to bring it to Ottawa. I am preparing a pitch at Hacking Health Ottawa with hopes to garner interest in entering the Hack-a-thon at the end of May 2019. I am building a small team to help me strengthen the pitch with the hope of raising awareness of the health impacts of ACEs. The goal for the Hack-a-thon is to develop solution(s) to the barriers faced in the implementation ACEs screening. My aim is to get one of our local community health centres involved to pilot ACEs screening. I am currently collecting information on real and percieved barriers to its implementation. I also know a physician in Edmonton who has imbedded this into his practice for some time now. I will be reaching out to him during my preparation for the hack-a-thon. Should you be interested or know of another physician in Ottawa that would like to take this on, please get in touch. My Email is firstname.lastname@example.org. Thank you, Michelle
Thanks for raising this important issue, Max. Given the many ways that it affects a person’s health outcomes, the importance of knowing more about adverse childhood events (assessment and treatment options) is critical for all clinicians. It has likely influenced interactions of care for at least some of the patients most clinicians cared for in the past week, though we may not have been aware. But as others have commented, the readiness for a patient to explore the effect of their ACE needs to be the critical decision point about continuing with that conversation. Creating safety in the clinical relationship and ensuring continuity of care are pre-requisites to “opening the box”, else we risk re-traumatizing with unintentional abandonment and forcing the story to be retold over and over again. Supporting and strengthening coping skills are very different than exploring and (re)processing trauma; the former is something that many providers are capable of doing, while the latter is better done under the supervision of those with specialized trauma managed training.
Very many years ago, I went to see my family doctor to admit that I was an alcoholic. A perceptive and gentle physician, he responded with, “Tell me about growing up Frank.” That was the beginning of a long journey towards sobriety and personal progress. The culmination is a memoir I will be forever grateful to this fine doctor, who for some weeks, gave me a half hour to unburden myself – at the end of his long office days. I was near to killing myself and his care saved me. Please keep spreading the word about the long-term effects of childhood abuse and trauma.
Please don’t underestimate the power of just being heard. If we don’t allow survivors of trauma to be acknowledged we perpetuate their suffering. If we keep doing what we always do we will keep getting what we always get. Surely now is the time. Often trauma survivors believe they are deficit in some way, that what happened to them happened because they somehow deserved it. Trauma is when bad things happen to good people – to hear that from a first responder will help. Compassion and the ability to engage with someone who helps the person feel safe – most of us have that ability, don’t we?
As is often the case, it’s what happens AFTER a trauma that can lead to adverse or beneficial outcomes. That also applies to screening for trauma – bringing up past suffering and offering little to effectively address it most often only adds to allostatic stress load.
It’s a laudable goal, but hazardous considering how stretched the system is for resources. Broaching the subject can reactivate or worsen the patient’s trauma-related symptoms. If the primary care provider isn’t trained or local treatment has a long wait list (if it’s available at all), there is the very real possibility of making the patient worse, full stop.
We are working on training primary care providers on discussions of ACEs in adults health. There is a lot to do and much to be learned. But we cannot ignore the problem as if we are worried about opening Pandora’s box. The box is already opened and is manifested in poor health outcomes and dysfunctional behaviors. Helping patients acknowledge that is therapeutic, in and of itself. Disclosing the trauma to a trusted provider can be the first step to healing. If we wait until we have enough resources, we will never do it. In our population, more than a third of the patients have 5+ ACEs. We have to acknowledge that – to do otherwise would be malpractice.