ACE in the Hole
or Futile Fact?
At this point in my education I am not easily awed, much less shocked. Discovering the Adverse Childhood Experience research was a shock and awe campaign to my clinical sensibilities.
For the uninitiated, the ACE study was n=17,000 research sponsored by the CDC. It looks at the effects of childhood trauma on adult health and behavior. Each research participant completed a 10-item childhood trauma screen. They also provided a thorough health and behavior history. The participants were stratified by trauma history ("ACE Score”) to assess whether it was predictive of health outcomes. Their data proved statistically significant to a degree rarely seen in the human sciences.
In each of the graphs below the numbers on the X-axis are ACE Scores (i.e. how many of the 10 traumas the person endured as a child) and the Y-axis is the percentage of participants with a particular health outcome as an adult. I apologize for the low quality of the graphs.
Negative early childhood experiences, especially those involving family members and other caregivers, have a profoundly detrimental effect on adult health.
People with low ACE scores are amazingly free of these problems.
No, that's a poor word choice. It is not fine, it's horrible.
Let's try that again, inspired from a song my kids love, but I hate: "whatever, it doesn't matter, oh well”.
No, that's not right either. It does matter. It matters deeply. BUT, as it relates to my adult patients who are already demonstrating the health sequelae of childhood traumas, I haven't been able to identify anything I can do with these data.
Knowing the fact that horrible parenting or a chaotic childhood placed the patient on a nearly inexorable path toward health destruction is diagnostic, but not therapeutic.
How do I intervene?
How do I make it better?
How do I advise my medical and nursing colleagues?
I have attempted 3 (inadequate) responses so that at least I feel like I'm not being callous:
1. Normalize their Experience: I can say: "I'm sorry, you've been through horrible experiences in your life, and unfortunately, science and my own clinical practice has shown us that these experiences help to explain many of your health problems”. This might assist the patient in piecing together a different health narrative, and the empathy that it implies might fortify our therapeutic relationship. But, I've never seen it go very far.
2. Protect the Innocent: I haven't had occasion to do so, but I've often imagined that a reasonable MedFT intervention would be to go through the ACE research with an abusive parent. These data might be the missing piece to dissuading him from passing along this horrible family legacy to his children. After all, this is exactly what we do with pre-contemplative smokers (i.e. "Were you aware that 2nd-hand smoke can cause more frequent illness, asthma episodes, and perhaps even lung cancer in your children?"). So, yes, this might help the next generation, but it doesn't turn back the clock for the abusive parent in the room who is already addled with her own health problems from her parents' abuse.
3. Educate the Clinicians: Patients who were traumatized as children are some of the least rewarding for healthcare providers. They come to the room with intractable health problems and behavior which looks like an Axis 2 diagnosis. These are the patients who quickly get labeled and often get fired from a practice. Perhaps having the patient complete an ACE screen will assist the clinician in having more compassion and in passing less judgment to the patient. If so, that would be wonderful.
OK, there might be some clinical advantage to screening for childhood traumas. However, I remain unconvinced that it is a clinically relevant tool. The ACE score should NOT be the 6th vital sign (or the 7th or 8th, or however many there are now that we therapists keep adding our soft scales to the hard science of checking patients-in). Perhaps I will continue to bust out an ACE 1-2 times per year, but it's not about to join the PHQ9, GAD7, and Vanderbilt in the pantheon of primary care screens.
Embracing the ACES and Trauma Informed Care: The Time is Now
Randall, I am very pleased that you raise awareness of the importance of the
Adverse Childhood Experiences (ACES) research. However, I beg to differ
with your conclusion that there is no place for translating the significance of
the ACES findings into the design and provision of collaborative healthcare
To recap, the ACE study surveyed more than 17,000 mid-life adults about 10
categories of adverse childhood experiences (all forms of abuse, witnessing
violence, parental absence, incarceration, mental illness and substance abuse)
then linked their responses and health histories. Key findings included: 1) a high prevalence
of ACES – only 1/3 of those surveyed reported NO ACES - and 16%
reported 4 or more ACES; 2) a very strong correlation between ACES and numerous
health and behavioral health diagnoses, as well as high risk behaviors
associated with poor health outcomes; and 3) a cumulative effect, four or more
ACES translated into significantly higher rates of morbidity and mortality.
Results of the ACE study were first published
in 1998 and there have been numerous replications since then. Additionally over the last 20 years there has
been a plethora of neuro-scientific studies demonstrating the negative impact
of toxic stress, trauma and adversity on health and development. In spite of this, few health and human
services organizations, CFHA among them, actively advocate to integrate this
research into practice. Trauma informed care (TIC) is an approach which both
acknowledges the importance of the ACES and provides a framework for how
organizations and systems must change in light of this knowledge. Fourteen
years is long enough - it is imperative that all health and human services
systems, including collaborative care models, become trauma informed now.
The concept of trauma informed care, first introduced by Fallot and
Harris in 2001, requires that all services designed to assist vulnerable
populations (health, behavioral health, education, housing, welfare etc…)
acknowledge the prevalence of and pervasive impact that violence and
victimization play in the lives of many consumers and recognize the presence of
behaviors and symptoms associated with trauma. This understanding must
then drive the design of services to validate trauma survivors, promote their resiliency
and recovery, and reduce and eliminate policies and practices that may be
traumatizing or re-traumatizing.
To promote trauma informed care, a number of individuals and organizations
have defined core principles and developed models of TIC (Sandra Bloom, Sanctuary Model, Community Connections, The National Child Traumatic Stress Network to
name a few) All have at their core safety first and safety for all (consumers,
family members, employees). Additionally
most advocate the importance of establishing cultures where collaboration,
democracy, consumer choice and control, and establishing positive relationships
CFHA is in an excellent position to be a strong advocate for trauma informed
care. The core principles of TIC are embedded in the organization's self
description which states: collaboration isn’t just a word in our name;
it defines who we are, how we interact with each other and other organizations.
We believe deeply that collaboration is an essential element necessary for
re-visioning healthcare, specifically, and society, generally. And echoed
in its mission to
promote comprehensive, cost-effective integrated health care and achieves this
mission through education,training,partnering,
consultation,research and advocacy.
Randall your "shock and awe" in response to learning about the ACE
research is noteworthy, yet your follow-up statement that you don’t know how to
use the information is dismaying. You suggest that perhaps the ACES can be
used to: 1) to normalize the trauma experience,
2) protect the innocent (prevent the transmission of trauma to the next
generation), and 3) educate providers.
These ideas are a good start toward becoming trauma informed, but much more
needs to happen and CFHA can take a leadership role in ensuring that it does.
With CFHA's urging, ALL collaborative care
providers and organizations can be sensitized to the prevalence and impact of
violence and trauma, not only in consumers/patients but among providers/staff;
they can learn to address secondary traumatic stress (the impact of exposure to
traumatic material from consumers/patients); they can provide
psycho-educational materials about trauma and toxic stress; they can integrate
routine screening for trauma exposure and trauma symptoms; they can identify, refer to, and integrate evidence based trauma-focused treatment; they can closely
and deeply examine and change their policies, protocols, standards and
practices to ensure that they do not re-traumatize, and they can involve trauma
survivors in the process of transforming services. Above all, each CFHA member can use his or
her sphere of influence to be a champion for trauma informed care. Together we can shift the fundamental
question that still permeates far too much of the health/behavioral health care
services system from:
wrong with you?" to "What has happened to you?" – the ACE study data
make it clear why we must do this now.