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Point / Counter-point 5

Posted By Randall Reitz and Leslie Lieberman, Thursday, March 29, 2012


Trauma History:

ACE in the Hole

or Futile Fact?

 

Randall Reitz


 

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.

 

 

 

 

 

 

2 Conclusions:

  1. Negative early childhood experiences, especially those involving family members and other caregivers, have a profoundly detrimental effect on adult health.
  2. People with low ACE scores are amazingly free of these problems.

Fine.

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

Leslie Lieberman

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 practice.

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 are paramount.

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: What's wrong with you?" to "What has happened to you?" – the ACE study data make it clear why we must do this now.


Randall Reitz
Leslie Lieberman

Leslie Lieberman, MSW directs the Multiplying Connections Initiative in Philadelphia. This program's mission is to build and sustain a trauma informed system for young children using relationships and connections as the vehicles for change.  For more information visit their website at www.multiplyingconnections.org or contact Leslie at llieberman@healthfederation.org


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Peter Fifield says...
Posted Thursday, March 29, 2012
I read the Poverty Clinic article in the New Yorker and it mentioned the ACE Study...very shocking and full of awe. I like the ACE screen and I have contemplated adding it our intake patient assessment packet to primarily offer the providers knowledge and insight into the patient history more than anything. That being said, what do we do with this knowledge? Good question...how that guides the provider interaction is a topic that necessitates a thesis.
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Sarah Woods says...
Posted Thursday, March 29, 2012
I think perhaps not enough credit has been given to "response" #2! As family therapists, we know that interventions that focus on the family have the ability to create changes throughout the system. We also know that the intergenerational transmission of abuse patterns is affected by parent mental health (e.g. http://www.sciencedirect.com/science/article/pii/S0145213401002861). So, combining this type of assessment with a PHQ-9, etc. would give a more thorough picture of patient functioning and potential points of intervention for the patient AND their family.

There is much evidence that intervening with parenting enhances parents' self-esteem, increases emotional self-regulation, promotes problem-solving, and improves mood, not to mention increases positive family interactions (e.g. http://www.triplep-america.com/documents/Triple%20P%20as%20a%20Public%20Health%20Approach.pdf). I would venture that these improvements, resulting from family interventions focused on preventing or improving parenting skills could also help to alleviate the physical concerns/symptoms these adult patients are reporting. As MedFTs, we know that physical and mental health are tightly intertwined! I think response #2 doesn't sound so "inadequate" and that perhaps screening for childhood abuse experiences could enhance our picture of primary care patients and perhaps our treatment plans.
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Randall Reitz says...
Posted Thursday, March 29, 2012
Leslie, thanks for playing Jane Curtain to my Dan Ackroyd. I promise not to follow Dan's example by mimicking Rush Limbaugh's recent language in my rejoinder. You make a number of very important points, many of which I hadn't consider previously. I especially appreciate the wealth of resources you present.

That being said, I re-assert my initial question: how can knowing the details of my client's ACE score improve my care to the client? Outside of your self-evident suggestion of not "re-traumatizing" the client in the exam room, what do I do next? Will knowing the ACE help with smoking cessation (since victims are more likely to smoke)? Will knowing the ACE help with preventing a suicide attempt (since victims are more likely to attempt suicide)? What do I do with this miserable data point once I have entered it into the EMR?
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Leslie Lieberman says...
Posted Friday, March 30, 2012

Randall, I've enjoyed playing the beautiful, bawdy and brainy Jane Curtain. As a macro-level social worker who has designed programs at the intersection of behavioral health and public health for more than 25 years, my attention is generally focused on more global issues - what data tell us about populations and using research to catalyze/support organizational and systemic changes that improve delivery of and access to health care. Nonetheless, as a social worker I also adhere to the principle that "one must start where the client is". Knowing your client's ACE score can deepen your compassion, as you point out, and help establish a trusting, open relationship. Additionally, while your client may present as a smoker asking/knowing the ACEs can lead to discussion/disclosure of other ACE related health/behavioral health concerns that hadn't been considered. I've posted your question to the ACES Too High Network, http://acestoohigh.ning.com/,a national on-line group "working together to lower ACE scores." Network membership includes a number of practitioners (including Felitti and Anda -the ACE study principle investigators) who have used the ACE questions in their clinical practices. I look forward to their answers to your question.

Thanks, Leslie
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Kalma Kartell White says...
Posted Friday, March 30, 2012
What is so insidious about some of the ACE Study findings is that individuals do not have to experience the worst of childhood abuse experiences to rack up a significant ACE score -- they do not have to have been parented by perpetrators or have inadequate parents. Household dysfunction, mental illness of a parent, divorce, separation from a parent are not necessarily about "terrible parents as Randall's comments seem to imply." (Have any of the subsequent ACE follow-ups included community violence?) Relatively low level small traumata that continue over time or occur in different forms can add up and seriously impact individuals with toxic stress. The impact of so-called small traumata has been noted in other areas of the literature.

What helps with healing, with or without traditional trauma treatment is education, empowerment, safety, relationships, resilience, all of which can take place or be enhanced at any point in a person's life. It seems to me that if individuals can remove or lessen trauma-related toxic stress at any point in their lives it can impact their health, if not in terms of cure, at least in terms of improving quality of life and reducing impact of illness. Unless all of Randall's clients(?) are in last stages of life, being trauma-informed and providing information to persons with lived experience can be of great benefit and perhaps in some cases, even extend life not only in terms of how they "feel" having reduced their toxic stress, but also in terms of how individuals are able to care for themselves and possibly prevent further deterioration. Wouldn't that kind of research be interesting?

Kalma Kartell White, MEd,
Behavioral Health Training and Education Network
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David D. Clarke says...
Posted Tuesday, April 3, 2012
Dr Reitz and I are colleagues and I have lectured twice on this subject at the CFHA meetings. He raises the key question about ACES: what is the benefit to a patient of knowing this information?
The benefit, which can be considerable, derives from relieving the long-term psycho-social consequences of ACEs. The two most fundamentally important of these consequences are low self-esteem and unrecognized anger about the ACEs. A helpful initial approach to the first is to point out to the ACE survivor that a hero in our society is someone who has overcome a difficult mental or physical challenge for a good cause. ACE survivors have done exactly that. If they can view themselves in these terms they will move toward a reversal of the low self-esteem that is the most common legacy of ACEs. This is of fundamental importance in reversing many of the negative health and social behaviors common in ACE survivors.
A helpful initial approach to the unrecognized anger is to ask the ACE survivor to imagine a child they care about growing up exactly as the survivor did. (ACE survivors often struggle to recognize the magnitude of the difficulty they endured as children, until they imagine it happening to a child they know). Then, when they feel ready, I ask them to write a letter (rarely mailed) to the person(s) who mistreated them, expressing their memories and emotions as completely as they can.
After these initial steps, counseling with a therapist who has interest and expertise in helping adult ACE survivors is an obvious follow-up.
My experience with the above is based on detailed interviews with over 4000 ACE survivors referred to me for medically unexplained symptoms or refractory functional syndromes. Not only did these typically improve in response to the above but I often noticed improvement in substance abuse (including tobacco), eating disorders, depression, anxiety and willingness to move on from dysfunctional personal relationships. Self-care skills also tend to improve substantially.
A group of experts in treating the long-term somatic consequences of ACEs has collectively created the Psychophysiologic Disorders Association (PPDA). Our website www.ppdassociation.org is due to launch in about a month (subject to delay of course). We are offering a one day conference to teach treatment techniques (primarily aimed at mental health professionals but all are welcome) on Saturday, Oct 6, 2012 at the New York Academy of Medicine, co-sponsored by NYU. (Registration will be via the website.) There is also much more information in Chapter 3 of my book which you can read more about at www.stressillness.com. (All earnings from the book and from my speaking fees are donated to the PPDA which is a 501c3 non-profit.)
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Randall Reitz says...
Posted Wednesday, April 4, 2012
Dear Readers, Leslie posted a parallel blog at the website "acestoohigh", which also garnered several strong responses, read here: http://acestoohigh.ning.com/profiles/blogs/how-can-the-aces-be-used-in-primary-care?xg_source=shorten_twitter
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