This is the second in a series of live blogging posts from the 2015 CFHA Conference in Portland, Oregon. Check back for one more.
The ACE Study: Linking Childhood Trauma to Long-Term Health and Social Consequences
CFHA 2015 Conference Plenary Session 2
Friday October 16, 2015 – 8:30 a.m. to 10:00 a.m
|Vincent J. Felitti, MD, Co-Principal Investigator, Adverse Childhood Experiences (ACE) Study
Colleen Fogarty: Dr. Felitti is the past Chief of Preventive Medicine for Kaiser Permanente, and co-PI for the Adverse Childhood Experiences (ACE) Study. He begins by showing two pictures. There’s a question embedded in these two pictures: a newborn infant, and a 20 year old lying on the sidewalk; Dr. Felitti poses the question of how we can predict or create the outcome for the 20 year old depicted and he notes that in the 17 years since the first ACE publication, despite intense academic interest there has been essentially no clinical implementation of the findings.
He summarizes the findings that show ACE’s are common, powerfully predict health risks and social malfunction. “If we thought that smoke billowing out of the house was the cause of the problem, then fire departments would bring fans to blow the smoke away.”
Stephanie Trudeau: Dr. Felitti notes that the study began as a process of how to understand physical and mental traumas better. Studying findings show that the repressed role of ACE in adult wellbeing, disease and social function turns gold to lead. ACE indicators are common and disturbing and are mostly unrecognized. However, they are powerful predictors of adult social malfunction, health risks, biomedical disease and premature death. Integrating these finding into primary care medical practice appears to produce a significant reduction in health care costs.
Dr. Felitti presents a case study of what he calls the “Index Patient” whom he treated while working in a San Diego obesity clinic. He shows a photo at age 8, age 28 at 408lbs, and then age 29 at 132lbs. What is the core diagnosis? Which photo represents the patient’s problem??
Colleen: Dr. Felitti reflects on the Index Patient who lost so much weight in one year. Then he shows the re-gain curve the same patient experienced after the successful treatment intervention. He reflects on the patient’s disclosure of being sexually propositioned after her weight loss, and this contributing to her re-gain of weight. Further patient interviewing led her to disclose incest during her childhood. Many subsequent patients in the program disclosed child sexual trauma or other significant family or personal traumas. This collection of clinical disclosures, stories led Dr. Felitti and his collaborators to design and carry out the ACE study, which contained both retrospective and prospective design.
Dr. Felitti notes substantial difficulty in IRB approval, as the board was concerned that patients, upon being asked about difficulties in their childhood, would become suicidal. The IRB approved the study when they agreed to have a clinician carry a cell phone 24x7 for 3 years; they did this and received no calls during that time. In contrast, Dr. Felitti reports that the team received many notes of gratitude, summed up by a patient who wrote that, “I was afraid that I would die and no one would know what happened to me.”
Stephanie: ACE indicators/categories (with %) fall into three categories: Abuse, neglect, and household dysfunction. Abuse includes psychological abuse by parent (11%), physical abuse by parents (28%) and sexual abuse by anyone (28% or W, 16% for M). Neglect includes emotional (15%) and physical (10%). Household dysfunction: alcoholism or drug use in home (27%), loss of parent, death, divorce, mother abandonment (23%), depression or mental illness (17%), mother treated violently (13%), imprisoned household member (5%).
The ACE study questionnaire is 4 pages long, completed at home, and includes a face-to-face interview and a full medical assessment. ACE researchers used this style to ask the questions: “I see on the questionnaire that … can you tell us how that has affected you later in life”. This open approach turned out to be powerfully effective.
Study results show that 67% of participants experienced at least one category of ACE and that one ACE predicts an 87% chance of at least one other category of ACE being present. Women are 50% more likely than men to have a score over 5.
Colleen: Dr. Felitti shares comments via video of a man who had losses in his childhood and subsequently became a smoker, alcoholic, and user of drugs. The man says, “Twenty five years, [I had] poor childhood experiences with drugs, alcohol, cigarettes. I had no idea that the nicotine played such an important part in…keeping the door closed to the memories. I found that it blocked emotions and memories…” Dr. Felitti notes that addiction highly correlates with characteristics intrinsic to that individual’s childhood experiences.
In another video a morbidly obese woman shares her reaction to the recommendation of bariatric surgery. She reflects, “I cope with life with food…I feel like he’s taking away my safety [by suggesting bariatric surgery] I’m not ready yet to get the weight off and not be able to get it back. I can’t be safe then.”
Stephanie: The patient videos are very powerful! Dr. Felitti suggests clinicians with a focus on ACE can ask “How old were you when you first started putting on weight…why do you think that age and not another”? What function does the “dysfunction” serve to our patients? Let’s ask! What is perceived as the problem is actually someone’s unconscious solution to problems we know nothing about. For example, what if depression is a normal response to abnormal life experiences?
Colleen: So, what can clinicians do? Gather a trauma informed history from patients and develop an approach to patient care using that information. Primary prevention is crucial; but we don’t yet know how to do this!
For more information about the ACE study, click here:
Colleen Fogarty MD, MSc, is the Director of the Faculty Development Fellowship and Assistant Residency Director at the University of Rochester/Highland Hospital Department of Family Medicine.
Stephanie Trudeau, MS, LAMFT, PhD student University of Minnesota. Behavioral Health Intern and Research Assistant in the Department of Family Medicine and Community Health at their Broadway Family Medicine Residency Clinic.