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.
There, I said it.
Now you say it: Do you like the ACE screen? Do you use it in primary care settings? How have you made it clinically relevant?
||Randall Reitz is the Director of Social Media for CFHA and the Behavioral Science Faculty at the St Mary's Family Medicine Residency in Grand Junction, Colorado. He studied family therapy at Brigham Young University and Indiana State University.|
He is the author of CFHA's CollaboBlog.