During the 2015 CFHA
conference plenary, Vincent Felitti likened poor health behaviors (e.g.,
smoking cigarettes; IV drug use; overeating) to the smoke in a house fire. If
you see the smoke as the problem, and use fans to blow the smoke away, you will
not only fail to put out the fire, you will fan the flames. Treating poor
health behaviors as the primary problem, without attending to the real underlying issue(s), will have a
similar effect, according to Felitti.
Felitti’s analogy reminds
me (KL) of the Process Model of Addiction and Recovery (Harris &
Tabor-Wilkes, 2011), whereby the desire to cope with negative feelings caused
by underlying pain (be it spiritual, emotional, relational, physical, etc.)
drives the decision to adopt an unhealthy or compulsive behavior (e.g.,
hoarding, smoking, IV drug use, alcohol, overeating). While this behavior may
provide an instantaneous but short-lived rush of relief, the resulting feelings
of shame and guilt are longer lasting. This perpetuates the experience of pain,
thereby re-starting the cycle.
The pain that people are
trying to overcome often began in childhood, as a result of what Felitti,
Robert Anda, and their research team (1998) call Adverse Childhood Experiences,
or ACEs. The main categories of these experiences include household
dysfunction, neglect, physical abuse, psychiatric disorder of a parent,
parental substance abuse or incarceration, childhood maltreatment, and sexual
abuse. These experiences can be objectively scored on a questionnaire. Scores
range from zero to ten. Ten indicates that the respondent experienced an event
in each of the ten categories at least once.
An ACE score of four or more (at
least one event in four different ACE categories) correlates strongly with
increased prevalence of chronic disease in adulthood, as well as a high
prevalence of multiple unhealthy lifestyle behaviors, such as smoking, IV drug
use, and promiscuous sex (Felitti et al., 1998). In a sampling of findings from
the longitudinal ACE study, Felitti and Anda (2010) summarize other strong and
significant relationships of ACE scores to biomedical disease, psychiatric
disorders, unhealthy behaviors, and healthcare costs.
During the plenary, Felitti
highlighted that people who are seeking to relieve their pain are mostly
interested in feeling relief as quickly as possible. They typically are not
thinking about the long-term consequences of their choice. Hence the ineffectiveness
of telling a smoker about the likelihood of future lung disease. Instead of
inducing behavior change, the response is akin to: "Smoking provides me relief
right now, which is what I need.” Until the underlying pain is
addressed/treated, the likelihood of people being willing to change an
unhealthy behavior they have adopted to help them cope is pretty slim.
from understanding this truth, successful intervention should rely on a
multi-faceted approach; comprehensive and integrated health care is an ideal
way to address and treat pain from the past. Yet, we can do better than that. Particularly
in primary care/family medicine, we train clinicians to be proactive, not
merely reactive. As such, prevention of ACEs is vital for individual, family,
and population health.
At our primary care
clinic, Southern Colorado Family Medicine (SCFM), the proactive approach we
developed to prevent ACEs for our patients is called SCAN: Score, Connect, and
Nurture. First, we educated our entire
clinic staff about ACEs and then trained our clinicians how to talk to patients
about ACEs. We now assess ACEs in expectant
parents and parents of 0-18 year old patients, focusing our efforts on breaking
the cycle of ACEs often observed across generations. We perform universal
assessments on this targeted population because ACEs affect everyone,
regardless of sociodemographics. We educate parents about what having
experienced ACEs means for their health and what can be done to try to decrease
the risk of their children going through some of the same experiences.
intervention centers on meeting participants where they are. For example, with
parents who have experienced ACEs, the clinician normalizes and explains that
some people feel they have overcome some of their difficult experiences from
childhood but may feel "tripped up” by others. To help meet their specific
needs, all families are offered resources by a family resource specialist, a
social worker embedded in our clinic by a local community resource organization.
Examples of resources offered include parenting education and support with home
visits by a community-based parenting specialist, financial assistance,
children’s books, and mental health treatment referrals.
Of the many success
stories we have had throughout the year, one example that stands out is one of
our first SCAN families. This couple was
expecting their first baby while facing multiple psychosocial concerns. In
addition to having minimal social support, they were being evicted from an
apartment that was later condemned. Of the ten main categories on the Adverse
Childhood Experiences questionnaire, the expectant mom endorsed 9 of them, and
the soon-to-be father had experienced all ten ACE categories, a score of 10 out
Yet, their ACEs scores
and their struggles represent the beginning
of their SCAN story, not the end. Both parents also scored highly on a measure
of resiliency--also part of the SCAN intervention--indicating they were
resourceful and skilled at successfully overcoming challenges. They were scared
and voiced a strong desire to parent their child differently than they
themselves had been parented. They were motivated to get help in order to be the
parents they wanted to be to their child. We provided them with a supportive
and understanding healthcare environment, and our Family Resource Specialist
linked them with several resources to boost their confidence and enhance their
Ultimately, we assisted them in locating safer housing, helped him get
a new job, connected them with mental health services, and enrolled them in a
parenting education and home visiting program for continued support after the
baby was born. The impact of the SCAN intervention, including their perception
of our healthcare environment as safe and accepting, was made evident when,
after a later traumatic event occurred, they returned to our clinic to seek
additional care and support.
The adoption of unhealthy
behaviors is not the only explanation behind the strong connection between ACEs
and later development of chronic disease, as pediatrician Nadine Burke Harris
explains in her TEDMED talk on the profound ways in which the
ACE study changed her clinical practice. Even so, reframing our way of looking
at unhealthy behaviors--not as problems themselves but as adaptive solutions to problems--broadens our
perspective and increases the likelihood with which we are able to intervene
and help patients to adopt healthier behaviors.
References and suggested
Burke-Harris, N. (2014). How childhood trauma
affects health across a lifetime. TEDMED 2014.
Felitti, V. J., & Anda, R.
F. (2010). The relationship of Adverse Childhood Experiences to adult medical
disesae, psychiatric disorders, and sexual behavior: Implications for
healthcare. In The Hidden Epidemic: The Impact of Early Life Trauma on
Health and Disease. Ed. Lanius, R. & Vermetten, E. Cambridge University
Felitti, V. J., et al. (1998). Relationship
of childhood abuse and household dysfunction to many of the leading causes of
death in adults: The Adverse Childhood Experiences Study. American Journal
of Preventive Medicine, 14, 245-258.
Harris, KS, Smock SA, Tabor Wilkes, M. (2011).
Relapse Resilience: A Process Model of Addiction and Recovery. Journal of Family Psychotherapy 22 (3),
|Kaitlin Leckie, PhD, LMFT, is the Director of
Behavioral Medicine at the University of Texas Medical Branch’s Department of
Family Medicine in Galveston, Texas. |
|Kristine Miller, D.O., is a faculty physician in
Pueblo, Colorado, at Southern Colorado Family Medicine Residency, where she
serves as the Clinic Director and Director of Osteopathic Education. |