Guiding physicians to integrate ACEs

There is more information about my approach to ACEs in a brief blog post here:  http://www.stressillness.com/blog/?p=1549#more-1549

My experience is based on detailed interviews with over 4000 ACE survivors referred because of MUS/FS.

Nora and David. I am excited about your comments. I have downloaded your respective pieces of information and will be reading them. Nora, I serve as President of the Native American Children's Alliance, a group that works to support children in Indian Country who are victims of sexual abuse. We are small, but growing. I will incorporate your information into what I share. As a former executive in a Tribal Health System, I did attempt to inform my peers about abuse without much success. David, I have looked at your PowerPoints for the second workshop on your website and am definitely on board. Chronic disease and MUS are rampant within Tribal Health and we need to develop a mechanism to address it. Thank you both for sharing and helping to educate me further.

Many clinicians omit inquiry about ACEs due to a lack of formal training about how trauma-informed care can produce improved outcomes in adults.  As described in my lecture in Calgary in June (Canadian CFHA), my main focus is on patients with medically unexplained symptoms or chronic functional syndromes (MUS/FS) which comprise 25-30% of primary care patients.  In this group ACEs are highly prevalent and treating their long-term effects can relieve MUS/FS even when other approaches have failed.  Details of what I learned from interviewing thousands of these patients are described at www.stressillness.com and in my book (all royalties donated to a non-profit).

As a forensic psychologist, my work is to evaluate children with intellectual and developmental disabilities following maltreatment, usually at school, but also by other entities responsible for their care and well-being. In most cases, there has been ongoing and severe abuse over a long period of time.  The children changes in significant ways in all domains.  Parents were at a loss as to the cause of these sudden changes in their children.  Although most had "fleeting thoughts" that something "could be happening at school," they quickly dismissed them with the belief that "they are professionals" and would never do such a thing.  But they do. Most took their children to their doctor (pediatrician/developmental pediatrician or mental health specialist) for help. Not one mentioned abuse, even though presented with a "typical" list of changes i the child. Not one. Thus we have initiated the "Rule Out Abuse Campaign."  I do not know the reason this is the case, but I imagine it may be an overriding focus on the child's (adult's) disability. We have developed materials to fix this problem, available on our website: disabilityandabuse.org.  They explain the problem and the solution including signs and symptoms of abuse, new DSM definition of PTSD for children with I/DD among others.  We are seeking quicker identification of child abuse as a cause of global changes in the child that "scream" abuse. Please let us know of how we can expand our campaign. Please become an "Ambassador" by informing pediatricians and clinicians in your reach!

As a former Executive for 2 rural Alaska health care systems, I worked in an environment where ACE's were ubiquitous. As I struggled to develop a healing protocol with a rare resource, physicians and medical care providers, I realized that a medical care professional's highest and best use was to provide medical care. I came across research that also identified a category of diagnoses referred to as MUS (Medically Unexplained Symptoms). Dr. Felitti shared with me his questionnaire, on that could be completed online and in person as well as the writeup given to physicians about the ACE's experienced by their patients at Kaiser Permanente. I also had my provider team visit Cherokee Health Systems in Knoxville, TN and explore their team approach to medical provider and behavioral health specialist. With about 30+ years of experience now, their system truly appealed to me. I also began to see how much nutrition plays a role in many types of behaviors and started to favor a trio assessment approach. A Patient/Client fills out a questionnaire, takes a nutrition centered blood test and is screened by a medical provider. The screening questionnaire I envision includes not only ACE's data, but the pace and sequence of behavioral adoption during the life experience of the Patient/Client. In this model, the medical provider provides care (if needed, and care is frequently not needed). Up to 70% of patient visits are apparently with MUS. The knowledge gained from this assessment is shared with the patient. What Dr. Felitti shared with me is that patients who received information from the assessment and the impact of ACE's in their lives led to one third fewer office visits during the next 2 years (then it ended). For this reason, the first step in the healing protocol I envision is "Knowledge." By discussing the impact of ACE's in development of behaviors, I believe we can move away from a blame/shame type of approach to care. By blame/shame, I point to any of the campaigns against drugs, alcohol, violence or other negative behaviors. If medical and nutritional needs do not provide resolution for the issues care is being sought, then the Client can be offered participation in the healing protocol. 

Alteration of unhealthy behaviors and beliefs is not easy. To put this responsibility on medical provider when there is an alternative that is less expensive and perhaps more comprehensive seems a better practice to me. In my work in rural Alaska, medical providers are precious and rare. Meeting just medical demands is often impractical. Using billing available for behavioral health, we discovered that seeing just 3 clients a day would pay for a behavioral health provider and free up medical skills to meet medical needs. I urge the study partners to think about a different approach.