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8 Myths About Screening For Adverse Childhood Experiences

 

By Laura Shamblin, MD FAAP
Most of us have now heard of the Adverse Childhood Experiences Study published by Drs. Felitti and Anda in the American Journal of Preventative Medicine in May of 1998. The study and many follow up studies have shown a direct and dose dependent relationship between adverse childhood experiences, or abuse, neglect, and household dysfunction, and adult risky behaviors and health outcomes. As a Pediatrician and advocate for Trauma Informed Care, I’d like to take this opportunity to address some of the objections to screening for ACEs that I have come across. It is true that some areas of research are still emerging, such as protocols, but in other ways we are twenty years behind using the information we have to make a positive difference in our patients lives and in training new physicians to be more comfortable addressing social and experiential determinants of health.
Myth #1 People don’t want to talk about their personal or family traumas.
In several studies, the vast majority of patients did not mind answering a screening tool at a primary care visit. (1,2) Clinics who have adopted ACEs have found using a cover page with a short explanation of the relationship between childhood traumas and adult health outcomes to be helpful. It has also helped to have ACEs screening papers given to the patient to be filled out either at home before the visit, or in a private patient room before seeing the doctor rather than in the public waiting room. Any adoption of a new screening tool should ideally have input from a patient advisory group before implementation to account for concerns of different patient populations. (3)
Myth #2 Filling out a questionnaire may cause someone to remember suppressed memories of childhood abuse and have a sudden onset or worsening of mental health issues.
This concern has been brought up in a couple of published articles (4), however there are many more articles recording the use of ACEs screening tools in various outpatient settings without reference to this situation actually happening. The ACEs questionnaire has also been given and shown to many, many large audiences at conferences and trainings and again, there has never been a case brought to light of any major mental health consequences, to my knowledge. On the contrary, many people express appreciation and even relief to learn the associations between childhood experiences and adult behaviors and health outcomes. They know there is a problem, and it is helpful to put a name to it and therefore be able to get more information about treatment and recovery steps that can be taken. There is mention of patients being uncomfortable with the information on health outcomes being given without being accompanied by information on resilience, buffering, and positive and compensatory experiences. (5)
Myth #3 There aren’t any truly evidence-based interventions for childhood trauma. We shouldn’t make families aware of the negative health outcomes, because there is nothing proven to help them.
This assumes that all positive screens will need a behavioral health care referral. In a large study of 3 community pediatric clinics in the Chicago area, screening for ACEs only resulted in referral for mental health care in 2% of patients. (6) In a feasibility study in a family medicine practice including adults, no new referrals were made. (1) When those services are needed, there are several modalities of treatment that have good evidence for use in children and are recommended by the AAP. At the top of the list would be Trauma-Focused CBT followed by PCIT and CPP. TBRI is also a growing modality with good results among the adoption community and schools but less research funding nationally. More information about treatment modalities can be found here. https://www.traumainformedmd.com/treatments.html#/
For the many who do not need a referral, parenting resources such as local parenting classes (check with churches, hospitals, and pregnancy centers), as well as anticipatory guidance and education provided by the physician, is likely the most helpful resource and is the most asked for by parents. There is growing evidence that positive experiences in childhood as well as healthy attachment relationships with at least one adult both have a buffering effect on children who experience multiple ACEs. These positive experiences and relationships provide resilience as well as support for healing. (7,8)

For more visit https://www.traumainformedmd.c...ldhood-experiences#/

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“The Clinical Relevance of Attachment Theory and Research


There's now overwhelming empirical support for the fact that early experience is a powerful force in development. But what can clinicians draw from this work, beyond feeling reassured that their clinical intuition isn't simply an "article of faith"? For one thing, this extensive work can bring perspective to questions such as why change is so difficult and why emotional closeness can be so scary to some people. Long before children have the language and conceptual tools to process experience, negative or even traumatic patterns of interaction are incorporated in the brain, the functioning of their psyche, and even in the molecules that control the expression of their genes. Therefore, people can get "lost in familiar places" as they continually recreate their earliest patterns of interactions across the lifespan. One role of a therapist is to bring awareness to such patterns and then intentionally create new pathways for clients to take as they unlearn their long-established habits.
Another important implication of attachment research is that it's possible to develop a secure state of mind as an adult, even in the face of a difficult childhood. Early experience influences later development, but it isn't fate: therapeutic experiences can profoundly alter an individual's life course. Further, therapists can learn from attachment researchers' hard-earned insights into human development which features of relational experience are the most effective at optimizing well-being. When parents are sensitive to a child—when they pay attention to and tune in to the signals sent by the child, make sense of these signals and get a glimpse of the child's inner experience, and then respond in a timely and effective manner—children are likelier to thrive. The essential features of a therapeutic relationship mirror this process in many ways.
The brain continues to remodel itself in response to experience throughout our lives, and our emerging understanding of neuroplasticity is showing us how relationships can stimulate neuronal activation and even remove the synaptic legacy of early social experience. Developmental trajectories are complex, often having "islands" of positive relational experience, even within largely negative histories. Through therapeutic relationships and reflective practice, one can make contact with these islands—the "angels" in the nursery, to quote developmental psychologist Alicia Lieberman—and cultivate their growth to the benefit of parents, children, and adults alike. In this way, clinical practice can use the power of our attachment relationships.” 

we can find strain in the attachment relationships in peds at 4 months with the ages and stages social emotional... 

And the ASQ is the kind of thing peds should do... Just saying. 

 

https://www.drdansiegel.com/up...he-verdict-is-in.pdf

I wouldn’t screen as there are no available treatments that are also effective for most of our patients.  CBT is not effective for significant attachment trauma or dissociation which most severely traumatized patients have and I am not willing to be a partner in drugging traumatized kids which is too often what happens in the real world we all live and work in.  


“Only the most easily protocolized treatments, like CBT, prolonged exposure, medications, and EMDR, have been thoroughly researched. Interestingly, though medications have been shown, over and over again, to be only marginally helpful for PTSD, they keep being prescribed to the tune of billions of dollars per year. In contrast, somatic therapies, such as Sensorimotor psychotherapy and Somatic Experiencing, haven’t been thoroughly researched for their efficacy, nor has hypnosis, which for about a century was widely regarded as the treatment of choice for PTSD. There’s also little “hard” evidence for Internal Family Systems therapy, or neurofeedback, even though many clinicians who specialize in the treatment of traumatized individuals consider these among the most effective treatments currently available.

 The result of the politics of diagnosis and “evidence-based” treatments is that in most settings that depend on insurance reimbursement, clinicians are mandated to use treatments of questionable efficacy. The fact that study after study shows that these mandated treatments have at best a 40 percent drop in symptomatology, which is only slightly better than placebo, after a third of the patients drop out, seems not to have raised enough concern about wasted lives and wasted resources to affect their growing influence. Meanwhile, the VA, by its reliance on evidence-based approaches, has been a major factor in discouraging the expanded exploration of effective treatments. So once again, we’re faced with a political reality: many of the treatments sophisticated clinicians would consider most effective are only available to people who can pay out of pocket.”

https://www.psychotherapynetwo...00-0000-000000000000

Last edited by Former Member

Might we consider all forty+plus categories of ACES ('Adverse Community Environments' and 'Adverse Childhood Experiences') found in the World Health Organization's WHO ACE International Questionnaire ?

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