National collaborative provides roadmap for doctors to ask about adult patients' ACEs, current trauma

 

How do you ask patients about current and past trauma? And how do you respond to their disclosures? Those are two key questions that members of a national collaborative who are among the early adopters of trauma-informed care practices have answered in a recent article in the journal Women’s Health Issues.

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Dr. Edward Machtinger

To Dr. Edward Machtinger, the lead author of the paper entitled, “From treatment to Healing: Inquiry and response to recent and past trauma in adult health care”, the article is also a call to action. “In this paper we especially say this is a framework for adult health care. These are ways of asking about current and past trauma for adults.” And why are they focusing on the adult health care system? 

“We believe that adult health care providers have a huge role to play in addressing adverse childhood experiences (ACEs), for two reasons,” says Machtinger, director of the Women’s HIV Program and Center to Advance Trauma-Informed Health Care at the University of California at San Francisco. “So many of the ACEs are adult-mediated and, as we know, many of the ACEs perpetuate so many health conditions. So, if we can help a mother heal from her addictions to alcohol or crack cocaine, if we can help a father heal from his own childhood trauma and its consequences and stay out of prison, and stay alive, I can’t imagine a more impactful way to interrupt generational cycles of trauma.”

Fundamental to asking about trauma and responding to it, writes Machtinger and his peers, is cultivating a trauma-informed environment that acknowledges that past and current trauma is widespread, and frames patient care around the question “What happened to you?” rather than “What’s wrong with you?” It also requires health care providers to think about what would help inspire a feeling of safety and build trust so that patients feel comfortable sharing their ACEs and current trauma with their health care providers.

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Dr. Brigid McCaw

Handouts that cover sensitive topics are one way to create a safe environment. “Having [information] available in the exam room, or the waiting room or in the restroom — for victims of intimate partner violence, sometimes the only time they’re alone is in the restroom – having information like that is often a very powerful way of helping patients get ready to disclose what’s going on in their lives,” says Dr. Brigid McCaw, director of the Family Violence Prevention Program at Kaiser Permanente in Oakland, Calif.

And, adds McCaw, key to her patients’ comfort level in sharing any current or past trauma in the home is building into her workflow one-on-one time between clinicians and patients.“There’s no way that people can often reveal the depth of what has happened in their lives or what is going on in their lives unless they’re confident that there’s a clinical setting where that will be private,” she says.

The collaborative also emphasized that health care providers need to have resources and referrals in place for patients. If, for example, a patient discloses that there’s violence in the home, the authors wrote, “affirm that she or he does not deserve to be treated that way; express concern for the patient’s safety and that there are many helpful resources; and offer a warm handoff to an onsite social worker or to a local or national domestic violence agency to provide ongoing support services, preferably while the patient is still on site.”

By putting their collective experiences together — which also included getting input from patients — the collaborative developed different options for asking people about their ACEs in different ways. Some people like to use screening tools, others like to read information, while others prefer talking to a health care provider about what can be a very sensitive and sometimes stigmatizing topic, says McCaw.

The options for inquiring about ACEs include: “Assume a history of trauma instead of asking.” Patients can be educated about the links between traumatic life experiences, illnesses and coping behavior and can be offered referrals for support.

Another option is: “Screen for the impacts of past trauma instead of for the trauma itself.” Both this approach and the first one do not require patients to describe details of ACEs, explain the authors. In this second approach, the collaborative suggested screening for symptoms and conditions that are often associated with ACEs, including “anxiety, post-traumatic stress disorder, depression and suicidality, substance use disorder, chronic pain and morbid obesity.”

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Naina Khanna

And the authors say that included in an approach that’s sensitive to trauma, health care providers can forge more trusting relationships with their patients if they do not judge them for behaviors they used to cope with their ACEs and current trauma. “If we can really understand the behaviors that can be perceived as problematic or challenging to deal with in a health care setting, if we can get providers to understand that these ‘challenging’ behaviors are really coping strategies and mechanisms that people are using to survive their history of traumatic experiences, then we can start a new type of conversation about what wellness really means to an individual,” says Naina Khanna, a coauthor, a sociology PhD student at University of California at San Francisco, and the executive director of the Oakland, Calif.-based Positive Women’s Network-USA, an organization that empowers women living with HIV.

Machtinger describes how that’s worked for him at the Women HIV Program: “Three of my patients today talked openly with me about their crack addiction. That was a sign they were comfortable revealing things that they could be fearful or ashamed of revealing. Our clinic is a place where people don't feel judged. We understand that a crack problem is not a character problem, but a way to cope with an intractable trauma that they’re feeling.”

Another option for asking about ACEs is with an open-ended question, the authors wrote: “Difficult life experiences, like growing up in a family where you were hurt, or where there was mental illness or drug/alcohol issues, or witnessing violence can affect our health. Do you feel like any of your past experiences affect your physical or emotional health.” 

If the patient answers yes, one suggested script that health care providers can use to reply, according to the article, is: “I am so sorry that happened to you. Past traumas can sometimes continue to affect our health. If you would like, we can talk more about services that are available that can help.”

The authors also described a wide range of traumatic experiences that can impact their patients’ health including community violence, war, racism, homophobia and xenophobia, and experiences in the foster care, immigration and criminal justice systems.

The fourth option proposed for health care providers is to use a structured tool to explore past traumatic experiences. An example of a screening tool, write the authors, is the ACE questionnaire, which asks patients whether they have experienced 10 types of childhood trauma, including sexual and physical abuse, witnessing violence within the home, having a parent who uses drugs or alcohol or has a mental illness. If selecting an ACE screener, the authors wrote, “It is essential that the patient be able to discuss their responses with the provider in private.” 

LeighKimberg
Dr. Leigh Kimberg

To introduce any of these options, health care providers also need to deploy some tools to ensure they’re taking care of themselves. In the article they’re described as the 4 Cs: Be calm; contain the interaction; care for the patient and yourself; focus on coping. “I mean those 4 Cs to be for patient and the provider at the same time because when the patient has experienced trauma and they’re dysregulated or upset,  especially because there are frightening power dynamics that happen in the health care setting where one feels very vulnerable, the provider would be focusing on their own breath, their own grounding, their own selfcare simultaneously with helping to transmit that to the patient, whether it’s done out loud or not,” explains Dr. Leigh Kimberg, who developed the 4 Cs, is another coauthor, and is a primary care physician at San Francisco General Hospital and a professor of medicine at UCSF.

“We don’t know yet which approach is best — which one is most acceptable to patients and providers and ultimately links patients with a history of significant trauma to the treatments they want and need,” says Machtinger. “ So, for now, we provide concrete options and scripts for providers and they can use the ones that feel best to them and their patients.

But Machtinger and his colleagues are clear that health care providers need to embrace a practice that recognizes how central recognizing trauma is to health care.

“The alternative, not inquiring about and addressing past trauma using any approach, in our opinion, will predictably lead to worse experiences and outcomes of care for all involved.”

 

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Andrea Feller posted:

What do folks think about this, in the context of the many groups who are using ACEs as a parental history taking point of data information? In other words, do you have evidence it is OK to ask parents (if you are a pediatrician or FP seeing kids e.g.) just their total ACEs score, and then take it from there, without delving into their history? e.g. you can then tell them they deserve to discuss their risk with their PCP. And also what the score means in terms of how they are experiencing being a parent or how challenging it is? This line was striking:  If selecting an ACE screener, the authors wrote, “It is essential that the patient be able to discuss their responses with the provider in private.” 

This is an important discussion and figuring out the tertiary trauma approach vs. a more universal ACEs approach is very interesting to me.

Dear Andrea-These are great questions! As a co-author on both of the papers from this group, I do want to say that these papers were focused primarily on adult-medicine practice; they are insufficient to fully address the nuances and complexities of the pediatric setting.  I do partner with pediatricians and try to think about this work in pediatric settings in the San Francisco Health Network--so I will comment based on this partnership and decades of trauma work.  The safest way for us to address trauma (included in our published model in this paper) is to provide EDUCATION about trauma and resilience before any type of 'screening' is done so that parents or patients can decide what they would or wouldn't like to disclose.  In most studies related to asking about violence and relationship abuse--disclosure rates about violence (or the often used euphemistic "safety" which patients don't understand) in healthcare settings are FAR lower than known prevalence; so, education is key to contextualizing the screening experience and making sure that people are given important information and resources regardless of disclosure.  

If doing ACES or IPV screening after education, then, yes, one should be fully prepared to address the results.  Ideally, this would mean integrated services where parental mental health concerns and social disadvantage or distress (housing, food, legal challenges, discrimination, IPV) could be addressed with integrated care model in the pediatric setting or, at least, through easily accessible services.  If screening for IPV (which should be done in peds) then the response needs to be worked out fully in advance. Clearly, maternal depression also impacts the well-being of children as well--so it is important to address not just the traumas themselves but the sequelae of trauma. 

Finally, it would be wonderful if practices monitored their programs or participated in evaluation.  It is important to ask diverse patients about their experience with the process of education and screening and response.  My experience is that it can be very healing for people to disclose trauma when they are ready. Yet, at the same time, my patients appreciate talking about what feels most HEALING to them rather than processing extensive trauma details in the context of a primary care visit.  Many practices are asking about resilience in addition to trauma/adversity. People appreciate discussing what people and experiences are helpful and healing to them and their children. See a new BCE (benevolent childhood experiences) scale below.  

Here is a discussion about skepticism about an ACE screening approach:

https://www.acesconnection.com...y=480528347621012306

Here is a new"benevolent childhood experiences" scale--my guess is that mom's might really appreciate this and would love to see it studied further!

https://www.sciencedirect.com/...ii/S0145213417303587

Best wishes,

Leigh Kimberg, MD

UCSF/SFDPH

Laurie Udesky (ACEs Connection Staff) posted:
Linda Simpson posted:

I would like to have a printer friendly version of this to give to health providers and others I connect with. Useful !!

 

Hi Linda,

Glad you find it useful.  I suggest copying and pasting the following url into your browser to get to the journal article, or clicking on the hyperlink under Women's Health Issues in the article above.

Here's the url:

https://www.whijournal.com/article/S1049-3867(18)30550-4/pdf

A misunderstanding … I was referring to a printer friendly version of your blog post. The photos do not copy. I copied and pasted a version with no photos anyway - 3 pages rather than 8 if I'd printed from the screen.

ALSO, I did get to the article and printed that as well.

Many thanks for your attention.

Andrea Feller posted:

What do folks think about this, in the context of the many groups who are using ACEs as a parental history taking point of data information? In other words, do you have evidence it is OK to ask parents (if you are a pediatrician or FP seeing kids e.g.) just their total ACEs score, and then take it from there, without delving into their history? e.g. you can then tell them they deserve to discuss their risk with their PCP. And also what the score means in terms of how they are experiencing being a parent or how challenging it is? This line was striking:  If selecting an ACE screener, the authors wrote, “It is essential that the patient be able to discuss their responses with the provider in private.” 

This is an important discussion and figuring out the tertiary trauma approach vs. a more universal ACEs approach is very interesting to me.

Andrea:
Those are great questions. My two cents is we need way more input from parents, before, during, and after to measure how the different approaches feel, work, help (or don't) in order to make sure that what's created as best practice is best for all. I think having parents a part of the process throughout, is essentials, and especially beneficial to have as many parents as health providers being able to weigh in. Having one token parent rarely gives a person without a lot of power the ability to share openly, honestly, and in a way that creates any change.

I'm on school council and the rule is that there has to be at least as many parents as school teachers and staff or parents stop speaking up and participating because if they realize they have no impact, why volunteer and show up at meetings (which others are usually being paid to attend as part of their work)? That said, the meetings are held at the school, during school hours (hard for working parents or for being a neutral place). It's just not an effective way to get real and true feedback, when it comes to say, parent engagement, an issue our school is addressing right now, there are often few parents at the table. 

Those of us at the table, are tempted to say, "Parents won't engage," instead of looking at why, how come, what might make it so that parents don't show up? Do we make it a space (with childcare, at a reasonable hour, where if any are compensated all are compensated, is our committee representative of the school body? etc., etc. etc.) or do we just keep doing the same things and getting the same results and saying that's just the way it is and how we do things here. It's been a real uphill battle at our school and one I'm struggling with myself. It's really hard to go against the flow, to ask for things to be done differently, and to be "that parent" when you have a kid in the school and you don't want them to get any blow back for being too demanding or critical. Relying on people for healthcare, as an individual or a family, is pretty vulnerable as well.

I appreciate your question and am curious what others do, say, see, notice and if/how parents perspectives are gained. 

Cissy

Linda Simpson posted:

I would like to have a printer friendly version of this to give to health providers and others I connect with. Useful !!

 

Hi Linda,

Glad you find it useful.  I suggest copying and pasting the following url into your browser to get to the journal article, or clicking on the hyperlink under Women's Health Issues in the article above.

Here's the url:

https://www.whijournal.com/article/S1049-3867(18)30550-4/pdf

What do folks think about this, in the context of the many groups who are using ACEs as a parental history taking point of data information? In other words, do you have evidence it is OK to ask parents (if you are a pediatrician or FP seeing kids e.g.) just their total ACEs score, and then take it from there, without delving into their history? e.g. you can then tell them they deserve to discuss their risk with their PCP. And also what the score means in terms of how they are experiencing being a parent or how challenging it is? This line was striking:  If selecting an ACE screener, the authors wrote, “It is essential that the patient be able to discuss their responses with the provider in private.” 

This is an important discussion and figuring out the tertiary trauma approach vs. a more universal ACEs approach is very interesting to me.

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