When a pregnant woman visits the Jefferson County Public Health clinic in Port Townsend, WA, a town of about 9,000 people on the northeast tip of the Olympic Peninsula, she’s asked the typical questions about tobacco, alcohol and other drug use. She’s also screened for something that most public heath departments, ob-gyns or primary care providers don’t even consider asking: her childhood trauma.
That’s because the public health nurses at Family Health Services know that a childhood full of toxic stress causes a lifetime of health problems, and, if not addressed, is usually passed on from parent to child.
But setting up a system to screen for child trauma, which seems so logical in hindsight, wasn’t an easy thing to do, says Quen Zorrah, a public health nurse who led the effort. Even after years of talking, reading research and preparation, the staff was still reluctant. But in the end, she and her co-workers concluded: If we can teach a client to put on a condom, we can ask a client about ACEs.
ACES are adverse childhood experiences, or child trauma. When 10 types of child trauma were measured in a CDC study of 17,000 people in San Diego, researchers were stunned to discover that not only it was very common, but it raised the risk of adult onset of chronic disease to unimagined levels. Even more startling was that these 17,000 people were middle-class, college-educated, mostly white people. And they all had jobs and good health care, because they were all members of Kaiser Permanente, the health maintenance organization where the study took place.
The CDC’s ACE Study measured physical, emotional and sexual abuse; emotional and physical neglect; living with a parent who’s an alcoholic or addicted to other drugs; witnessing the abuse of a mother; a family member in prison or diagnosed with mental illness; and a loss of a parent through divorce or abandonment. (Of course, there are other possible traumatic events a child can experience – such as severe illness, homelessness or surviving a catastrophic tornado or flood – but those were not measured.)
From this list, researchers determined each person’s ACE Score. Each type of trauma counts as one. Nearly 70 percent of the participants had an ACE Score of at least 1. And the odds were very high that if someone had one trauma, there were others. In other words, if your dad was an alcoholic, it’s likely that there was also emotional abuse in your background.
The study showed that the higher the ACE score, the higher the risk of disease, suicide, violent behavior, or being a victim of violence. People with an ACE score of 4 or more had starkly higher rates of heart disease and diabetes than those with ACE scores of zero. The likelihood of chronic pulmonary lung disease increased 390 percent; hepatitis, 240 percent; depression 460 percent; suicide, 1,220 percent. The percentages climbed to grim and astounding levels as the ACE score increased – people with an ACE score of 6, for example, had a 4,600 percent increase in the likelihood of becoming an IV drug user. And people with high ACE scores die, on average, 20 years earlier than those with low ACE scores.
ACE Study co-founder Dr. Vincent Felitti says that ACEs are the “most important determinant of the health and well-being of our nation.” Dr. Robert Anda, the other co-founder, calls ACEs a “chronic public health disaster.”
The reason that childhood trauma causes adult onset of chronic disease was determined by a group of researchers, including neurobiologist Martin Teicher and pediatrician Jack Shonkoff, both at Harvard University, and neuroscientist Bruce McEwen at Rockefeller University. They figured out that the toxic stress of chronic and severe trauma damages a child’s developing brain. It essentially stunts the growth of some parts of the brain, and fries the circuits with overdoses of stress hormones in others.
Children with toxic stress live their lives in fight, flight or fright (freeze) mode. Unable to concentrate, their brains are incapable of learning and they fall behind in school. They respond to the world as a place of constant danger, not trusting adults and unable to develop healthy relationships with peers. Failure, despair, shame and frustration follow.
As they transition into adulthood, they find comfort by overindulging in food, alcohol, tobacco (nicotine is an anti-depressant), drugs (methamphetamines are anti-depressants), work, high-risk sports, violence, a plethora of sexual partners….anything that pumps up feel-good moments so that they can escape – even briefly – the sharp, tenacious claws of agonizing memories and despair.
Several staff members in Family Health Services learned about ACE concepts in 2003, when Washington State’s Family Policy Council, which partners with 52 community public health and safety networks across the state, invited Dr. Felitti to speak at one of their meetings.
The Family Health Services staff came away determined that it was their responsibility to share the information with their clients.
After a small community grant became available, the staff of the Family Health Services applied to set up a system for ACEs screening. “We determined that we just had to figure it out on our own,” says Zorrah.
The biggest obstacle was fear. They thought that if they asked people questions – such as, “Did an adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way? Or attempt to actually have oral, anal, or vaginal intercourse with you?” -- they’d go into crisis. They also worried that clients would feel despair, shame or doomed when they learned their score.
Ironically, this fear of asking questions also occurred during the CDC’s ACE Study. The study’s advisory group was so worried about a patient having a psychological crisis that Dr. Felitti was required to wear a pager 24 hours a day, 7 days a week.
Even though they knew that none of the 17,000 people in the CDC’s ACE Study in San Diego ever had a problem after answering the study questions, the Family Health Service staff still prepared for a crisis before they began screening for ACEs in 2009. Spoiler alert: Not one ever occurred.
The nurses discovered what Drs. Felitti and Anda had learned: “People are already thinking about their childhood abuse,” says Zorrah. And the people who don’t want to think about it simply say they don’t have any problems.
An important part of the preparation was for all eight staff members to complete their own ACE survey so they’d know what the client might be feeling. “We did so privately,” says Zorrah. “For some of us, it was really hard to answer the questions.”
Since 2009, between 200 and 300 people have been screened for ACEs. It’s part of the routine intake assessment for pregnant women and their spouses or significant others, for parents involved with Child Protective Services, or for parents with children who have special health care needs.
The screening isn’t mandatory, says Zorrah. But most people want to complete the questionnaire as part of their health history. The assessment includes a two-page questionnaire, plus a short form of the ACE questionnaire.
Clients fill out the paper forms first, then meet with a nurse for an hour. Before telling them their score, the nurse provides them with appropriate health information – such as the health risks of tobacco, domestic violence, ACEs, of not getting adequate nutrition. They include the ACE information as part of routine health education and screening. “Once people have the test results, they don't listen the same way,” says Zorrah.
So far, most of their clients have ACE scores that are higher than the state average. That’s not surprising, notes Zorrah, because Family Health Services targets a high-risk population, people in Jefferson County who have had the most difficult lives, the people with the most health problems, including obesity, heart disease, diabetes, depression and higher rates of being victims of violence.
So, starting a conversation about a person’s score requires sensitivity:
- "Becoming pregnant often brings up thoughts of one's own childhood, thoughts of wanting to make life better for your child, making healthy changes.”
- “These questions help us understand your health risk.”
- "Science has proven what we all knew -- the bad things that happen to kids causes problems for their whole life."
- “People who have childhood trauma often have more health problems.”
The staff strives to make sure clients understand that the science is new because “we don't want them to feel guilt or shame about what their parents did or what they did as parents,” explains Zorrah.
They tell them that most people have a score of 1 or 2, and that responses to higher ACE scores – such as alcoholism, drug addiction, obesity, depression -- are normal. “For somebody who is an ACE survivor, a sense of shame is going to be one of their fundamental feelings,” Zorrah says. “When we normalize it, explain it as a science-based thing, it helps them reframe to move away from shame.”
The client responses?
“Well, duh!” was typical.
So was: “No wonder I'm so messed up.” “No wonder I’m sick all the time.” “No wonder I can't quit using…..drugs, alcohol, cigarettes.”
When one woman in her 60s who was parenting her grandchild was told that her ACE score was an 8, she said: “These are very, very good questions. Nobody has asked me about this before.” Understanding her own past motivated her to agree to mental health services for her grandchild.
“It's really quite an amazing experience to sit with somebody,” says Zorrah, “discuss the research, give them their score, and then have them say: ‘Now my life makes sense.’”
The nurses make sure to acknowledge how difficult life is with a high ACE score. They say: “How have you managed to get through your life with such an ACE score.?” or “People with a high ACE score like yours usually have to work harder at just about everything.”
The ultimate goal is to help people find their own motivation to change by giving them an understanding of their own life story and health risks, and then encourage them to make things different for their children.
“We see ACEs screening as a two-generation intervention,” Zorrah emphasizes. “It's an educational opportunity, and they get a score and a whole process to promote positive health behavioral changes affecting them and their child.”
It took the staff of Family Health Services a year to become comfortable with and confident about the process. “It was important for us for us to realize that it is not our job to fix their life or tear down their defenses, but to respect wherever it is they're starting from,” says Zorrah. “In fact, it may be unique opportunity for this client to sit with somebody who can really listen.”
But not everyone’s ready to talk about their childhood trauma. Zorrah recalls one man who was ordered by Child Protective Services to talk with her. He was livid that his children were in foster care, she says. He denied every question on the assessment and said his ACE score was zero. “I talked to him about brain development and trauma,” says Zorrah. “In the discussion, he disclosed that he had lived in over 30 foster homes. I asked him: “How did this affect you?’ ‘Fine. I've had a perfect life.’ I took this as a cue that he was not ready to discuss his own experiences. So we discussed the research. We talked about brain development. At end of visit, he thanked me for that visit. His defenses went down.”
Although Zorrah never saw him again, she feels that he took away some valuable information about himself and his children.
Zorrah’s looking forward to the time when asking about childhood trauma will be a normal part of any healthcare visit, so that everyone understands that a difficult childhood can contribute to a lifetime of health problems.
The changes that Family Health Services has made has inspired the community’s “Our Kids: Our Business” campaign, which kicks off next month. The campaign comprises a series of workshops and conferences for community members and health care professionals so that they can start the process to figure out how to integrate ACE concepts into their own practices.
Today, the staff of Family Health Services assumes that all of their clients are ACE survivors. The score is powerful,” notes Zorrah, “but the most important thing that we're doing is offering them this information that is sensitive and respectful and that helps them start to think about protecting their children from having a similar ACE score and, of course, moving forward with other positive changes in their life.”
Here's the Family Health Services clinic prenatal health history questionnaire -- prenatal-health-history-form.doc.
Here's the clinic's parent health history questionnaire -- parent-health-history-form.doc