Study shows most pregnant women and their docs like ACEs screening

 

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Would pregnant women participate in surveys from their doctors asking them about whether they had experienced trauma in their childhood? In surveying moms-to-be at two Northern California Kaiser sites, clinicians discovered that the women were receptive to filling out an adverse childhood experiences (ACE) survey, according to a study that was published earlier this year in the Journal of Women’s Health.

In fact, researchers found out that the vast majority of pregnant women — 91 percent of the 375 women— were “very or somewhat comfortable,” filling out the ACE survey. Even more, 93 percent, said that they were comfortable talking about the results with their doctors. The women were surveyed from March through June 2016 at Kaiser Permanente clinics in Antioch and Richmond, CA.

ACE refers to the groundbreaking CDC/Kaiser Permanente Adverse Childhood Experiences Study that tied 10 types of childhood trauma, including living with an alcoholic family member or experiencing verbal abuse from a parent, to a host of health consequences. (Got Your ACE Score?)

The higher the number of ACEs that people have, researchers learned, markedly increases their risk for poor health outcomes, as well as social and economic consequences. Having four ACEs, for example, nearly doubles a person’s risk for heart disease and cancer, raises the risk of attempted suicides by 1200 percent and alcoholism by 700 percent.

The study, first published in 1998, emerged with a growing body of ACEs science that includes: how trauma affects the brain; how toxic stress has epigenetic effects from one generation to the next; how toxic stress from trauma results in short- and long-term health consequences; and how appropriate supports can build resilience and heal the harmful effects of toxic stress from ACEs. (ACEs Science 101.)

Dr.CareyWatson
Dr. Carey R. Watson

What really stood out for Dr. Carey Watson, one of the authors of the study, was the number of patients who felt strongly that their doctors should ask them about their ACEs. Around 85 percent of the participants “strongly or somewhat strongly agreed” that doctors should ask their patients about ACEs.

“it was really, really eye opening to me,” she said. “I was used to screening patients for ACEs, but I wasn’t sure how they would feel about it later.” 

Researchers also screened patients for how resilient they are in coping with adversity using the Connor Davidson resilience screening scale.  “We were interested in framing the conversation with patients in a way that might be more empowering or positive,” Watson noted. (Interpreting how patients’ resilience and ACE scores translate to health outcomes is the focus of an upcoming study by Watson and her peers.)

But Watson and her colleagues were also well aware that beyond their patients, they really needed to understand how their fellow physicians would feel about screening their prenatal patients about their ACEs. Would they find it acceptable, they wondered? Watson said that she was well aware that many of her colleagues were reticent about asking their patients about childhood trauma, wondering if a conversation would “open up a can of worms,” as Watson put it. That worry, said Watson, was perfectly understandable.

“This is a very foreign concept and uncomfortable for providers. It was not anything that any of my colleagues learned about in medical school,” Watson said.

A pre-pilot survey of clinicians showed they had “moderate” concerns about ACEs screening. After the pilot, which included training in trauma-informed care – how to talk in a sensitive manner to patients — their confidence and knowledge around ACEs screening increased.

“The fact that they felt, ‘yeah, we could totally do this,’ was a dramatic difference from where we started from.”

Unsurprisingly, one issue that clinicians agreed on, according to the study, was the need to ensure that resources and referrals for follow up for patients who were screened for ACES were firmly in place. 

In surveying clinicians after the pilot, researchers learned that among the key reasons clinicians were comfortable with ACEs screening was that it was incorporated well into their workflow, including how they flagged patients for follow-up in the electronic health record, and because they were also screening for resilience.

“I think it would have been very difficult to have ACEs [screening] without the resiliency score, because then you wouldn’t have known what their coping mechanisms, and coping ability would be. We can’t change the trauma—the trauma is done. But the resilience piece, the coping piece, is the piece we can work on,” wrote one clinician in a survey that was quoted in the study article.

To Watson, the reason for taking the first steps in finding out pregnant women’s response was clear and goes to the very core of her work as the physician site lead at Kaiser Antioch's Family Violence Prevention Program, and why she says she’s so interested in ACEs science. 

“I already knew that people who were experiencing violence or witnessing family violence when they were children were more likely to experience intimate partner violence or become perpetrators of family violence, “she said. Witnessing a mother being physically abused is one of the 10 ACEs, along with experiencing physical, verbal or sexual abuse; experiencing physical or emotional neglect; living with a family member who’s depressed or diagnosed with other mental illness; living with a family member who’s addicted to alcohol or some other substance; having a family member who’s incarcerated; and losing a parent to separation, divorce or other reason.

Subsequent to the ACE Study, other ACE surveys have expanded the types of ACEs to include racism, witnessing a sibling being abused, witnessing violence outside the home, witnessing a father being abused by a mother, being bullied by a peer or adult, involvement with the foster care system, living in a war zone, living in an unsafe neighborhood, losing a family member to deportation, etc.

The ACE Study clearly shows that men and women who have high ACE scores (four or more) are more likely to perpetrate domestic violence, as well as be victims of domestic violence. The survey of the pregnant women showed that 54% reported 0 ACEs, 28% reported 1–2 ACEs, and 18% reported more than three.

In this study, which she oversaw at the Kaiser Antioch campus, Watson was able to begin zeroing in on an all-consuming idea: “What if we talk to expectant parents about ACEs and give them the support they need to help them heal from ACEs and help prevent that intergenerational cycle?”

Obstetricians, the journal article explains, are uniquely positioned to help break the “transgenerational cycle of ACEs,” by educating their patients about the health harms that ACEs can cause and giving them support and referrals, if necessary.

Watson has heard feedback from her patients that leads her to believe that she and her colleagues are on the right track.

“I’ve had some patients who said ‘This has always been on my mind. I’ve been afraid for my own children, because of their experiences in the world, because of high ACEs. But I’ve never known who to talk to about this or where to get help. I’m grateful to start the conversation.’” 

In fact, because of their patients’ positive response to ACEs screening, Kaiser Antioch decided to continue screening patients  and began again in April 2018. In fact, because of their patients’ positive response to ACEs screening, Kaiser Antioch decided to continue screening patients  and began again in April 2018. They’re looking at  mental health, preterm birth, breast feeding rates, and substance use as they relate to patients' ACEs and resilience.

“This is a learning time and it may be that we decide to expand or adjust based on continued learning,” Watson notes. “At this point we plan to continue indefinitely.”

 

 

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Rebeca Corona posted:
Laurie Udesky posted:
Rebeca Corona posted:

We are in the grassroots stage on presenting ACEs in Wyoming.  I was trained by Dr. Anda in October and became a certified trainer for ACEs this past Spring.  I will be training our Home Visitors in September.  I feel the best way to get doctors to receive the training in ACEs is through their patients asking if they know about ACEs scores.

Hi Rebeca, I am curious if anyone else you work with or who was trained along with you is reaching out to doctors in your area about ACEs screening? I would love to hear about that. You could also write me offline at: ludesky@acesconnection.com. Thanks for writing!

I will ask at our next ACEs WY conference call on the 23rd. 

Thanks Rebeca, that sounds great!

Laurie Udesky posted:
Rebeca Corona posted:

We are in the grassroots stage on presenting ACEs in Wyoming.  I was trained by Dr. Anda in October and became a certified trainer for ACEs this past Spring.  I will be training our Home Visitors in September.  I feel the best way to get doctors to receive the training in ACEs is through their patients asking if they know about ACEs scores.

Hi Rebeca, I am curious if anyone else you work with or who was trained along with you is reaching out to doctors in your area about ACEs screening? I would love to hear about that. You could also write me offline at: ludesky@acesconnection.com. Thanks for writing!

I will ask at our next ACEs WY conference call on the 23rd. 

Vincent J. Felitti, MD posted:

Congratulations on what you are starting in TPMG!  We found it very helpful in San Diego to ask patients how they thought their ACEs had affected them later in life. And we Listened.  Slowly we realized that in this process we were also Accepting someone who had just told us about one of the dark secrets of their lives. 

A totally unexpected discovery was that this had a profound effect on lowering outpatient and ER utilization  during the subsequent year.  You might want to measure that effect in TPMG.  It could be the basis of an important insight for  publication on reducing the cost of medical care.  

 

Dr. Felitti,

Thanks for your comment.  I was in one of my areas doing a Mental Health observation with a family.  It was interesting that she began talking about how her husband and her (one with PTSD and the other sexual abuse) behaviors/reactions affects their children.  It led to a great discussing about ACE's.  She said she was going to have her doctor and MH therapist look into it more deeply.  She is hoping to attend the training I will be doing in October. 

Laurie Udesky posted:
Rebeca Corona posted:

We are in the grassroots stage on presenting ACEs in Wyoming.  I was trained by Dr. Anda in October and became a certified trainer for ACEs this past Spring.  I will be training our Home Visitors in September.  I feel the best way to get doctors to receive the training in ACEs is through their patients asking if they know about ACEs scores.

Hi Rebeca, I am curious if anyone else you work with or who was trained along with you is reaching out to doctors in your area about ACEs screening? I would love to hear about that. You could also write me offline at: ludesky@acesconnection.com. Thanks for writing!

In addition to word of mouth by patients, we are trying to connect with hospitals and Kiwanis clubs to do presentations.

Jane Stevens posted:

Yes...the Southern Colorado Family Medicine at the St. Mary-Corwin Medical Center in Pueblo, CO, is. See this article: https://acestoohigh.com/2016/1...childhood-adversity/

Thanks so much Jane for pointing me to that great article. It really highlights the way in which implementing trauma-informed training and ACEs screenings and interventions, along with building relationships with patients works to reduce ER visits.

Vincent J. Felitti, MD posted:

Congratulations on what you are starting in TPMG!  We found it very helpful in San Diego to ask patients how they thought their ACEs had affected them later in life. And we Listened.  Slowly we realized that in this process we were also Accepting someone who had just told us about one of the dark secrets of their lives. 

A totally unexpected discovery was that this had a profound effect on lowering outpatient and ER utilization  during the subsequent year.  You might want to measure that effect in TPMG.  It could be the basis of an important insight for  publication on reducing the cost of medical care.  

 

Dr. Felitti, Thanks so much for your input on this! I wonder if there are any practices now that are tracking the correlation between the reduction of ER visits and outpatient utilization with ACEs screenings and referrals. I know that the Santa Barbara Neighborhood Clinics, which began rolling out ACEs screening in its pediatric population last fall, is tracking ER utilization and other health outcomes as part of a pilot study. They're also one of the pilot sites of the National Pediatric Practice Community on ACEs. 

Congratulations on what you are starting in TPMG!  We found it very helpful in San Diego to ask patients how they thought their ACEs had affected them later in life. And we Listened.  Slowly we realized that in this process we were also Accepting someone who had just told us about one of the dark secrets of their lives. 

A totally unexpected discovery was that this had a profound effect on lowering outpatient and ER utilization  during the subsequent year.  You might want to measure that effect in TPMG.  It could be the basis of an important insight for  publication on reducing the cost of medical care.  

 

Mem Lang posted:

It makes sense and great news (though not truly surprising) to know most pregnant women want this info, as it's is one of the biggest windows of opportunity in life to rethink and reframe what has happened to you in your childhood and if you're going to make some inroads into this new framework, this will be one of the most crucial times.  Akin to the sensitive stages in child development.

This knowledge is welcomed because of the heightened awareness of the imperative of raising your child/ren as best as one can.  That's the easier part. The harder one being finding therapists who truly get it and can truly help.

Hi Mem,

That's a great point. Based on the reporting I have done around ACEs screening, doctors provide resources for patients to refer them to based on what their needs are. Then the work is up to the patient/client to find a therapist who specializes in whatever modalities someone is looking for. And that definitely can take some searching from what I hear.

Rebeca Corona posted:

We are in the grassroots stage on presenting ACEs in Wyoming.  I was trained by Dr. Anda in October and became a certified trainer for ACEs this past Spring.  I will be training our Home Visitors in September.  I feel the best way to get doctors to receive the training in ACEs is through their patients asking if they know about ACEs scores.

Hi Rebeca, I am curious if anyone else you work with or who was trained along with you is reaching out to doctors in your area about ACEs screening? I would love to hear about that. You could also write me offline at: ludesky@acesconnection.com. Thanks for writing!

Rebeca Corona posted:

We are in the grassroots stage on presenting ACEs in Wyoming.  I was trained by Dr. Anda in October and became a certified trainer for ACEs this past Spring.  I will be training our Home Visitors in September.  I feel the best way to get doctors to receive the training in ACEs is through their patients asking if they know about ACEs scores.

Rebeca: I believe in that approach as well. I've found few doctors who know about ACEs, so far, but some are at least interested. Cis

We are in the grassroots stage on presenting ACEs in Wyoming.  I was trained by Dr. Anda in October and became a certified trainer for ACEs this past Spring.  I will be training our Home Visitors in September.  I feel the best way to get doctors to receive the training in ACEs is through their patients asking if they know about ACEs scores.

We have a federal nonprofit,Early Head Start program, that serves pregnant moms and their children to 3 yrs. of age.  This information is essential for these mom's to learn about.  Talk about being proactive!

It makes sense and great news (though not truly surprising) to know most pregnant women want this info, as it's is one of the biggest windows of opportunity in life to rethink and reframe what has happened to you in your childhood and if you're going to make some inroads into this new framework, this will be one of the most crucial times.  Akin to the sensitive stages in child development.

This knowledge is welcomed because of the heightened awareness of the imperative of raising your child/ren as best as one can.  That's the easier part. The harder one being finding therapists who truly get it and can truly help.

On one Resilience measurement scale, I scored 4 points higher in Resilience, than my ACE score. I don't immediately recall which Resilience scoring tool I used, but it's nice to have options, and evidence-base rankings of scoring tools. I believe the last ACE scoring tool I used was the WHO ACE International Questionnaire. Thank You, Laurie Udesky, for posting this.

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