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Medical Authorities with Academic Blinders look the other Way: Reject ACES

Recently a family doc published a "Viewpoint" in the Journal of the American Medical Association suggesting restraint and caution in using the ACEs screening tool (Campbell TL. Viewpoint, Screening for Adverse Childhood Experiences (ACEs) in Primary Care: A Cautionary Note, JAMA Published Online: May 28, 2020, doi:10.1001/jama.2020.4365) because (1) there were no evidenced based treatments, (2) asking the questions would offend patients and parents, and (3) risk of labeling people with such exposures as high risk.

A good group of us (Jeoffry B. Gordon, MD, MPH, (Member, California Citizens Review Panel on Critical Incidents (child abuse fatalities), Charles B. Nemeroff, MD, PhD, (Matthew P. Nemeroff Professor and Chair, Department of Psychiatry and Behavioral Sciences, Mulva Clinic for the Neurosciences, Director, Institute of Early Life Adversity Research, Dell Medical School, The University of Texas at Austin, Vincent Felitti, MD, (Retired, Chairman, Preventive Medicine, Kaiser Permanente of San Diego), Randell Alexander MD PhD, (Professor and Chief, Division of Child Protection and Forensic Pediatrics, University of Florida – Jacksonville);  Thomas Boat, MD (Professor of Pediatrics, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center); David L. Corwin, MD (Professor and Director of Forensic Services, Pediatrics Department, University of Utah School of Medicine, President, American Professional Society on the Abuse of Children); Drew Factor, MD, MPH (Independent Internist, member of the Trauma-Informed Practices Subcommittee, Essentials for Childhood Initiative Program, California Dept of Public Health); Pradeep Gidwani, MD, MPH, FAAP (Medical Director, Healthy Development Services and First 5 First Steps Home Visiting Services, American Academy of Pediatrics, California Chapter 3); Tasneem Ismailji MD, MPH (Co-founder and Board Member, Past President and Board Chair, Academy on Violence and Abuse); Richard Krugman, MD (Distinguished Professor of Pediatrics, Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, University of Colorado Medical School); Martin T. Stein, MD (Professor of  Pediatrics Emeritus, University of California San Diego) with extensive experience submitted a contrasting "Viewpoint" outlining all the reasons we found ACEs (and similar screening questionnaires) to be an important and underused clinical tool with lots of potential benefits.

I am writing to inform you all that the editors of JAMA did not find it worth their while or important enough to publish a rebuttal. It seems mainstream medical thought still is more than ignorant but is, in fact, positively ashamed, embarrassed and avoidant of the fact that child abuse is so common and has so much effect on health outcomes.

I encourage others who have the same frustrations, or who have similar experiences to share them here.

The substance of our reply to Campbell and JAMA is in the following 10 points:

  • Child Abuse and neglect are epidemic in the United States. In multiple studies 20 to 25 per cent of the adult population has had a significant ACEs exposure. The effects of CAN impact a substantial number of our patients even while we physicians remain unaware.
  • Campbell is correct CAN is not the disease. The physical and psychological adaptations to the trauma/stress of CAN contribute to pathology. (Think of the relation between cholesterol and coronary artery disease, acute anemia and syncope.)
  • Campbell assesses the value of ACEs screening against the US Preventive Services Task Force’s recommendations on screening asymptomatic people for primary prevention. He misses the fact that most of the procedures assessed by them are applied to populations that have a prior predicted prevalence of 1 in 2,000 to 10,000. ACEs screening is not being recommended for primary prevention purposes, rather for “risk assessment” of patients, some of whom may have unidentified symptoms, to initiate intervention.  In children before age 18 the population prevalence is at least 1 in 8, while among USA adults it is 1 in 4 to 5.
  • Knowledge of CAN trauma through using ACEs screening can improve prevention and treatment of many other common existing physical diseases, e. g. obesity (This is how the ACEs paradigm was discovered), smoking/COPD, substance abuse.
  • Identifying CAN trauma through ACEs screening can improve the prevention and treatment of many other mental illnesses.  Like Dr. Campbell, contemporary psychiatry, through the DSM paradigm, defines CAN as “an environmental condition, not a disease” thus overlooking the contribution that the distinct psychological trauma of CAN contributes to many DSM defined diseases as a co-morbidity thus impairing research, prevention and treatment of those diseases.
  • Without a doubt the sequelae of CAN as revealed by ACEs screening are a complex bio-psycho-social problem. Optimal treatment of this pathology in the clinic does not easily lend itself to a simple or quick pharmacologic or technologic remedy. Thus while it inevitably may put stress on the busy clinical practice this problem does evoke the caring and compassion at the heart of medicine and competent specialized interdisciplinary resources are available across the country to provide support to primary care clinicians.
  • Campbell makes an important observation when he observes, “No interventions have been shown to improve outcomes for children or adults who report a high number of ACEs.” Screening for and compassionate, nonjudgmental listening to patients talk about their ACEs is the first healing modality. Child abuse specialists have explicitly remarked “child abuse and neglect has been relatively ignored (by the major sources of federal research funding)….As a result, the field is now… at least twenty to thirty years behind the rest of child health.” Children, abusive parents and traumatized adults are unlikely to advocate for themselves like those with other diseases. Screening for ACEs will function to raise awareness of the impact of this condition among medical practitioners and stimulate more research.
  • While in the abstract there may be a “risk…whether the respondents will be offended or upset by answering personal questions about ACEs or whether the ACE questionnaire will erode the trust between clinician and patient or parent,” the overwhelming experience of those of us in frontline medicine using ACEs is the gratitude patients often express for having the opportunity to open up for the first time about their experience and the new intimacy created in the doctor patient relationship. At Kaiser, the ACEs questions as part of a general health assessment produced no complaints when used over 400,000 times. In fact, one internist reported that initiating the use of the ACEs questionnaire in his practice cured his ‘burnout.’
  • Considering that there are over 3 million cases of child abuse resulting in over 2000 child fatalities in the USA annually (about twice as many deaths as are caused by childhood cancer) physicians should be eager and feel an ethical imperative to use ACEs screening to intervene in current or ongoing CAN situations without being constrained due to “insufficient evidence (that ACEs screenings…have been proven to improve outcomes” in individual patients.  As in other medical situations (e.g. infectious disease, epilepsy, dementia) case identification may be as significant in a public health context as knowledge of effective therapy for the individual. In addition, for all the reasons enumerated here and especially to create the opportunity to intervene to prevent harm to helpless children, rather than waiting for proven treatments, it remains important to continue and expand ACEs screening.    
  • There has been a chronic shortage of appropriate medical attention to the trauma of CAN. Krugman recently observed, “For more than fifty years, not enough has been done to tackle the national problems of child abuse and neglect….(This) gaze aversion…seems to be operative today in the paucity of research on the causes, treatment, and impact of all forms of child abuse and neglect on the health and well-being of children, adolescents, and adults….We need all Americans (and the health professionals who serve them) to view child abuse and neglect not just as a social and legal issue, buy as a health, mental health, and public health concern. We need to remove the shame and stigma that accompany the diagnosis.”
  • There is no better way to start improving this situation that to promote ACEs screening at every clinical encounter.

Jeoffry B. Gordon, MD, MPH

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Comments (12)

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But, Alas, pediatricians are medical clinicians, not police. If they did not ask about language skills they may never uncover a hearing problem that could be treated. If they do not ask about home environment, they may overlook abuse -which they have the responsibility and skills to treat.This is not prejudice, punishment or stigmatization but caring outreach and risk assessment in the vast majority of circumstances.

You DO NOT NEED AN ACE SCORE to get a psychosocial history.  You do not need to put a family at risk to do a psychosocial history and provide services to patients.  I know.  I have been doing it for 20 years.  

All this score can be used for when put in the medical record is to harm children, parents and families.    

If I were forced to get this score, I would tell all my patients that the government is forcing me to ask you questions that could put you at risk for having your children removed from your care.  

Last edited by Marie Archambeau

I can see this information used to discriminate against disadvantaged people.  Pediatricians should not be collecting scores that can be used in a harmful way against children or parents.   

You are basically asking a parent to put a number on the chart associated with their name that represents the "parental risk factors" for child abuse and neglect that we all know about from the various medical textbooks we use.  I was looking at Zitelli and the ACE questions are listed in the section as "Parental Risk Factors."   No one wants child abuse and neglect.  We all have seen it and a lot of us have lived through it.    However,  all over the world, in general, the person (s) who will be most able to be there for a child is the parent almost all of the time.   I don't want us to forget that.  

We could start by learning what children need developmentally and working to make sure every child gets that, then there is no need to try to repair something later.  

The better off parents are more sophisticated generally.  They know better than to give this information (on average).  So that leaves us with a number that would be pretty difficult to intrepret.   Lots of savvy or wary parents know not to respond or to give a zero or a 1.    I don't think this is a good way to determine who is at risk.  Certainly a score alone does nothing to change child outcome,  Psych drugs can make things worse.  Robert Whitaker who wrote Anatomy of an Epidemic spoke at BVK's trauma conference.   He really implores us to 1. Understand the very negative effects of psychotropic medications on the developing brain and 2. Advocate for our patients because we are their voice at least as best we can be.   

I don't feel that it is ethical to prescribe kids most of these psychotropics now that I know what I do about how dangerous these are.   If I were forced to prescribe them, I would leave medicine.  I would sooner work at a hamburger shop than harm a child patient or parent who is relying on me to give honest health information.   

But, Alas, pediatricians are medical clinicians, not police. If they did not ask about language skills they may never uncover a hearing problem that could be treated. If they do not ask about home environment, they may overlook abuse -which they have the responsibility and skills to treat.This is not prejudice, punishment or stigmatization but caring outreach and risk assessment in the vast majority of circumstances.

Billing Codes Directly Associated with a Score Less than 4 or 4 or more.:

DHCS Operational Implementation Element Description\Payment

Effective Date January 1, 2020

Attest to Completing Training By July 1, 2020

Target Population Children and adults up to 65

Provider Types Almost all

Rate $29 HCPCS Codes

G9919: ACEs score of 4 or greater, high risk • Screening performed – result indicates patient at high risk for toxic stress; education and interventions (as necessary) provided

• G9920: ACEs score of 0 to 3, lower risk • Screening performed – result indicates patient at lower risk for toxic stress; education and interventions (as necessary) provided

You are correct.

I can see this information used to discriminate against disadvantaged people.  Pediatricians should not be collecting scores that can be used in a harmful way against children or parents.   

You are basically asking a parent to put a number on the chart associated with their name that represents the "parental risk factors" for child abuse and neglect that we all know about from the various medical textbooks we use.  I was looking at Zitelli and the ACE questions are listed in the section as "Parental Risk Factors."   No one wants child abuse and neglect.  We all have seen it and a lot of us have lived through it.    However,  all over the world, in general, the person (s) who will be most able to be there for a child is the parent almost all of the time.   I don't want us to forget that.  

We could start by learning what children need developmentally and working to make sure every child gets that, then there is no need to try to repair something later.  

The better off parents are more sophisticated generally.  They know better than to give this information (on average).  So that leaves us with a number that would be pretty difficult to intrepret.   Lots of savvy or wary parents know not to respond or to give a zero or a 1.    I don't think this is a good way to determine who is at risk.  Certainly a score alone does nothing to change child outcome,  Psych drugs can make things worse.  Robert Whitaker who wrote Anatomy of an Epidemic spoke at BVK's trauma conference.   He really implores us to 1. Understand the very negative effects of psychotropic medications on the developing brain and 2. Advocate for our patients because we are their voice at least as best we can be.   

I don't feel that it is ethical to prescribe kids most of these psychotropics now that I know what I do about how dangerous these are.   If I were forced to prescribe them, I would leave medicine.  I would sooner work at a hamburger shop than harm a child patient or parent who is relying on me to give honest health information.   

Last edited by Marie Archambeau

Billing Codes Directly Associated with a Score Less than 4 or 4 or more.:

DHCS Operational Implementation Element Description\Payment

Effective Date January 1, 2020

Attest to Completing Training By July 1, 2020

Target Population Children and adults up to 65

Provider Types Almost all

Rate $29 HCPCS Codes

G9919: ACEs score of 4 or greater, high risk • Screening performed – result indicates patient at high risk for toxic stress; education and interventions (as necessary) provided

• G9920: ACEs score of 0 to 3, lower risk • Screening performed – result indicates patient at lower risk for toxic stress; education and interventions (as necessary) provided

 

Jeoffry,
I did appreciate the opportunity to add to the rebuttal :-). We live in a traumatized society and the more we understand trauma the more we see how wide spread and pervasive the effects. I so appreciate a site like ACEs Connection where we see all that is emerging and evolving in leaning towards and finding ways to invite more of that connection, compassion, succor and support. It also helps sensitive practitioners have so much more to offer.
 

 

Is it Social Justice to take disadvantaged kids (or any kids) and to collect their Name, DOB, Medicaid Number and a  Billing Code representing 4 or more ACES or Less than 4 ACES and send that information to the state?  Can you tell me Jeff  please; is that your idea of Social Justice?   It is not my idea of Social Justice and all I have seen from the California community is getting a score - nothing about how to talk to parents about the score or anything.... Just GET THAT SCORE DOCTOR.  This does not seem on the up and up to me,    CYW and California is totally going around the American Academy of Pediatrics. WHY?

This dividing people up based on an ACE score has a real potential to label and stigmatize kids and mostly, direct them into pharmacological drug treatment. Also, where is the significant studies on Neurofeedback?  If we want to use neurofeedback with kids (and I think NFB has a lot of potential), we should be studying neurofeedback and determining the best way to go about doing it with kids.  

This is From CYW site:

"MULTIDISCIPLINARY TREATMENT

Child, adolescent, and young adult patients of BCHC who have been exposed to four or more ACEs, or who have one to three ACEs plus significant symptoms, are referred for multidisciplinary treatment. Families receive care coordination services and may also receive a combination of psychotherapy, psychiatric care, and biofeedback based on their individualized care plan.

  • PSYCHOTHERAPY

    We provide a variety of evidence-supported treatments and promising practices that share core principles of culturally competent, trauma-informed therapy that are appropriate for children and families from diverse cultural backgrounds. These include Child Parent Psychotherapy (CPP), Infant Parent Psychotherapy (IPP), Trauma Focused Cognitive Behavioral Therapy (TF-CBT), Dialectical Behavioral Therapy (DBT), and Cue-Centered Therapy.

  • PSYCHIATRY

    Psychiatrists provide medication evaluations of children and caregivers, psychotropic medication management, and clinical consultation to the multidisciplinary team.

  • BIOFEEDBACK (PERIPHERAL AND NEUROFEEDBACK)

    These services build awareness and control over body processes such as muscle tension, blood pressure, and heart rate to help patients recognize and better regulate their fight or flight response. Neurofeedback is a form of biofeedback in which individuals learn to regulate their neurological function, or brainwave activity. With both bio- and neurofeedback, our main objective is to raise the brain’s threshold to toxic stress by increasing resiliency, flexibility, and stability." 

  • There is nothing here about getting to the bottom of what happens to human biology and the developing human nervous system via interactions in the environment.  Parents need to know that Babies need rhythmic stimulation of the somatosensory systems of the body - vestibular, sight, sound, touch, stretch receptors in the gut, thermal regulation, etc.  Then as they get older, they need integration of all that information through play, first with the mother in the first year of life and then with the father in the second year and then through social play with groups of other children of varying ages.   You know, I saw a new hashtag that Dr. Garner has been using #ThinkDevelopmentally, and I agree, it is time to think developmentally and provide kids with what human biology needs to become what we consider to be human.  Humans need these kinds of interactions to develop empathy, compassion and to become social beings.  Providing this algorithmic "treatment" after the fact leaves out way too much and no pediatrician should be caught in the trap of thinking that this is all we need to do to do right by our smallest and most vulnerable patients.    

PS: These are the courses from CYW / California for ACEs --- How can the state be promoting universal screening right now as I write this without a module on  Communication and Anticipatory Guidance Around ACES?   This is all about collecting data on people without any plan or approach to proper management or even prevention and that is where I started to question the motivations of this movement. 

"

CYW Learning on Demand Courses

Course 1 – ACEs: The Science & Foundational Framework CEU/MOC AVAILABLE!

There are now decades of science helping us understand how adversity and toxic stress can impact health and what interventions and protective factors can help prevent and mitigate the damage. In this course, you’ll learn how exposure to ACEs and toxic stress affects the brain and causes multi-systemic effects, leading to disruption in the ways that the neurological, endocrine, and immune systems operate — and how knowing this might help improve clinical decision-making.


Course 2 – Implementing ACEs Screening in Clinical Practice

There’s no one-size-fits-all way to do ACEs screening — what will work for your practice depends on many factors including your healthcare setting type, patient population, and goals. This course takes you through the key considerations, developed through working in the field with early adopters, that should be explored to help you develop an ACEs screening protocol for your unique practice. This course also provides sample planning worksheets, workflow, scoring algorithm, suggested patient resources and referrals for post-screening, and many other helpful supports.

 


Course 3 – Prepare your Practice

Successful ACEs screening depends on more than a well-planned patient experience. A strong back-end organizational and administrative structure, as well as well-defined policies and procedures, are also critical for making your screening program run smoothly. This course reviews what you should consider, including electronic health record (EHR) data capture and reporting, billing, QI Performance Improvement methodology, and staff training and self-care. We also discuss best practices for creating implementation leadership and administration and colleague buy-in.

 


Course 4 – Communication & Anticipatory Guidance around ACEs

This more advanced course provides information that will help you continue to improve your ACEs screening program. We delve into proven techniques and frameworks that can help you build patient/caregiver trust and encourage patient/family participation in recommended interventions. This course also provides sample patient education tools, patient education job aids and staff scripts you can modify to use in your own practice.

 

 

Thank you for being so concerned and so passionate. As an advocate for  good medicine and good therapy and for helping traumatized kids, I recognize some of your concerns, but others, in my experience, are not as significant as you think.

(1) There is a lot of family violence, We have to do everything we can to prevent it and to treat its effects.

(2) CYW is definitely not the government, Dr. BH may be part of government now but I see that as a great success in changing public policy to deal with these family tragedies. CYW is a medical practice passionately expanded to study and treat child hood trauma. It goes way beyond the doctor's office model to supply many disciplines and any modality which has the potential to work as well as to do research and to educate the public and health professionals.  Beyond this its public presence has a successful track record of raising consciousness about child abuse and catalyzed people power and resources to work on the problem.

(3) The ACEs Medical program is not a labeling or surveillance mechanism. Payment will require a billing code not an ACEs score and patient circumstances will be the confidential property of the doc or clinic. I can see a future when scores linked to patients are used for research with the usual ethical protections to determine which treatment works, etc.

(4) I passionately agree that psych meds are largely over used and mostly ineffectual in cases of mental distress after abuse. I am proud to work with Dr. Nemeroff because he advocates for attention to this condition in the public square and because I have the opportunity to talk (actually debate) with him about his misguided ways.

 

 

Is it Social Justice to take disadvantaged kids (or any kids) and to collect their Name, DOB, Medicaid Number and a  Billing Code representing 4 or more ACES or Less than 4 ACES and send that information to the state?  Can you tell me Jeff  please; is that your idea of Social Justice?   It is not my idea of Social Justice and all I have seen from the California community is getting a score - nothing about how to talk to parents about the score or anything.... Just GET THAT SCORE DOCTOR.  This does not seem on the up and up to me,    CYW and California is totally going around the American Academy of Pediatrics. WHY?

This dividing people up based on an ACE score has a real potential to label and stigmatize kids and mostly, direct them into pharmacological drug treatment. Also, where is the significant studies on Neurofeedback?  If we want to use neurofeedback with kids (and I think NFB has a lot of potential), we should be studying neurofeedback and determining the best way to go about doing it with kids.  

This is From CYW site:

"MULTIDISCIPLINARY TREATMENT

Child, adolescent, and young adult patients of BCHC who have been exposed to four or more ACEs, or who have one to three ACEs plus significant symptoms, are referred for multidisciplinary treatment. Families receive care coordination services and may also receive a combination of psychotherapy, psychiatric care, and biofeedback based on their individualized care plan.

  • PSYCHOTHERAPY

    We provide a variety of evidence-supported treatments and promising practices that share core principles of culturally competent, trauma-informed therapy that are appropriate for children and families from diverse cultural backgrounds. These include Child Parent Psychotherapy (CPP), Infant Parent Psychotherapy (IPP), Trauma Focused Cognitive Behavioral Therapy (TF-CBT), Dialectical Behavioral Therapy (DBT), and Cue-Centered Therapy.

  • PSYCHIATRY

    Psychiatrists provide medication evaluations of children and caregivers, psychotropic medication management, and clinical consultation to the multidisciplinary team.

  • BIOFEEDBACK (PERIPHERAL AND NEUROFEEDBACK)

    These services build awareness and control over body processes such as muscle tension, blood pressure, and heart rate to help patients recognize and better regulate their fight or flight response. Neurofeedback is a form of biofeedback in which individuals learn to regulate their neurological function, or brainwave activity. With both bio- and neurofeedback, our main objective is to raise the brain’s threshold to toxic stress by increasing resiliency, flexibility, and stability." 

  • There is nothing here about getting to the bottom of what happens to human biology and the developing human nervous system via interactions in the environment.  Parents need to know that Babies need rhythmic stimulation of the somatosensory systems of the body - vestibular, sight, sound, touch, stretch receptors in the gut, thermal regulation, etc.  Then as they get older, they need integration of all that information through play, first with the mother in the first year of life and then with the father in the second year and then through social play with groups of other children of varying ages.   You know, I saw a new hashtag that Dr. Garner has been using #ThinkDevelopmentally, and I agree, it is time to think developmentally and provide kids with what human biology needs to become what we consider to be human.  Humans need these kinds of interactions to develop empathy, compassion and to become social beings.  Providing this algorithmic "treatment" after the fact leaves out way too much and no pediatrician should be caught in the trap of thinking that this is all we need to do to do right by our smallest and most vulnerable patients.    

PS: These are the courses from CYW / California for ACEs --- How can the state be promoting universal screening right now as I write this without a module on  Communication and Anticipatory Guidance Around ACES?   This is all about collecting data on people without any plan or approach to proper management or even prevention and that is where I started to question the motivations of this movement. 

"

CYW Learning on Demand Courses

Course 1 – ACEs: The Science & Foundational Framework CEU/MOC AVAILABLE!

There are now decades of science helping us understand how adversity and toxic stress can impact health and what interventions and protective factors can help prevent and mitigate the damage. In this course, you’ll learn how exposure to ACEs and toxic stress affects the brain and causes multi-systemic effects, leading to disruption in the ways that the neurological, endocrine, and immune systems operate — and how knowing this might help improve clinical decision-making.


Course 2 – Implementing ACEs Screening in Clinical Practice

There’s no one-size-fits-all way to do ACEs screening — what will work for your practice depends on many factors including your healthcare setting type, patient population, and goals. This course takes you through the key considerations, developed through working in the field with early adopters, that should be explored to help you develop an ACEs screening protocol for your unique practice. This course also provides sample planning worksheets, workflow, scoring algorithm, suggested patient resources and referrals for post-screening, and many other helpful supports.

 


Course 3 – Prepare your Practice

Successful ACEs screening depends on more than a well-planned patient experience. A strong back-end organizational and administrative structure, as well as well-defined policies and procedures, are also critical for making your screening program run smoothly. This course reviews what you should consider, including electronic health record (EHR) data capture and reporting, billing, QI Performance Improvement methodology, and staff training and self-care. We also discuss best practices for creating implementation leadership and administration and colleague buy-in.

 


Course 4 – Communication & Anticipatory Guidance around ACEs

This more advanced course provides information that will help you continue to improve your ACEs screening program. We delve into proven techniques and frameworks that can help you build patient/caregiver trust and encourage patient/family participation in recommended interventions. This course also provides sample patient education tools, patient education job aids and staff scripts you can modify to use in your own practice.

 

 

Jeoffry,

Although I have concerns about required screening for ACEs in a society and medical culture that has little understanding of trauma, still commonly believes the only effects of trauma are psychological, often tells individuals with “functional” diseases, mental health conditions, low income or who are discriminated against that it’s all in their heads, does not provide health insurance and mental health treatment for all – I believe it is important to move forward because of all that we know and how much is available that can help prevent, reduce, buffer and treat risk factors.

As a family physician and an assistant professor at the NH - Dartmouth Family Residency Program 20 years ago, I provided full spectrum care, including obstetrics. I left medicine because I felt something was missing in what I could offer. Knowing about ACEs and effects of other types of trauma might have helped me stay in medicine. When I think back to my patients, I think how many would have cried in relief simply to know that ACEs were a risk factor for their asthma, diabetes, heart disease, cancer, alcoholism, depression, anxiety, hypertensive crises and more. To have learned that it was not "their fault" nor "all in their heads." To have learned there were things they could actually do.

As an adult who’s had a disabling chronic illness for 20 years, understanding trauma has made all the difference in my being able to relate to, work with and improve my health. That said, I remain very selective about which of my health care professionals I talk to about trauma.

As someone who changed careers and retrained as a psychotherapist specializing in trauma and integrating existing research revealing links between adversity and risk for chronic diseases of all kinds – I believe we need to incorporate the science of trauma into every class and course and clinical training for health care professionals and to require that health insurers and policy makers (among many others) become trauma-informed.

Over 50% of the US population has a chronic physical disease, 20% or more have a mental illness and rates are increasing. We know from ACE and related studies that trauma is an enormous risk factor for diseases of all kinds. We know that an ACE score of 2 increases the risk of ever being hospitalized for an autoimmune disease by 70% (Dube, Felitti et al). This is a very low – and very common – ACE score that could involve having a parent who is depressed and divorced. The science includes but goes well beyond CAN.

We know as you also describe, such as from pioneers at the Children’s Clinic in Portland, Oregon that experiences of screening have been so positive most “would never go back.”  We know from Vincent Felitti’s statement above and from the experience of screening over 400,000 patients at Kaiser that it went well and that it can provide comfort and decrease office visits. We are learning from Robert Maunder’s work that physicians are more likely to screen when they realize that ACEs are a risk factor for medical conditions (and not only for psychological conditions)

Crandall et al’s study on the preventive effects of counter-ACEs is an example of existing strategies known to buffer and reduce the impact of ACEs. We know that when a child has a single supportive adult who cares, it makes a difference. This could be their physician. We know that investing in our communities and not leaving it all to health care professionals has a significant impact (Bornstein). Screening is a way of starting until we have enough of an informed population (of people with symptoms, health care professionals and beyond) to make changes at all levels. It seems we have to start somewhere and not wait until somehow all the ducks are lined up in a row. 

As a trauma therapist, I have learned that all kinds of therapies are effective in healing the effects of trauma. This is recognized in the field of mental health, which remains highly separate from medical care. I also know that it is the single most important factor that has helped me gradually recover from a disabling chronic illness, along with using other tools that we’re learning can help reverse epigenetic changes associated with threat signaling in our nervous and immune and other organ systems. Dr. Nadine Burke-Harris presents clear examples of how an understanding of ACEs helps her provide better medical care in her book The Deepest Well.

What is most needed is for us – as a society – to become trauma informed. Screening and educating screeners is a start. An Institute for Healthcare Improvement pilot that included 8 US emergency departments is finding that “education enabled staff to reduce the use of patient restraints. ‘When I just acknowledge they are upset and I understand that upset, it takes about 40% of their agitation right off the top.’ As a result, nurses reported being able to better care for patients experiencing a behavioral health crisis. It can reduce the trauma we cause as health care professionals and may also reduce staff burnout, which is a real problem (Kuehn).

It may be not so much that we have no treatment, but that we have not yet studied these effects very broadly in chronic medical conditions because we, as a medical system, have not recognized the role of trauma.

Small studies, anecdotes, and case studies exist of reductions in chronic illness symptoms and even cures after healing trauma. Getting published, however, can be a challenge, and like Michael, my initial attempts to get an article published about the role of trauma in type 1 diabetes have been declined. I suspect it may be a challenge to write about trauma for a medical journal. This is one of our obstacles to getting the word out.

Ultimately, I think one of the pressing issues that will help with screening in the most effective, compassionate, least-harmful way, is that physicians and other medical professionals need to learn about trauma. Medicine needs to catch up with the science. Maybe prescriptions to start screening will facilitate this process. Maybe this will increase and interweave an understanding of ACEs and the many other forms of adversity that affect health into and throughout our curricula and do so more rapidly – and ensure that it is not just a weekend or semester long course but part of all of our courses throughout our training and clinical programs.

 

References

Children’s Clinic in Portland – ACEs article

“Two years in — with more than 1500 parents having taken the survey — “the 27 pediatricians who are using the survey say they’d never go back to the way they did things before,” says Gillespie, in implementing ACEs screening at the Children’s Clinic with pediatricians Teri Pettersen and RJ Gillespie.  

Bornstein, D. (2013, August 10). Tapping a Troubled Neighborhood’s Inner Strength (Part I of III). The New York Times. http://www.nytimes.com/2016/08...r-strength.html?_r=0

Crandall, A., Miller, J. R., Cheung, A., Novilla, L. K., Glade, R., Novilla, M. L. B., Magnusson, B. M., Leavitt, B. L., Barnes, M. D., & Hanson, C. L. (2019, Oct). ACEs and counter-ACEs: How positive and negative childhood experiences influence adult health. Child Abuse and Neglect, 96, 104089. https://doi.org/10.1016/j.chiabu.2019.104089

Dube, S. R., Fairweather, D., Pearson, W. S., Felitti, V. J., Anda, R. F., & Croft, J. B. (2009). Cumulative childhood stress and autoimmune diseases in adults. Psychosomatic Medicine, 71(2), 243-250. http://www.ncbi.nlm.nih.gov/pubmed/19188532

Kuehn, B. M. (2020, Jan 29). Trauma-Informed Care May Ease Patient Fear, Clinician Burnout. JAMAhttps://doi.org/10.1001/jama.2020.0052

Maunder, R. G., Hunter, J. J., Tannenbaum, D. W., Le, T. L., & Lay, C. (2020, Apr 15). Physicians' knowledge and practices regarding screening adult patients for adverse childhood experiences: a survey. BMC Health Services Research, 20(1), 314. https://doi.org/10.1186/s12913-020-05124-6

Ms Mead I am so grateful for your heartfelt comments. It must have taken a lot of thought and energy to put together such an extensive essay. Your intimate passion and concern come through and I share it.  I am glad you found a way (in spite of personal circumstances) to put your wisdom and caring to use.

I would riff of your desire to see our society become "more trauma informed" to say I honestly think we live in a relatively brutal and unjust, selfish and violent society.  Child abuse is the unfortunate result of failing parents, in failing (multigenerational) families, in failing communities in a cold hearted world. The covid pandemic has shown off the wonderful dedication and compassion of the healing arts generally, but really mostly we spend our time putting band aids on society's failures, rather than swimming in a cultural stream of compassion, succor and security. The most a sensitive practitioner can do is provide a halo of caring, knowledge and support around every patient and take the extra energy to fight for social justice in the public square.

Jeoffry,

Although I have concerns about required screening for ACEs in a society and medical culture that has little understanding of trauma, still commonly believes the only effects of trauma are psychological, often tells individuals with “functional” diseases, mental health conditions, low income or who are discriminated against that it’s all in their heads, does not provide health insurance and mental health treatment for all – I believe it is important to move forward because of all that we know and how much is available that can help prevent, reduce, buffer and treat risk factors.

As a family physician and an assistant professor at the NH - Dartmouth Family Residency Program 20 years ago, I provided full spectrum care, including obstetrics. I left medicine because I felt something was missing in what I could offer. Knowing about ACEs and effects of other types of trauma might have helped me stay in medicine. When I think back to my patients, I think how many would have cried in relief simply to know that ACEs were a risk factor for their asthma, diabetes, heart disease, cancer, alcoholism, depression, anxiety, hypertensive crises and more. To have learned that it was not "their fault" nor "all in their heads." To have learned there were things they could actually do.

As an adult who’s had a disabling chronic illness for 20 years, understanding trauma has made all the difference in my being able to relate to, work with and improve my health. That said, I remain very selective about which of my health care professionals I talk to about trauma.

As someone who changed careers and retrained as a psychotherapist specializing in trauma and integrating existing research revealing links between adversity and risk for chronic diseases of all kinds – I believe we need to incorporate the science of trauma into every class and course and clinical training for health care professionals and to require that health insurers and policy makers (among many others) become trauma-informed.

Over 50% of the US population has a chronic physical disease, 20% or more have a mental illness and rates are increasing. We know from ACE and related studies that trauma is an enormous risk factor for diseases of all kinds. We know that an ACE score of 2 increases the risk of ever being hospitalized for an autoimmune disease by 70% (Dube, Felitti et al). This is a very low – and very common – ACE score that could involve having a parent who is depressed and divorced. The science includes but goes well beyond CAN.

We know as you also describe, such as from pioneers at the Children’s Clinic in Portland, Oregon that experiences of screening have been so positive most “would never go back.”  We know from Vincent Felitti’s statement above and from the experience of screening over 400,000 patients at Kaiser that it went well and that it can provide comfort and decrease office visits. We are learning from Robert Maunder’s work that physicians are more likely to screen when they realize that ACEs are a risk factor for medical conditions (and not only for psychological conditions)

Crandall et al’s study on the preventive effects of counter-ACEs is an example of existing strategies known to buffer and reduce the impact of ACEs. We know that when a child has a single supportive adult who cares, it makes a difference. This could be their physician. We know that investing in our communities and not leaving it all to health care professionals has a significant impact (Bornstein). Screening is a way of starting until we have enough of an informed population (of people with symptoms, health care professionals and beyond) to make changes at all levels. It seems we have to start somewhere and not wait until somehow all the ducks are lined up in a row. 

As a trauma therapist, I have learned that all kinds of therapies are effective in healing the effects of trauma. This is recognized in the field of mental health, which remains highly separate from medical care. I also know that it is the single most important factor that has helped me gradually recover from a disabling chronic illness, along with using other tools that we’re learning can help reverse epigenetic changes associated with threat signaling in our nervous and immune and other organ systems. Dr. Nadine Burke-Harris presents clear examples of how an understanding of ACEs helps her provide better medical care in her book The Deepest Well.

What is most needed is for us – as a society – to become trauma informed. Screening and educating screeners is a start. An Institute for Healthcare Improvement pilot that included 8 US emergency departments is finding that “education enabled staff to reduce the use of patient restraints. ‘When I just acknowledge they are upset and I understand that upset, it takes about 40% of their agitation right off the top.’ As a result, nurses reported being able to better care for patients experiencing a behavioral health crisis. It can reduce the trauma we cause as health care professionals and may also reduce staff burnout, which is a real problem (Kuehn).

It may be not so much that we have no treatment, but that we have not yet studied these effects very broadly in chronic medical conditions because we, as a medical system, have not recognized the role of trauma.

Small studies, anecdotes, and case studies exist of reductions in chronic illness symptoms and even cures after healing trauma. Getting published, however, can be a challenge, and like Michael, my initial attempts to get an article published about the role of trauma in type 1 diabetes have been declined. I suspect it may be a challenge to write about trauma for a medical journal. This is one of our obstacles to getting the word out.

Ultimately, I think one of the pressing issues that will help with screening in the most effective, compassionate, least-harmful way, is that physicians and other medical professionals need to learn about trauma. Medicine needs to catch up with the science. Maybe prescriptions to start screening will facilitate this process. Maybe this will increase and interweave an understanding of ACEs and the many other forms of adversity that affect health into and throughout our curricula and do so more rapidly – and ensure that it is not just a weekend or semester long course but part of all of our courses throughout our training and clinical programs.

 

References

Children’s Clinic in Portland – ACEs article

“Two years in — with more than 1500 parents having taken the survey — “the 27 pediatricians who are using the survey say they’d never go back to the way they did things before,” says Gillespie, in implementing ACEs screening at the Children’s Clinic with pediatricians Teri Pettersen and RJ Gillespie.  

Bornstein, D. (2013, August 10). Tapping a Troubled Neighborhood’s Inner Strength (Part I of III). The New York Times. http://www.nytimes.com/2016/08...r-strength.html?_r=0

Crandall, A., Miller, J. R., Cheung, A., Novilla, L. K., Glade, R., Novilla, M. L. B., Magnusson, B. M., Leavitt, B. L., Barnes, M. D., & Hanson, C. L. (2019, Oct). ACEs and counter-ACEs: How positive and negative childhood experiences influence adult health. Child Abuse and Neglect, 96, 104089. https://doi.org/10.1016/j.chiabu.2019.104089

Dube, S. R., Fairweather, D., Pearson, W. S., Felitti, V. J., Anda, R. F., & Croft, J. B. (2009). Cumulative childhood stress and autoimmune diseases in adults. Psychosomatic Medicine, 71(2), 243-250. http://www.ncbi.nlm.nih.gov/pubmed/19188532

Kuehn, B. M. (2020, Jan 29). Trauma-Informed Care May Ease Patient Fear, Clinician Burnout. JAMAhttps://doi.org/10.1001/jama.2020.0052

Maunder, R. G., Hunter, J. J., Tannenbaum, D. W., Le, T. L., & Lay, C. (2020, Apr 15). Physicians' knowledge and practices regarding screening adult patients for adverse childhood experiences: a survey. BMC Health Services Research, 20(1), 314. https://doi.org/10.1186/s12913-020-05124-6

No we should not be asking these ACEs in the Peds office.  I don’t think that any of our patients should have their name, DOB, medicaid number and a billing code sent to the state documenting 4 or more or less than 4 ACEs.  This HAS A REAL POSSIBILITY of misuse.   We took an OATH to do no harm and this could cause real harm.   Also your second “expert”  is Dr. Nemeroff. He has been a real proponent for psychotropic use in kids.   That right there is a red flag to me. 

Jeoffry,

I share your frustrations. I give credit to JAMA for publishing several articles, over the last six months, on ACEs, but am disappointed they didn't see the value of printing  your letter.  No doubt all of us, who have been bitten by the ACEs bug, have multiple stories of disappointment in how others don't "get it".  (Last year, I submitted a Point of View paper to JAMA, describing my experience in addressing ACEs with my patients, and it was denied.) My frustration now, as in those past situations, is eased by the undeniable increasing momentum in awareness of ACEs. Our challenge is to soldier on with raising awareness.  I wonder how we could effectively use social media to get all of us with ACEs Connection to pass our resounding message to JAMA and other medical journals.

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