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California PACEs Action

Trauma-Informed Care as a Universal Precaution: Beyond the Adverse Childhood Experiences Questionnaire [jamanetwork.com]

 

By Nicole Racine, Teresa Killam, and Sheri Madigan, JAMA Pediatrics, November 4, 2019

Experiences of childhood adversity are common, with more than 50% of adults reporting having experienced at least 1 adversity as children and more than 6% exposed to 4 or more adverse childhood experiences (ACEs). There is currently a controversial debate in the medical field as to whether the ACEs questionnaire, which asks about abuse, neglect, and household dysfunction before age 18 years, should be administered as routine practice by pediatricians. While some argue that identifying and addressing ACEs can lead to support that may promote resilience and help decrease the well-established health burden of ACEs, others caution against its limited evidence and effectiveness as a universal “screening tool” as well as its potential harms in terms of revictimization and increased patient stigma. Although research on the potential benefits and consequences of universal screening for ACEs is in its infancy, the ACEs questionnaire has been rapidly adopted into pediatric care settings across North America. For example, $45 million has recently been allocated to state funding in California to increase ACEs screening and trauma-related training in pediatric care settings. Moreover, there are now 27 states that have statutes and resolutions associated with ACEs and trauma-informed approaches to care.

Given this widespread adoption, which likely cannot be halted altogether, we encourage practitioners to adopt a trauma-informed approach to patient care, which extends well beyond the use of a single ACEs questionnaire. Trauma-informed care (TIC) realizes the universal effect of trauma; recognizes how trauma presents in children, families, and staff; and responds in a way that resists retraumatization. Trauma-informed care is rooted in the assumption that any child or adult could have a trauma history, and this approach should be used across medical settings with all patients whether an ACEs questionnaire is administered or not. Given the high rates of adversity in the lives of children and families, TIC should be a universal precaution.

Two decades ago, a fundamental paradigm shift on the understanding of the development of health and mental health difficulties across the lifespan was spurred by the original ACEs study. This study found an association between experiences of adversity in childhood and the pathogenesis of health, disease, and mortality. Understanding the consequences of exposure to “toxic stress” as a result of childhood adversity has galvanized initiatives to identify exposure to ACEs within the medical community. In a policy statement, the American Academy of Pediatrics called on pediatricians to “screen for precipitants of toxic stress” because of physicians’ unique position to identify adversity in the lives of children and youth. Accordingly, clinical assessment tools on how to implement the ACEs questionnaire into routine practice have been developed. However, this early adoption has been deemed premature.

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As an internist, I have no experience using the ACE Study findings in pediatrics, but I can share our experience integrating the ACE findings into adult medicine. An unusual Preventive Medicine Department at Kaiser Permanente in San Diego was providing  highly comprehensive medical evaluation to 58,000 adults a year.  Step 1 of this process involved filling out a quite lengthy medical history questionnaire at home. The ACE questions were integrated into this for 440,000 consecutive adult members evaluated over an eight year period. While it is possible to do anything wrong, we had  no patient complaints.  Instead, there were many letters and other expressions of thanks.  An outside mathematician carried out a 135,000 patient study to see whether this ACE integration had any discernible effect.  To our surprise, it triggered a 35% reduction in outpatient visits and an 11% reduction in ED visits in their subsequent year compared to their prior year.  The multi-billion dollar implications of this cost-saving initially triggered the Vermont Legislature to pass legislation designed to support this ACE integration in medical practice.  Since then, twenty-two more legislatures, most recently California's have passed similar laws.

The question of course is: What does one do with this information once it is obtained?  What we did was to say to our patient, "I see on the Questionnaire that ....   Can you tell me how that has affected you later in your life?"  And we Listened, period.  We did one other thing, but it took the patients to help us see that:  we still Accepted them after learning their dark secrets.  It turns out that Asking (best done initially via an inert mechanism filled out at home), then Listening, and implicitly Accepting are a powerful form of Doing.  We are now discovering what more can be done, now that we understand  the underlying causal  problems as well as their manifest symptoms.  

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