As a family doc practicing in San Diego, I was privileged to hear Dr. Vincent Felitti talk about his inspired development of the CDC-Kaiser Permanente Adverse Childhood Experiences Study (ACE Study) and the link between ACEs and many adult mental and physical diseases directly from him only a few years after his original insight.
Yet, although I had a lively clinic and learned how to manage a vast array of medical conditions over the next 25 years, like most primary care providers I never paid attention to the importance of childhood maltreatment and trauma. Then, when I was treating a couple of homeless patients whose history of child abuse resulted in a very handicapped adult existence, I received little support from my clinic colleagues, but discovered the depth of the resources in our community that were focused on this problem. After 35 years in practice this was the first time I ever heard the phrase “Trauma Informed Care.” A bit more exploration confirmed that medical professionals (except pediatricians), generally whether by culture, shame, ignorance, neglect, misplaced priorities, or confusion, largely overlook the specific needs of the many adults (about one in seven) who had been traumatized as children, in their policies and protocols, in their training, and in their clinical practice. This must be changed, since trauma due to child abuse and/or neglect can have a major effect on adult health and function.
Lately there has been a series of articles in the various peer reviewed medical journals (1,2,3,4,5) that, in discussing screening for child abuse and neglect trauma after recognizing the powerful epidemiological prevalence studies, emphasize the problems of using an ACEs or similar screen rather than the importance of stepping up to take responsibility and facilitating expansion of treatment capabilities. Recently these articles seem to be a critical reaction to the California ACEs Aware initiative. Perversely this results in important, widely read medical journals conveying a sense that there are good reasons for the average practitioner not to become involved, not to screen, not to bother and not to take responsibility to treat adults harmed by childhood trauma, thus re-enforcing barriers to care.
- The first criticism is that the ACEs screen is a simple minded score and is not a validly standardized measure of childhood exposure to the biology of stress. Merely adding dissimilar experiences with equal weights as different exposures have a differential impact; omitting many possible equally traumatic factors; not discerning age and sex may have differential response to an adverse experience; not evaluating experience clusters; not assessing the frequency, intensity, or chronicity of exposure; not having a precise threshold for significance; being subject to both positive and negative recall bias and omitting positive experiences which build resilience and minimize impact. These factors are certainly important, especially for research, and peer-reviewed journals are the place to discuss them, but these nuances are not important in the primary care clinic except as they pertain to the care of a specific patient. On the contrary, simple and quick is an advantage. In fact, an even more simple approach may be more practical. It would be just as functional to replace the ACEs screen with a single “universal precaution” question such as “When you were a child did you ever have experiences that were very upsetting, tragic, physically or emotionally harmful, or so painful that may impact your life now? If so, it may be beneficial to talk about them and I am ready to listen.” The ACE survey is a simple tool to start a conversation about an existing pathogenic problem that may be unrecognized or previously unrevealed. (Currently the California project is also using it as a tool to educate doctors about childhood trauma’s contribution to disease.)
- The second criticism is that the ACEs screen can be offensive and will cause respondents to be offended or upset by answering personal questions about ACEs and thus erode the trust between clinician and patient or parent. This overlooks a large body of clinical experience focused on the art of medicine. Clinicians using the ACE survey rarely encounter an offended or uneasy patient. In any case, a defensive patient can avoid this issue by giving negative responses. On the contrary, often patients express explicit gratification for opening up the conversation, often for the first time in the patient’s life. The ACEs screen can provide the beginning of a more intimate, honest, and intense doctor-patient relationship. Just getting the issue out can give the patient great therapeutic insight and benefit. Empathic listening and support is of the essence and, in some cases, this alone can provide the gateway to improvement. This perspective is re-enforced by the experience with now nearly universal acceptance of screening for domestic violence.
- The third criticism is that offering an ACEs screen without proper training, attention and follow up is harmful. This is a practical valid concern. Questions about traumatic experiences are deeply personal and potentially painful and distressing. Inattention or poor follow-up in the clinic to a positive screen can cause more harm. Using the ACEs screen requires careful planning, training, and resource allocation. The California Aces Aware initiative has wisely built practitioner training into its program.
- The fourth criticism is that the ACEs screen will pejoratively label patients and cause investigation of healthy patients who have experienced positive or remedial factors creating resilience. This criticism seems to reflect projected continuation of the cultural attitude of shame toward child maltreatment experiences. Any practitioner using the ACEs screen must always be ready to acknowledge a positive screen with an extension of empathy and lack of judgment. A positive screen must always be considered in the context of the patient’s actual complaints. Medicine does not have the needed resources to evaluate and treat all the patients who have had childhood trauma and want help, never mind devoting resources to patients who had childhood trauma and are doing well. No claim has been made that a significantly positive ACEs score predicts future disease in an otherwise healthy patient.
- The fifth criticism is that the ACEs score is a poor tool for preventive medicine screening. This is a paradigm distortion. Screening for childhood trauma in adults is not for primary prevention. The screen is not to assign risk, but to identify current problems. It is for disease case finding and may improve the treatment of alcoholism, chain smoking, hypersexuality, depression, anxiety, sleep disorders, obesity, cardiovascular disease, diabetes, among others, as well as problems with relationships and social skills.
- The sixth criticism is that ACEs data has provided epidemiological knowledge only. The claim is made that ACE scores are associated with increasing population risk of health and social problems, but they cannot be applied and are not predictive at the individual level. Knowledge about epidemiology, however, can set priorities and draw attention. In fact, this is true throughout medicine with most diseases. Epidemiology documented an explosion in lung cancer cases and then (with controversy) validly linked it to smoking, but could not identify which smoker would get lung cancer, so medicine undertook the task of preventing smoking generally, both in the community and in individual patients to great benefit.
- The seventh criticism is that primary care clinicians do not have the time to implement the ACEs screen. This might be accepted but for the fact that child abuse trauma is so common and intertwined with so many mental and physical disease processes that it can no longer be overlooked. Using ACEs is a tool to educate physicians as well. Using positive screens as a start will improve care and outcomes across the board. Undoubtedly, taking on the issue of child maltreatment trauma will stress the busy clinic by requiring an expanded paradigm for management. Occasionally among adult patients and more frequently among children mandated reporting to legal authorities is required. This may be stressful, make the practitioner uneasy, fracture the usual expectation of patient confidentiality and be time consuming. There is no established quick therapy like a medication. (Existing psychiatric pharmacology is notoriously ineffective.) Empathic listening and support is of the essence and can provide the gateway to improvement without a commitment to extended talk therapy. On the other hand, a “fifteen minute hour” of trauma informed cognitive behavioral therapy frequently repeated can be quite successful. Optimally an easy referral for ongoing care is available for trained trauma informed counseling. Physicians also need to be trained to focus on and intervene in the contribution of child maltreatment trauma to many adult chronic diseases such as asthma, emphysema, obesity and irritable bowel syndrome, among others.
- The eighth criticism is that no interventions have been shown to improve outcomes for children or adults who report a high number of ACEs is flatly wrong. There are a myriad of reports (not experiments – which may be unethical in some circumstances) especially by psychologists and social workers on specific counseling techniques that are beneficial. Simple identification and empathy are very important. The elements of trauma informed care are continuously being elaborated. Innovative techniques like eye movement desensitization therapy (EMDR) in PTSD may be effective. Even though the long term effects of child maltreatment trauma were established 40 years ago, much of the attention has gone into describing the morbidity in children and intervening there. The very outline and extent of its effects in adults is still in the process of exploration and documentation. Structuring good treatment and outcome studies on an evidence based basis has yet to be accomplished due to (a) low priority at the NIH, (b) denial of pathogenic significance by American psychiatrists, (c) naturally low advocacy by the families and patients involved, (d) continuing societal shame and avoidance, and (e) ongoing medical ignorance of child maltreatment trauma’s significant impact on health throughout the life cycle (6,7).
It seems to me that general medical journals bear a responsibility to put these considerations in context by increasing publications that emphasize practical clinical considerations in the management of child maltreatment trauma by front-line practitioners. In particular many of the issues raised are straw horses that have an out-sized negative effect on practitioners and raise the threshold for initiatives to provide needed care. Meanwhile practitioners caring for patients who have experienced child abuse trauma should not be confused nor inhibited by these critical articles.
All of us should join in professional advocacy to raise sensitivity to the prevalence and impact of child abuse trauma in the medical community, to promote treatment by a broader array of practitioners, and more attention to supporting prevention and treatment in the public policy arena.
- 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
- Baldwin JR, et al, Population vs Individual Prediction of Poor Health From Results of Adverse Childhood Experiences Screening, JAMA Pediatr. 2021; 175(4):385-393. doi:10.1001/jamapediatrics.2020.5602
- Anda RF, Porter LE, Brown DW, Inside the Adverse Childhood Experience Score: Strengths, Limitations, and Misapplications, Am J Prev Med 2020;000(000):1−3,doi.org/10.1016/j.amepre.2020.01.009
- Austin AE. Screening for traumatic experiences in health care settings: a personal perspective from a trauma survivor. JAMA Internal Medicine, Published online May 3, 2021. doi:10.1001/jamainternmed.2021.1452
- Finkelhor D, Berliner L, Screening for Traumatic Childhood Experiences in Health Care Settings, JAMA Internal Medicine, Published online May 3, 2021 E1
- Machtinger EL, Lieberman A, Lightfoot M, Research, Practice, and Policy Implications of Adverse Childhood Events, JAMA Pediatr. Published Online: May 10, 2021.doi:1001/jamapediatrics.2021.0810
- Krugman R, Narrative Matters, Ending Gaze Aversion Toward Child Abuse and Neglect, Hlth Aff, 2019; 38(10):1762-1765. doi:10.1377/HLTHAFF.2019.00573.