Medical Authorities with Academic Blinders Look the Other Way and Reject ACES

@Michael Arenson posted:

I have truly benefitted from this discussion. I believe a pediatrician asking children about trauma in a trauma informed way and in the context of an authentic healing relationship is less traumatizing than what these kids and young adults are exposed to everyday at school, at home, and on tv.

I do agree we shouldn’t be focusing only on aces. I think we should take a strengths based approach after identifying aces, and identify Positive Childhood Experiences (PCEs) to do so. Trying to turn ACEs into sources of strength and resilience would be my goal, instead of an abscess that continues to silently fester in many.

I just watched the documentary on Jeffrey Epstien and the pyramid scheme of sexual abuse and trafficking he engaged in. I found myself wondering, of the hundreds of underage girls he sexually abused and trafficked, how many of them were seen by a pediatrician? Probably most. And how many of those pediatricians could have done a screen for ACEs and changed the trajectory of these girls lives. Even if only 10% of the girls disclosed of the 100’s, that’s a substantial group of people.

One of the women in the documentary went to news media outlets and tried to tell them about Epstien and his connections (namely to then presidential candidate Trump as well as to Hilary's husband Bill Clinton) and said, “I just needed someone to listen to me”. Pediatricians could have been that for her. Maybe should have been that for her.

There are a lot of unanswered questions, but there is a large number of children (almost 1 in 8) who have had four or more traumatic experiences early in childhood which (a) puts them at risk for experiencing more ACEs, and (b) causes oftentimes silent suffering and toxic stress. 

As a pediatrician, I'm playing with different approaches. Maybe we don't screen the children but instead screen the parents to try to stem the generational cycles of trauma. Maybe we screen only for PCE's and worry about the folks who have very low PCE scores instead of high ACE scores. Maybe we simply use the screening tool as a risk assessment by de-identifying specifically which ACEs children/families say "yes" to, so that we simply know the ACE score and not the specific trauma. (I realize this last one has been touched on in this thread and there are strong feelings about it). What the evidence shows, though, is that with or without evidence-based treatment (a) these terrible things are happening, (b) oftentimes to the most vulnerable children in our society, and (c) when they do happen to children and adults, a major intervention we can do is simply listen and validate feelings and simply be there for people. The research won't be perfect, but it does feel to me a little like we're waiting to know all the information when, perhaps, we know enough to begin to bring the science into our clinics.

I really look forward to further discussion.

Sincerely,

Michael Arenson, MD, MS, MA

Pediatric Resident

University of Washington and Seattle Children's Hospital

(Views are my own)

Thanks for taking the time to post your very thoughtful comment. Obviously early in your career you are already sensitized to the issues and your antennae and values will serve you well through your practice as we all grow in wisdom. I support all your comments.

BTW I just read the long (and sad) history of the development of the rape kit in the New York Times. The cogent point here is that in 1970 neither the police nor medical culture were sensitive enough to this type of aggression toward women to investigate it, curtail its perpetrators or to treat its victims appropriately. This obviously was a cultural neglect that was far from benign. We are a bit further along in identifying child abuse and neglect but we have along way to go before we adequately protect children and know how to augment their resilience.

I have truly benefitted from this discussion. I believe a pediatrician asking children about trauma in a trauma informed way and in the context of an authentic healing relationship is less traumatizing than what these kids and young adults are exposed to everyday at school, at home, and on tv.

I do agree we shouldn’t be focusing only on aces. I think we should take a strengths based approach after identifying aces, and identify Positive Childhood Experiences (PCEs) to do so. Trying to turn ACEs into sources of strength and resilience would be my goal, instead of an abscess that continues to silently fester in many.

I just watched the documentary on Jeffrey Epstien and the pyramid scheme of sexual abuse and trafficking he engaged in. I found myself wondering, of the hundreds of underage girls he sexually abused and trafficked, how many of them were seen by a pediatrician? Probably most. And how many of those pediatricians could have done a screen for ACEs and changed the trajectory of these girls lives. Even if only 10% of the girls disclosed of the 100’s, that’s a substantial group of people.

One of the women in the documentary went to news media outlets and tried to tell them about Epstien and his connections (namely to then presidential candidate Trump as well as to Hilary's husband Bill Clinton) and said, “I just needed someone to listen to me”. Pediatricians could have been that for her. Maybe should have been that for her.

There are a lot of unanswered questions, but there is a large number of children (almost 1 in 8) who have had four or more traumatic experiences early in childhood which (a) puts them at risk for experiencing more ACEs, and (b) causes oftentimes silent suffering and toxic stress. 

As a pediatrician, I'm playing with different approaches. Maybe we don't screen the children but instead screen the parents to try to stem the generational cycles of trauma. Maybe we screen only for PCE's and worry about the folks who have very low PCE scores instead of high ACE scores. Maybe we simply use the screening tool as a risk assessment by de-identifying specifically which ACEs children/families say "yes" to, so that we simply know the ACE score and not the specific trauma. (I realize this last one has been touched on in this thread and there are strong feelings about it). What the evidence shows, though, is that with or without evidence-based treatment (a) these terrible things are happening, (b) oftentimes to the most vulnerable children in our society, and (c) when they do happen to children and adults, a major intervention we can do is simply listen and validate feelings and simply be there for people. The research won't be perfect, but it does feel to me a little like we're waiting to know all the information when, perhaps, we know enough to begin to bring the science into our clinics.

I really look forward to further discussion.

Sincerely,

Michael Arenson, MD, MS, MA

Pediatric Resident

University of Washington and Seattle Children's Hospital

(Views are my own)

I don't believe that it would be socially just or even very wise 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?  I think we all know that our systems of justice aren't all that just.   Shouldn't doctors be very concerned that such a score we collect on a child or a parent could be used to make it easier to take kids away from families or force families into certain types of treatments based on an algorithm that some bureaucrat comes up with?  

The symptoms that accompany Toxic stress from a higher ACE score are actually manifestation of normal human brain development.  No psyche drug will ever change the way that synapses arrange themselves in the brain of a developing human exposed to developmental factors like neglect, emotional abuse,  housing instability or lack of nutritious food.  The  brain is not actually functioning abnormally.   A brain that develops in an adverse environment can be anxious, panicky, aggressive and reactive because humans have to be quick to react and hypervigilant in order to survive a dangerous environment.  No amount of talking is going to convince a brain that needed hypervigilance to survive to give that up.    

I see that neurofeedback is listed as a treatment,   I would like to see the studies on Neurofeedback and how to best use it safely before recommending it as a therapy.  

This is the Algorithm on treatment from the 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." 

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• Another major concern that I have is that there is nothing here about getting to the bottom of what happens to human biology and the structure and function of 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 (babies need to be carried and held next to the body of the mother most of the time in infancy) - vestibular, sight, sound, touch, stretch receptors in the gut, thermal regulation, etc. Babies need to see human faces for proper social development.  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.  Humans need these kinds of safe and compassionate human interactions to develop empathy, compassion and to become competent social beings. Prevention seems the best strategy to me but you do not need this Score to prevent the developmental consequences of not being seen or known in relationship and you cannot drug or talk the developmental consequences away. A human brain that develops in the context of fear and danger will be hypervigilant, aggressive, reactive, fearful and phobic because that is what human biology and physiology does. 

• From the work of  Dr. Teicher-- a brain developing in fear and danger has varying combinations of Poor development of the Corpus Collusum, Arrested development of the Left Hemisphere, Increased blood flow in the Cerebellar Vermis, and Increased Beta Activity in the Temporal Lobes (mainly on the right),

PS: These are the courses from CYW / California for ACEs ---I do not understand how we can be ready to Screen for ACEs but we don't have a module for doctors on how to provide anticipatory guidance and talk about ACEs?   

I hope the conversation can continue.   I see it as really dangerous to collect this number  on our patients and put it on a chart.  Certainly before we do this, we should know what the potential dangers are and we should give that information to our patients so that they can give us their truly informed consent.   

"CYW Learning on Demand Courses

I think one of the problems with the universal ACEs screening discussion is lumping children and adults together.  There should be two different discussions.  I approach this as an internist so it’s hard for me to comment about ACEs screening with children.  My experiences are with adults.  Here’s my opinion - screening  everyone who walks into a clinic with a 10 item ACE questionnaire, with little explanation, preparation, resources, and training is not the right approach.  I have heard about that happening in several primary care practices and was what a physician leader wanted to do here at my institution a few years back.  He had heard the a presentation that my team gave to incoming med students and was ready to start screening the next day.  He had a response that many physicians have once they hear about ACEs and their impact on adult health – we have to start asking everyone!  He was disappointed when I told him our clinics weren’t ready for that and that I wasn’t sure that was the right approach even after more education, etc.  We have taken more of a “case-finding” approach here – focusing on the symptoms of ACEs rather than the score itself.  So many of our patients have uncontrolled chronic disease, anxiety, depression, “non-compliance”, etc. – we teach our students and residents to inquire about a history of trauma, childhood or adult, with those patients who are showing the outcomes (which is actually the majority of patients).  The inquiry can be pretty simple, for example saying “We’ve been working together on your health and it would help me to try to understand what might be the origins of some of the issues that you’re dealing with…” and then asking about what life what like when they were growing up, letting them tell a story rather than going over a checklist. A person with an ACE score of 1 can suffer strong impacts from that trauma, depending on the type, severity, and duration of the abuse.  A standard ACEs survey is a research tool - not a clinical one. 

So while I disagree with several of Dr. Campbell’s points and I find his views far too dismissive, I do think we have to be open to discussions about this with clinicians with different approaches - while still promoting more education, more resources, more prevention and moving towards trauma-informed care for all.  We need to counter Dr. Campbell’s article with practical advice form experienced clinicians and with evidence that is being gathered now.

Why does "sensitive medicine" require an ACE score on the medical chart of a pediatrics patient?   PS.... I have worked for 20 plus years with disadvantaged and impoverished pediatric patients as a MD.  I can't envision sensitive medicine resulting from a score on a set of questions given to patients in a mechanized fashion.   The sensitivity comes from the heart of a sensitive doctor who cares and knows his or her patients. .   

I have been waiting to see pediatric doctors, internists and FP docs call for the development of treatments and preventative measures for toxic stress.  Understanding what we can do and how we can prevent the effects of Toxic Stress is where the benefit would come from I think.   I really would not want to have this number on the chart of a child patient from a disadvantaged background.  I think that could be used in a very discriminating manner.  

@Craig McEwen posted:

This is an important conversation. One could easily argue (I have) that the traditional ACE measure is insensitive to many contextual factors that relate to race and racism, economic disparity, segregated communities, historical and generational trauma,  unequal community resources and more. After all, it was developed with a predominately white, middle class study population. Thoughtful medical practice ideally needs to attend to the broad environmental contexts of patients and help them find resources to diminish the sources of toxic stress. But that requires knowing the patient, not an ACE score, in my view.

I agree 100%. Certainly child abuse and neglect are more common in deprived socioeconomic circumstances which is why I have devoted much of my life to political and social justice causes, but other contexts are important as well. For instance,child abuse is more common in military and law enforcement families. Certainly creating a healthy environment and community is the best medicine. The cost benefit calculation for eliminating disparities is far superior to what we spend on medical technology. Medical services are mostly just band aids on the vagaries of life.

Also an ACEs score or answer sheet is like every piece of medical data: it has to be seen in context and its impact is always refined by knowing the patient. If you give me an EKG or a chest X-ray I can tell you about the implications of its abnormalities, but treating the problem starts with knowing the patient.

This is an important conversation. One could easily argue (I have) that the traditional ACE measure is insensitive to many contextual factors that relate to race and racism, economic disparity, segregated communities, historical and generational trauma,  unequal community resources and more. After all, it was developed with a predominately white, middle class study population. Thoughtful medical practice ideally needs to attend to the broad environmental contexts of patients and help them find resources to diminish the sources of toxic stress. But that requires knowing the patient, not an ACE score, in my view.

@Marie Archambeau posted:

We learned in medical school to ask about psychosocial factors for behavioral and many somatic health problems that come to the clinic. The PHQ-9 is a way to sell SSRI medications to children (and we never talk about the potential problems like irreversible sexual dysfunction, suicide YES Suicide, and over time Tardive Depression and physical dependence due to receptor changes on the post-synaptic nerve cell).  We could use better education on how experience leads to physical and psychological concerns but we DO NOT need to have a score like this on the chart associated with a child who cannot consent.  

I think your concerns require a technical type response. As a practicing family doc with 30 plus years experience, I know that the PHQ was developed with aid from Pfizer (which in my opinion often behaves more like a sovereign nation than a corporation), but sadness, melancholy and depression do exist and in a busy practice a screen helps raise an issue that otherwise might be missed. My experience is that medications do have their place and can be dramatically helpful, but in my office therapy began and depended on psychodynamic personal counseling (of course, or else I would not be the kind of doc to participate in this forum). My own personal clinical judgment is that more kids died by suicide once RX use was curtailed than would have died if meds were used more liberally. Also I am not familiar with Tardive Depression - any depressed person may be lethargic and withdrawn. Also as far as physical dependence goes I assume you mean the dysphoric feelings coming when RX is discontinued - that surely happens and clinically more with some meds than others, but  it is worth the risk if the meds have provided benefit and is easily managed. The point is that good medicine requires compassion, sensitivity and judgment and not global rejection of any or some possible techniques or therapies.

Also, it is “Toxic Stress” that creates biological effects - Not specifically or only the 10 components of the ACE Score. 

@Jeoffry Gordon posted:

Since you brought it up I have reviewed Anda's article and lecture. From a technical, research and scientific point of view he is quite correct. Parenthetically, his analysis would be applicable to many commonly accepted medical lab tests and endeavors. For example my lab reports kidney functions including commonly BUN and GFR. The lab may give normals by race but they are never adjusted by age although these tests do normally decline on average by age. Also throughout all clinical medicine a good doctor knows the literature, but average or statistically significant results never apply to the person before you. Did you know that a doctor has to treat 2000 healthy people with high cholesterol for 5 years with to avoid 1 heart attack? I would present the information to the patient before me in this fashion. Tests and screens do convey information that can be used in helpful judgements. That is the art of medicine.

The trouble with Anda's argument is that as he points out, the experience of adversity in childhood can have an impact on health throughout the lifespan WHICH IS CURRENTLY UNDERAPPRECIATED AND NOT SCREENED FOR throughout medical practice. The relatively recent adoption of almost universal screens for depression (PDQ-9) in the office and domestic violence in hospital ERs show the importance of screening activities to identify possible risks to mitigate them.

We learned in medical school to ask about psychosocial factors for behavioral and many somatic health problems that come to the clinic. The PHQ-9 is a way to sell SSRI medications to children (and we never talk about the potential problems like irreversible sexual dysfunction, suicide YES Suicide, and over time Tardive Depression and physical dependence due to receptor changes on the post-synaptic nerve cell).  We could use better education on how experience leads to physical and psychological concerns but we DO NOT need to have a score like this on the chart associated with a child who cannot consent.  

@Angelina M. Gutierrez posted:

To be super honest, "evidence based practice" is typically geared towards White, Western beliefs/ideals/traditions, and quite honestly do not fit well with BIPOC (Black, Indigenous, and other People of Color) populations for a number of reasons. Evidence Based should not be the only type of treatment deemed important or valid; THAT in my opinion would be harmful: forcing people to fit into a box that is not meant for them to fit in.

In these times when the masses are marching for systemic change, we as practitioners need to also allow that to transfer into our field, too. In my opinion, JAMA is just another oblivious, tone deaf entity that needs way more than a few diversity inclusion trainings a year. They too need an overhaul of their leadership/system, and to WAKE UP. 

I totally agree

To be super honest, "evidence based practice" is typically geared towards White, Western beliefs/ideals/traditions, and quite honestly do not fit well with BIPOC (Black, Indigenous, and other People of Color) populations for a number of reasons. Evidence Based should not be the only type of treatment deemed important or valid; THAT in my opinion would be harmful: forcing people to fit into a box that is not meant for them to fit in.

In these times when the masses are marching for systemic change, we as practitioners need to also allow that to transfer into our field, too. In my opinion, JAMA is just another oblivious, tone deaf entity that needs way more than a few diversity inclusion trainings a year. They too need an overhaul of their leadership/system, and to WAKE UP. 

@Craig McEwen posted:

I would hope that you post the rebuttal on ACEsConnection or a link to it so that we have the benefit of your analysis.  I, for one, found Dr. Campbell's critique of ACEs screening in JAMA to be thoughtful and very much in line with Dr. Robert Anda's sharp critique of the use of ACE as a screening tool in the American Journal of Preventive Medicine (see https://www.sciencedirect.com/...ii/S0749379720300581; a video of Anda speaking to these issues is also available at https://www.pacesconnection.com...23-min-ace-interface .

Since you brought it up I have reviewed Anda's article and lecture. From a technical, research and scientific point of view he is quite correct. Parenthetically, his analysis would be applicable to many commonly accepted medical lab tests and endeavors. For example my lab reports kidney functions including commonly BUN and GFR. The lab may give normals by race but they are never adjusted by age although these tests do normally decline on average by age. Also throughout all clinical medicine a good doctor knows the literature, but average or statistically significant results never apply to the person before you. Did you know that a doctor has to treat 2000 healthy people with high cholesterol for 5 years with to avoid 1 heart attack? I would present the information to the patient before me in this fashion. Tests and screens do convey information that can be used in helpful judgements. That is the art of medicine.

The trouble with Anda's argument is that as he points out, the experience of adversity in childhood can have an impact on health throughout the lifespan WHICH IS CURRENTLY UNDERAPPRECIATED AND NOT SCREENED FOR throughout medical practice. The relatively recent adoption of almost universal screens for depression (PDQ-9) in the office and domestic violence in hospital ERs show the importance of screening activities to identify possible risks to mitigate them.

Thank you for sharing this. I would also appreciate if you could share your response. A concern about ACEs came up recently with a student of mine, and I'd love to be able to share both sides to create an opportunity for some critical reflection.

I read a book "Murder by Decree.  The crime of Genocide in Canada."   Actually quite terrible.  I don't think that doctors should be asking parents these questions.  If doctors do.... I would advise my daughter not to answer.   This seems to me like a way that the state could get ahold of children or maybe decide who is fit to have kids and who is not.  

I would hope that you post the rebuttal on ACEsConnection or a link to it so that we have the benefit of your analysis.  I, for one, found Dr. Campbell's critique of ACEs screening in JAMA to be thoughtful and very much in line with Dr. Robert Anda's sharp critique of the use of ACE as a screening tool in the American Journal of Preventive Medicine (see https://www.sciencedirect.com/...ii/S0749379720300581; a video of Anda speaking to these issues is also available at https://www.pacesconnection.com...23-min-ace-interface .