PUBLIC HEALTH

Public Health Update

ACEs: The Quiet Cause

By Gwen Callaway, MPH, Todd Davenport, PT, DPT, MPH; and Maggie Park, MD

The story of one of the biggest breakthroughs at the intersection of public health and clinical care began in the 1980s at an obesity clinic in San Diego. Dr. Vincent Felitti wanted to know why nearly half the patients in his program dropped out even though most of them reported successfully losing weight. He found that the majority of the nearly 300 people he interviewed had suffered sexual abuse as a child. As a result, he theorized that their weight gain may have been a coping mechanism for mental health illnesses resulting from unresolved childhood trauma. Later, he launched a landmark study at Kaiser identifying strong associations between health challenges in adulthood and childhood adversity.

(Fig. 1: CDC)

Today, these are known as adverse childhood experiences (ACEs) which are potentially traumatic events or circumstances that occur during childhood and adolescence and are broadly grouped into three categories: abuse, neglect, and household dysfunction. These experiences may include sexual abuse, domestic violence, parental substance abuse, divorce, incarcerated relatives, discrimination, neighborhood violence, food or housing insecurity, intimate partner violence, or being in foster care. The effects of these events build upon each other and lead to toxic stress within the body that inhibits proper brain development, changes gene expression, unbalances the endocrine and immune systems, and increases the incidence of chronic disease. The number of categories of ACEs (ie. a person’s ACE score) is positively associated with the frequency of ischemic heart disease, cancer, chronic lung disease, skeletal fractures, liver disease, obesity, depression, and drug abuse. There is even growing evidence that long-term exposure to toxic stress can alter DNA structure. For children, these physiological changes translate to a higher likelihood of being disengaged from school; having social emotional challenges; adopting health risk behaviors; developing any number of chronic diseases, and therefore missing out on opportunities for education, employment, and income.

ACEs also occur more often in populations with greater socio-economic disparity. It has been estimated that 15 to 20% of the association between a person’s number of ACEs and their adult health risks are actually attributable to their socioeconomic conditions. In one particular study, the health effects of three ACEs (exposure to domestic violence, parental divorce, and residing with a person who was incarcerated) were entirely explained by an individual’s socioeconomic position in adulthood. This is further evidence of the close interchange between ACEs and the conditions in which a person lives, works, and plays.

Compounding this issue, parents can pass on the effects of their own ACEs to their children. In one study, each additional parental ACE led to worsening overall health status, increased rates of asthma, and increased excessive media use among children. These effects are cumulative so, for example, in the case of a parent with 6 or more ACEs their child is at greater than six times the risk of developing asthma.

But there is good news when it comes to combating the deleterious effects of ACEs on a child’s growth, development, and future– and it starts with the provider/ family relationship. Data from the National Survey on Children’s Health 2016 (NSCH) tells us that children with

two or more ACEs whose parents report that their child’s healthcare providers “always” listen, spend the needed time, and give needed information are more than 1.5 times more likely to live in families that practice four basic resilience skills. And there is evidence that those resilience skills can mitigate the effects of ACEs. According to the NSCH, children ages 6-17 years who have had two or more ACEs, but learned to stay in control when faced with challenges are more than three times more likely to be engaged in school compared to peers without those skills.

Providers can access various ACEs screening tools online where there are versions for parents, teens, and children with most taking the form of an approximately one page survey. Parents complete the survey on behalf of their children and a point is given for each scenario experienced. The point total is the child’s ACE score. Once the ACE score has been determined, discussing the results during the appointment is vital. The goal is to provide a safe space for families and to educate about trauma, its long-term effects, and feasible strategies to lessen them.

Broadly, one such strategy is to increase the number of positive childhood experiences (PCEs). These PCEs include the child having:

(1) felt able to talk to their family about feelings;

(2) felt their family stood by them during difficult times;

(3) enjoyed participating in community traditions;

(4) felt a sense of belonging in high school (not

including those who did not attend school or were homeschooled);

(5) felt supported by friends;

(6) had at least 2 non parent adults who took genuine interest in them;

(7) felt safe and protected by an adult in their home. As part of trauma-informed care, clinicians are encouraged to discuss positive parenting practices, connect children with mentoring and after-school programs, refer families to early childhood home visitation services, and help families set goals for themselves.

In a study of providers, the most often cited concern about screening for ACEs was the time constraints on appointments and being ill-equipped to handle a potential opening of the f loodgates of emotional trauma. However, after piloting screening programs, doctors have found these fears to be unwarranted and consider ACEs screening to be a powerful and informative tool. To that end, the ACEs Aware initiative, led by the California Office of the Surgeon General and the Department of Health Care Services, is training Medi-Cal providers on how to use ACEs and receive the $29 payment for each screening.

Locally, there have been some efforts to increase awareness of ACEs and trauma-informed care within the health care community. Last year, through a community grant from Dignity Health, the Child Abuse Prevention Council was able to collaborate with San Joaquin General Hospital pediatricians on their “ACEing Parenting” pilot project. Modeled on a program developed by pediatricians in Portland, Oregon, this program sought to boost provider confidence with screening and educate parents about their own ACE scores and how their childhood experiences could affect their parenting styles. In-home social support was provided, with parent coaching and activities to enhance parent-child attachment and bonding in an effort to mitigate abuse or neglect. These interventions strive to reduce the likelihood of intergenerational trauma.

Many community-based organizations in San Joaquin have been working to increase awareness around ACEs, both within their organizations and within the community. These efforts are now converging with the formation of a coalition led by St. Joseph’s and Reinvent South Stockton. This initiative, focused on addressing ACEs and creating

Adverse Childhood Experiences Revised Questionnaire California Surgeon General’s Clinical Advisory Committee

Our relationships and experiences—even those in childhood—can affect our health and wellbeing. Difficult childhood experiences are very common. Please tell us whether you have had any of the experiences listed below, as they may be affecting your health today or may affect your health in the future. This information will help you and your provider better understand how to work together to support your health and well-being.

Instructions: Below is a list of 10 categories of Adverse Childhood Experiences (ACEs). From the list below, please add up the number of categories of ACEs you experienced prior to your 18th birthday and put the total number at the bottom. (You do not need to indicate which categories apply to you, only the total number of categories that apply.)

Did you feel that you didn’t have enough to eat, had to wear dirty clothes, or had no one to protect or take care of you?

Did you lose a parent through divorce, abandonment, death, or other reason?

Did you live with anyone who was depressed, mentally ill, or attempted suicide?

Did you live with anyone who had a problem with drinking or using drugs, including prescription drugs?

Did your parents or adults in your home ever hit, punch, beat, or threaten to harm each other?

Did you live with anyone who went to jail or prison?

Did a parent or adult in your home ever swear at you, insult you, or put you down?

Did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way?

Did you feel that no one in your family loved you or thought you were special?

Did you experience unwanted sexual contact (such as fondling or oral/anal/vaginal intercourse/penetration)?

Your ACE score is the total number of yes responses.

Do you believe that these experiences have affected your health?

Not Much Some A Lot

Experiences in childhood are just one part of a person’s life story. There are many ways to heal throughout one’s life.

trauma-informed strategies, is in its formative stages, but is anticipated to offer a broad community-wide vision, mission, and action plan.

Medical providers of any specialty can implement screening programs in their practices and initiate conversations with their patients about ACEs. A good place to start would be to gain some insight into yourself and calculate your own ACE score. Remember, ACEs are common! Studies have shown that the conversation with patients typically lasts 3-5 minutes, and it may take time to become comfortable triaging your visits. Consider learning more about motivational interviewing and visit the ACEs Aware website even if you’re not a Medi-Cal provider. Have resources and referral tools ready for patients with positive ACE scores. Even if you don’t go as far as gathering ACE scores from your patients, some validation of their experiences and the impact of trauma on their lives can be therapeutic. In the words of Dr. Felitti himself, “Asking and listening…was in itself a very profound form of doing.”

Figure 1: h ttps://www.cdc.gov/violenceprevention/pdf/ preventingACES-508.pdf (page 10/40)

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