Great Biochemistry Class at Amherst College October 4,2012

Thanks for all the questions. Did Dr. Felitti have time to answer them all?? Also, there's a reference to a book in question 3 (asking about p. 79). To what book are you referring? 

It might be useful to copy and paste the info in your comment into a regular post that will appear on the main page. That way more people would see it! Let me know if you'd like to do so.

Cheers, J.

In response to a request from Jane Stevens, here are the questions that our students at Amherst College came up with. Would appreciate any responses that people would like to offer. Also, this is a community-based learning course, so the students will break into groups and do final projects that engage with community partners. I'm sure that some of the projects will deal with efforts to prevent ACEs, incorporate the study into clinical practice and public health, etc. Thanks.  RA

Presentation/Discussion with Dr. Vincent Felitti

Amherst College Biochemistry 330

October 4, 2012

1. Introductions, and Presentation by Dr. Felitti. (60 minutes)

2. A structured time for discussion of questions in the following areas. At the end of each section, a student will summarize what they heard, and we'll move on, with 10 minutes per section (Total 40 minutes):

A.  ACE Study design questions  

B.. How to integrate the results into clinical practice
C.. How has health care practice changed since the study, such as education of doctors as well as a wide variety of people providing health and human services.
D. How does your work take into account the work on stress by Bruce McEwen and others?

3. Open discussion and wrap-up. (20 minutes)

Questions Organized by Section

ACE Study design questions

1. How would you alter the study to incorporate the number of incidents within a category as well as their severity?
2. Can you speak more about the impact of gender and what differences in the medical and symptomatic manifestations you have found between the sexes?
3. On page 79 of your new book, you list the ACE categories that were tested for in the questionnaires of the ACE study. One of the factors was “not raised by both biological parents,” which can occur in different permutations. Do you think that children adopted at a young age by capable and nurturing foster parents, or children of gay couples (biologically related to one or neither of the parents) have a similarity to children raised, say, in an orphanage that goes beyond the surface level differences?
4. If not, you say that the ACE categories are strategically broad, where an ACE is constituted by any number of experiences in a category. Devising a survey this way will, as you mention, underestimate the correlation between higher numbers of adverse experiences in one ACE category. Is there any value in trying to heighten the correlation by creating subcategories within each ACE? We recognize the severity of an ACE or its frequency during childhood varies, and with the example above we can even say that some “ACE-positive” responses might not be measuring adverse experiences.
5. Why is it useful to write questionnaires with such broad categories and Boolean (y/n) answers for each?
6. First, I found the study very thorough and quite convincing on both a scientific level and, if you’ll permit the phrase, a common sense level. But I wondered to what extent the study results were influenced by the study’s inclusion only of people with health insurance. You mention that you used statistical analysis methods to adjust for effects of age, race, sex and educational attainment, and that, for various reasons, the study may underestimate the actual prevalence of ACEs. Did the study take place solely within the Kaiser Health Plan for ease of sampling? If so, how do you think a wider sampling of the non-insured population would compare with your results in the study? 
7. Because people can have very different backgrounds such as race, culture, and gender, I believe that a similar experience can have different impacts on people. One type of ACE may affect certain people more than others. How can this be taken into account in ACE studies? 
8. My first question concerns the use of the ACE Score in the study. The ACE Score seems to take into account the number of categories that the subject replies ‘yes’ to, and equates these experiences to generate a general number. I understand that not distinguishing between the experiences allows the study to easily compare subjects across categories, but it strikes me that certain influential factors may be being overlooked. For example, would there be a way to create an ACE Score that also considers duration of experience, age at experience, and/or intensity of experience? The last factor seems especially relevant, since not all of the ACES included in the study induce equal amounts of stress.   
9. As one of my other classmates had mentioned and looking back at what I thought was curious about the original ACE case study, I, too, wonder whether there was a reason as to why it was just assumed that subjects who did not report a certain ACE in some categories was simply considered as not having been exposed. Was there consideration of it being the other way around in that those who did not report an ACE were just uncomfortable with reporting it or something similar?  If they were considered to have been exposed, do you think the correlations would change significantly?
10. Quite a number of people have brought up the question of race playing a possible role in this study. Again, I am curious about that relation. I am also interested in a cultural aspect. In contrast to race, was culture something that was possibly considered as having an effect on the study? For instance, there are some cultures in which “humiliation” is a way of bring up a child (and I am speaking from an Asian upbringing where I had been humiliated many times as a child but do not see myself as having experienced an ACE). I am thinking about this mostly in terms of those coming from immigrant families, where one generation has grown up with a different cultural background from that of another generation (for example, immigrant parents versus their “Americanized” children). 
11. In another class of mine, we've been talking a lot about the use of surveys to determine the prevalence of mental illness in the general population. A major problem we've discussed is the balance between the consistency of presentation of the survey and the contextualization of symptoms. More specifically, if a survey's questions are very rigid, it loses the room for interpretation and the survey-giver cannot try to contextualize the symptoms as a doctor would. In the ACE study, the surveys were not overseen in any way-- how do you think this affected the results, especially given that patients are completing the survey retrospectively?
12. How do you think socioeconomic status and race play into the ACE results? It seems that lower socioeconomic status is closely associated with higher exposure to many of the risky behaviors described in the study-- for example, there have been studies showing that the diets of people of lower socioeconomic status tend to have much more calories, often for the sake of saving money. Do you think there's a way of untangling these different factors that play in to later health-- or do you think they would be best addressed as a cohesive unit?
13. You said that the study matches the ACEs retrospectively approximately 50 years after the fact. Would that, along with the problem of amnesia and dissociative responses skew the data?
14. The population surveyed was 80% white, all individuals had health insurance, and the average age is 57 years. There are many individuals who do not fit within this description, so how can we think about the wider applicability of the findings in the ACE study?  
15. Regarding the original ACE study, what was the reasoning for assuming that people who did not fill in a category of childhood exposure did not have an exposure in that category? I would imagine that if someone did not fill in a section of a survey that it would make more sense that they were uncomfortable filling out that section. Maybe the correlation between ACE’s and adult health risks might be even greater if the assumption was reversed.
16. My second question was sparked by a response that one of my fellow classmates posed. How do you think race plays into the ACE study? Do you think that it plays into the relationships presented in the ACE study? How do you think the data would look different if the racial samples were more equal or contained more minority individuals?   
17. A movie we watched recently, Stress: A Portrait of a Killer, presented the results of the Whitehall study showing that individuals ranking lower in a hierarchy experienced considerably greater levels of stress. Has there been any research addressing how ACEs affect individuals from different socioeconomic backgrounds? I think it would be very interesting to see if the long term disease rate differed significantly among ACE survivors of differing socioeconomic classes.
18. The study also discusses how coping mechanisms like smoking can increase risk for certain diseases. Has there been research about the effects of having positive and healthy coping mechanisms and to what extent they can reverse the risks from ACEs?
19. I know the motivation for this study was from personal observation. After conducting it and compiling all the information, was there anything that really surprised you about the correlations you found? For example, a correlation that you didn't notice through observation. 
20. Dr. Felitti, thank you for taking the time to meet with us. In terms of tallying the ACE Score, was there a significant reason as to why you chose to score only once for multiple incidents within a category? I realize that this will ultimately prevent overstating the effects of ACEs, but I feel as though having  exposure to multiple incidences of, for example, drug abuse would be significantly greater in damage to children than one. Was this tested in any way and if so, what were the results?
21. Another question that I have is if you have any theories as to why depression affects women more so than men, specifically in your ACE study. In Fig. 8.1a, women appear to have a significantly higher rate of lifetime history of depression as compared to the men across all 5 ACE scores. This suggests to me that perhaps women in general are just more prone, perhaps genetically, to depression and depression-like symptoms, but I am curious if there was any study done to see if ACEs biased sexually more against women than for men. Also, because the gender breakdown is shown in the book for only the depression aspect of the study, I am also curious as to what the gender breakdown is like for the other aspects such as suicide rate, prescription rate, and drug abuse. (Though I expect the suicide rate gender breakdown to be very similar to that of the depression rate gender breakdown.)

How to integrate the results into clinical practice

1. My first question is a question that was posed to the class. Given the correlations between adverse childhood experiences and large health problems, how do you propose a practical way for this knowledge to be use and incorporated into doctor’s daily interactions with patients.
2. I also think part of this issue of how best to serve the people comes from the physician’s ability to care for the person rather than the patient. I'm currently taking a sociology class called Drugs and Society where we are discussing the disconnect between psychotherapy and pharmacotherapy seen among many psychiatrists. Most if not all psychiatrists today are seeing patients in short 15 minute sessions, prescribing pills that best fit the symptoms of the patient without giving the patient therapy in conjunction. The effectiveness of such treatment, quickly prescribing meds and leaving the less profitable therapy for psychologists, is a question that can be extended to our situation. Once we more fully understand a patient’s history in terms of ACEs, how do we want to then go about caring for the person? Is it just a survey that we give once and forget about? Is it what the study did? Is it hiring a psychoanalytically trained psychiatrist to sit outside the doctor’s office to lure misunderstood patients into divulging their feelings post doctors visit? Physicians with knowledge about their patients ACEs have a lot more power and a much deeper understanding of how these past experiences might be affecting their current state of health. And with that comes an obligation to use this information to help the person, rather than ignoring it or leaving it up to them to go seek a counselor if they feel they need one. I'll quote Spiderman here: With great power comes great responsibility.
3. This question reaches into philosophical arguments about what healthcare means and what it looks like in real practice, but I think it's worth thinking about.
4. The first question that I had was, how can ACE studies be used in practice? Because ACE studies have found so many connections between health problems and ACE, incorporating such knowledge in treatment would have a very significant effect. But would the patients be willing to talk about their personal stories? Should the doctors have the responsibility in such aspect, or would it be more effective to have different health professions be involved? 
5. Do you encourage your patients to engage in talk therapy?  If so, has visiting a psychiatrist helped in the treatment of their physical illness? 
6. The ACE study lists primary, secondary, and tertiary prevention strategies for ACEs, which all need to occur in order to eliminate ACEs and also change health risk behaviors. What is your opinion on the role of the physician in treating health problems related to ACEs while still maintaining doctor-patient boundaries?
7. Hi Dr. Felitti:  Overall, I thought the article and study was extremely insightful. You started, “The very nature of the material in the ACE study is such as to make most of us uncomfortable. Why would a physician or leader of any major health agency want to leave the familiarity of traditional biomedical disease and enter this area of threatening uncertainty for which none of us have been trained?” I was just wondering what role do you see do doctors playing based on these findings? 
8. I spoke to how medical schools and practicing physicians might incorporate this study into their daily work above, but for hospitals and clinics I think giving a survey like Kaiser Permanente did would be a good first step. After patients have been engaged by the survey, their information could be reviewed by their physician (who would have knowledge about the study because it was part of their license renewal) for a more informed treatment and a more effective doctor’s visit for the patient. Ideally this would lead to a more honest and effective patient treatment system. 
9. As Christina similarly mentioned, given the apparent "benefit of having...the worst secrets of one's life understood by another," who do you think should be responsible for taking advantage of this revelation? You suggest a paradigm shift for primary medical care, but do you think that primary care doctors should be responsible for discussing these issues with patients, or do you think such patients should be referred to psychiatrists, or perhaps, should a new field be formed to address these new findings? It seems to me that the need for enough primary care physicians and their current lack of training in dealing with the ACE results would not make them ideal for helping patients cope with ACE’s, but forming a new field or introducing new training would take too long to help people in the next few years.
10. In conjunction to my previous question/group of questions are there patients who are already going through therapy or taking medications that seem to improve? At a certain number of ACEs does it not make a difference anymore?

5. My first question was already echoed in previous posts, but I still find it an interesting point to reiterate.  Are the euphemisms used to describe dangerous coping mechanisms part of the reason why these coping mechanisms are adapted in the first place? For example, staying that "I need my fix" to refer to alcohol or a drug hit, and "I need a cigarette to calm down". Are these, almost colloquial terms, part of the problem why these short- term coping mechanisms become acceptable in the first place? Do we need implement a change in the language to address this? 
6. Some  of  the ACEs that you  describe are commonplace for people of some socioeconomic background, many of whom would deny being affected by these factors. Do you believe that all individual with ACEs should be administered care , even if they deny being affected. Do you think there might be a danger to such denials?
7. How have ACEs and coping mechanisms shaped our language? I found your point on language especially intriguing; for instance you cited several phrases such as "I need a fix" and "Eat something, it will make you feel better" that reflect coping mechanisms but are also used colloquially.  Has our language changed to reflect social acceptance or dependence on these mechanisms? 
8. You cited that women have a fifty percent higher chance of experiencing an ACE than do men; what are the implications for how we treat ACEs given the gender disparity amongst those affected? How sensitive is the biomedical paradigm to gender?

How has health care practice changed since the study, such as education of doctors as well as a wide variety of people providing health and human services.

1. For students entering the medical field with a knowledge of this study and an understanding of the lifelong consequences for the individual as well as the whole community, what is your advice on how to incorporate this information into our studies in medical field and further down the line, how to incorporate this into daily interactions with patients?

2. In relation to the previous question, what do you think are the necessary next steps for medical school, hospitals and clinics to take to effectively incorporate these findings into their methods and practices?

 3.  I think that “psychosomatic” in the medical sphere probably has a negative connotation as an illness or symptom that can be alleviated if someone just “changes their mind.” Of course, the mind can’t be changed so easily (hence clinical psychology), especially in cases where abuse or trauma comes into factor. Do you think the word is relevant when talking about effects of stress on the body in the ACE study, or is it too tainted in common use? More broadly, how can we start training medical personnel to recognize some symptoms as ACE-related, when not all symptoms are related?

4. I was interested in hearing your thoughts about David Brooks’ recent Op-Ed in the New York Times that referenced your article. His conclusions, though obviously less rigorously scientific, made me wonder about the ACE study’s policy applications. Brooks writes: “When you look over the domestic policy landscape, you see all these different people in different policy silos with different budgets: in health care, education, crime, poverty, social mobility and labor force issues. But, in their disjointed ways, they are all dealing with the same problem — that across vast stretches of America, economic, social and family breakdowns are producing enormous amounts of stress and unregulated behavior, which dulls motivation, undermines self-control and distorts lives.” I agree with his basic premise, that psychological trauma negatively affects society at large in an incredible variety of ways. And the implication seems to be that we should address these concerns, though he leaves unstated how exactly to do so. Do you have any suggestions for specific ways of incorporating the ACE results into policy decisions, as Brooks suggests?

5. Should there be more integration of biomedical and psychosocial studies in the earlier education of doctors and other health professionals? By introducing the effects life experience can have on physical health, do you think professionals will be able to approach their further studies through this lens?  

6. One problem that our class has been struggling with is coming up with practical solutions to incorporating the results of these studies into medical care. Could you provide a succinct plan or several small steps that would effectively use your work to change how healthcare providers consider and treat patients and would not require large changes to the current system? If possible could you also elaborate on how, if feasible, this plan would be instituted on a national scale? 

7. It seems that one of the possible steps to using information gained from the ACE studies is to incorporate what is learned to the treatments of patients. However, where the line should be drawn in terms of when it could be too personal or just simply “too much information” seems like it could be of quite some debate. Also, when it comes to medical school, should students be trained to handle or deal with patients who have had ACEs? Or should that completely be left for specialists (such as therapists, psychologists, etc.) to handle? Just how much training should medical students get? 

8. The ACE study was published in 1998. Since then, what kinds of changes have you seen in the medical field that takes the study into account? Are you satisfied with these changes? Would you prefer different or more extensive measures had been taken?

9. You talk about the need for a social paradigm to talk about the "taboos" of ACEs- but what specific measures would you recommend do enact this social paradigm? You mentioned training doctors to talk to patients but there is a shortage of doctors for them to devote enough time to patients. How would doctors even broach the subject- would every patient be given the survey? Could these patients be referred to psychologists instead?

10. I am curious about the “reversion to prior baseline” in hospitalizations and doctor visits. Do you think that people will naturally need continual communication and help with dealing with their ACE’s? Or do you think that since the method of addressing the ACE’s is new and relatively crude (simply asking the patient to say how the ACE affected their life), a better one can be made in the future where there is no reversion?

11. You also state, “The findings of the ACE Study provide a credible basis for a new paradigm of medical, public health and social service practice that would start with comprehensive biopsychosocial evaluation of all patients at the outset of medical care.” Do you see this solution as being practical, as this could be extremely costly?

12. The ACE study is significant in two ways. It has a striking message about the impact of traumatizing experiences as youth, and it was performed on 17,000 people. These two together lead me to believe the ACEs study is comprehensive enough to stand on its own. I think at the very least it should be integrated into the general medical school course curriculum so that students are reading the study in their classes. Past medical school, this should be information disseminated to all physicians and those involved in the medical field. I think an effective way to do this would be to incorporate the findings of the study into the license renewal procedure for practicing MDs. This way in order to continue to practice, MDs will have to have knowledge about this important study.

13. One of the most important, and often most effective, measures used to stop the spread of disease is prevention. Given all that you and your colleagues have found about the correlations between ACEs and health problems in adults, what sort of preventative measures do you think are most effective at avoiding ACEs and their effects? 

14. My question to Dr. Felitti is whose responsibility is it to begin the change in philosophy about how clinical medicine is done? Should it be entirely the responsibility of the physician or the hospitals or the government to get the ball rolling on new treatment practices? There are a lot of traditional practices and techniques that are going to require changing that not everybody is going to be ready to go forward with.

15. Now that this groundbreaking study has been out for some years, have you any new insights concerning the better modes of coping with the various ACEs presented in the paper and their improvements on adult health? Since this paper's original release, have you personally seen change in the doctor-patient relationship? Have doctors become more involved with patients as to uncovering ACEs and finding a way to help their patients cope with their experiences? 

How does your work take into account the work on stress by Bruce McEwen and others?

1. My second question concerns other studies that our class has considered such as “Adverse childhood experiences, allostasis, allostatic load, and age-related disease” by Dr. Danese, and Dr. McEwen, and “Protective and Damaging Effects of Stress Mediators” by Dr. McEwen. These studies specifically focus on the biological and biochemical effects of elevated levels of stress, and both point out elevated levels of cortisol as a product. I was wondering if you would ever consider extending the ACE Study to include biological samples as well as questionnaires, and perhaps include tests for levels of cortisol and other hormones.

2. In a video interview we watched with a man who had gained weight, was it the realization that his ACE was associated with his weight gain that helped him lose the weight for good? Does that apply to the rest of patients? In the book, you also mentioned the role the doctor plays as "enlightened witness" in helping the patients tell their ACEs to a trusted source. In doing that, patients would need less visits to doctor offices and emergency departments but after two years, they would revert to the prior baseline of visits. Thus, there seems to be only a temporary correlation between the recognition and confession of ACEs to self-harmful actions- how would you make these recognitions "stick" and last beyond one year?

3. After reading your study, I wanted to know if the increased risk of disease among patients with many ACEs was due to a biological/biochemical change in response to stress (such as increased cortisol levels or a decrease in telomeric DNA) or due to individuals taking part in risky behaviors (smoking, alcohol, drug use) as coping mechanisms. Are there any plans to control for these variables and see which one yields a stronger correlation? And do you think it could affect patient care if one of these variables was more of a factor than the other?

4. Dr. Felitti, you mention a relationship between ACE score and later hallucinations.  While you correct for drug and alcohol abuse, you do not explain the cause of such delusions.  What did these hallucinations stem from?

 5. I am intrigued by the relationship between ACE score and miscarriage.  Are there steps that health care practitioners can take in order to address a patient's mental health and to help her to carry to term?

6. Of the treatment strategy and intervention program changes that resulted from this study's findings, what have you found has been helpful in preventing ACEs and in treating those you have experienced ACEs? Has a specific type of intervention been more beneficial than others (1-on-1 therapy, support groups, treatments for symptoms, e.g. nicotine supplements)  in the coping process?

7. While it's apparent that the more ACEs you have, the higher propensity for certain types of diseases you will have, have there been any outliers to this research? Those who have more than 3 ACEs, but do not present with coping mechanism such as smoking, who will then in turn not having cardiovascular or weight problems? Also when thinking about those outliers have you started, are you considering started, have you looked into trends on why they don't present with symptoms such as the other people (in relation to trying to find a way to help those that have the coping mechanisms already in place)?

Thanks for the update, Richard. I wondered how it went. I'm definitely interested in their questions. Will you post them? Also, did anyone take a photo? And what will the students do with this information? 

-- J.