How Can the ACES be Used in Primary Care?

The biggest problem that we have here is that there is a stigma towards many of our patients. This is especially apparent for those patients who are poor and who seem to live a chaotic life or who may have mental illness or addiction. There seems to be a strongly held belief that these folks are lazy or are other negative adjectives.  We have many patients here who have high levels of childhood adversity as the community has high levels of rural poverty.  Many of doctors and the social workers really look upon the behaviors that these patients exhibit in a negative way. The patients can sense that. I hear them express their pain from these experiences often to me in the clinic. For example I spoke to a women whose husband was a doctor in the area (many years ago when I was working in another state) about her experience. She told me about her brother. He is on disability and he drinks excessively due to the abuse suffered in childhood. He was drinking and got on a bike and fell and suffered  a laceration  that needed sutures. She took him to the ER and the doc said something like maybe next time you'll learn better. The nurse told the ER doc that that this man was the brother a local physician’s wife. All of the sudden the ER doc changed his attitude which understandably made her very upset.  I see this all the occurring frequently. My colleagues are often negative to our parents who have very chaotic and stressed lives (primarily those on Medicaid) and they have no understanding of trauma.  I will routinely see moms that get into the office but they are 30 minutes late. This puts me at odds with my colleagues because they have suggested to me that I am encouraging these patients to be irresponsible by seeing their children.  

I have tried to explain that in these families there can be multiple factors at work such as poor transportation access, self-esteem issues and anxiety that may make it difficult for some parents to get to the office on time or or the parent may skip the visit altogether.  I don't believe in this idea that we need to "punish" and let the parent know of their alleged irresponsibility.  Sure I know that it makes the schedule more difficult  but this lack of understanding is difficult for me to have to observe. It is harder to try to explain when it then looks like I am taking sides with "irresponsible" people.  I have often been ostracized for disagreeing with what my colleagues would like to make policy (if you are 10 minutes late, reschedule).  However insured patients are often treated differently—there was an accident that made me late, the roads were bad and everything in that case is okay.

I see this attitude in the OB unit also. I have seen our physicians laugh at some of the complex psychiatric issues the patients have. One mother had an obsession with eating foam out of a couch (she had a terrible trauma history) and as we were discussing the monthly “complex” cases this was mentioned and the whole group started laughing. I didn't laugh. To me hearing this was actually personally rather painful. 

Also the patients that are "drug seekers".  There is a very significant lack of understanding of these patients.  They are often described as annoyances for the day.  An understanding of how trauma affects behaviors could really make a difference in giving these folks the compassion they truly need, compassion that may be the first they have ever been given. I know compassion would be more likely to lead to  a path to healing for these patients than that of punitive and judgmental statements and mindsets. Healing is why we went to medical school. Changing attitudes is a steep uphill battle. 

So it is really a change of mindset that is needed. How to accomplish that, I don't really know.  I just know that changing the mindset and looking at people with an understanding of the trauma's they  have experienced is incredibly important.  Though this is very tricky I keep trying.

Excellent!! I do things very similarly and it works really well. 

I don't want to respond because I don't want to be judged but I am going to anyway because this is too important:

1. Low self-esteem is certainly the biggest problem (it is what I struggle with most). You can graduate from a top 10 medical school after this extreme depravity and poverty and the identity is still "I am worthless trailer trash". 

2. Anger is another big one. To survive you have to have a good anger box- with a very strong lock/frame/containment - you cannot show anger to the parents who are hurting you so you start to hurt yourself. As a kid I head banged a lot.  I am not nuts or crazy. This is a logical consequence of what very bad childhoods do to you.  You cannot show the anger you feel.  If you did your parents really do have the control and power to kill you. Society is not helpful either.  The teasing and bullying for being dressed in rags, the ridicule and the verbal attacks only make everything worse. I feel there are components of Power (others have it and are not using it wisely) and Control (you have none and whatever someone else decides to do to you, you have no say)..in some cases you not only are treated like a slave but your parents literally tell you that is what they consider you to be - their slave.

Many big people look down, beat and hurt you and never show compassion.  That creates a sense of self that is complete shame --- the only self you have is one of shame --with the associated low self-esteem and not just anger but for some, rage at the injustice. Please do not judge me (you likely wouldn't) I do that very well for myself.  

3. The somatic issues can be extremely startling -- my brother is a perfect example of this.   He remembers only very small fragments and pieces of his abuse.  When I discuss it, he dismisses me. It was unimportant. I can tell he remembers some but doesn't want to. .His face is melting.  Everything has been transferred to a "body that doesn't work"  he won't walk, use a spoon... almost as if he wants to go back and be a baby and the frightening delusions that "his face is melting and becoming deformed".  Unfortunately few have the understanding of what this kind of trauma can do to the mind. There is no one who is able in our rural area to slowly bring my brother out of this darkness and I fear this likely occurs to many people.  

But understanding ACEs can let someone know that what they went through was not normal and no one should have done this to them.   I first really got insight by learning what happened to rhesus monkeys in Harlow's Experiments.  Before that I just thought I was crazy and over reacting. Now I know this is a process -- long and arduous but having knowledge leads to a path. It also allows one to analyze How can we get others to understand the significance of this (I have likely paid at least 500,000 less in taxes as a pediatrician because of my low self esteem due to ACEs-- and obviously made less too).  That is embarrassing to say to and also fuels the low self esteem engine. However, the simple truth while leaving myself vulnerable, my brother who was working at Midland Dow and making 50,000 a year is no longer working and never will again, two younger siblings don't and cannot. And then there is the doctor who cannot shut up about aces and therefore in the medical field is brow beat down for working --probably too hard or in an inefficient manner ---to get others to understand why this is so important. 

Thanks, Donna.  The literature indicates patients with symptoms linked to ACEs and other forms of psychosocial stress are twice as numerous as those with diabetes, accounting for why I saw about 300 per year and yes, many were losing hope after an average of 3.5 years of illness.  Fortunately, nearly all can be helped substantially.

Wow! It must be so astonishing to a patient to be told you understand and they have "brain pain" as you explained it.  I bet many people at the end of hope, gained some light from being in your care, David.

Perhaps the ONE way that ACEs can be used clinically is that if the ACE score is significant, then the PROBLEM that the patient has as we see it, should be reframed into an understandable ADAPTATION from the patient's perspective as Dr. Felitti points out. By accepting the patient's problem as a normal and predictable adaptation to previous adversity, then we can approach the patient with a trauma-informed mindset that is more accepting, compassionate, and better able to convey that understanding to the patient. By avoiding condescending looks, tones in our voices, etc., for the patient who fails our best efforts to encourage better lifestyle behavior, we can then begin a healing conversation that ultimately should lead back to greater chances of effecting that lifestyle change.

Fascinating, David. Thanks for posting this. 

This question raises a range of responses in my head. I'll try to share them with you without being too random.

ACEs, as they exist as a specific questionnaire, should not be routinely used in a clinic setting since they have been validated primarily for research purposes.

On the other hand, the CONCEPT of ACEs should be routinely used in the clinic setting because they help us understand the many confounding issues that face us every day.

Adversity goes beyond the (9 or)ten categories that are typically used. In medicine, we serve the patient best by listening to THEIR story, not by defining the story we want to hear by creating certain categories. I have heard over three thousand stories of adversity in my years as a family physician and an emergency physician. In almost every case, the patient has appreciated my listening to their story and accepting them for who they are at that moment because of their background. In only a handful of cases, did individuals become disturbed or angry.

My typical approach has been guided by the patient; there was not "ONE WAY" that I did this. But some examples might be," We all experience stress in our lives - some good, some bad. Is there anything now that seems more stressful for you, or is difficult for you to deal with; how are your children? How comfortable are you in your relationship with your partner? Do you look forward to going to work each day? I suspect that bad things happened to you when you were younger that you wish wouldn't have happened. Can you tell me about that? Many people experience adversity in their lives. That might include things like parents who have alcohol or drug problems, divorce, separation, fighting among family members, physically hurting each other, calling names or yelling a lot; sexual behavior that wasn't good. Do you recall those types of experiences?"

I usually use the ACEs after a discussion about adversity. The actual score isn't of real clinical use except that some patients will say "all ten" when I go through the list. FOr the most part I say, "no wonder you are feeling the way you feel." Or, "The answer to your problem is very clear. You don't have to see any more consultants. You don't have to spend more money on exotic tests that are generally not revealing. It makes sense to me. You are NOT crazy. It is NOT all in your head; but it might be in your brain. Your previous experiences have left you with 'brain pain' and your brain is trying to be heard. There is help for you if you are ready to do the work. Etc."

Most patients thank me for helping them gain insight. THey wonder why their doctor hasn't told them about this. Or any other doctor, for that matter. I have seen patients who have seen more than fifty doctors from coast to coast looking for answers and I can give them the answer with about twenty minutes of discussion.

Letting them tell their secret, accepting them for who they are and where life has brought them, and giving them hope is, at least momentarily, a great relief. It is true that long-term recovery takes much more, but the few moments of time spent in the ED or the clinic to begin the process with a relatively short discussion, can turn whole lives around. It can save lives.

Yes, healing not in the one-off, "you're fixed" sense or even fully on the road. But healing as in the Relationship part of trauma-informed care (TIC). Alienation and disconnection from others (and even one's self) is not good for the immune system. This is why social animals, like humans, need to be and feel connected to one another. Being safely connected to each other is basically a species requirement for both the individual's and group's health. Every positive social experience (incl. a TIC approach w/ the PCP) contributes to the strength of the immune system as opposed to weakening it through disconnection. It may be clinically undetectable but it's in the direction we need to go in to not contribute to retraumatization. More the macroscopic view.

I'd like to respectfully challenge the idea that "connection" itself is healing.  Perhaps, for the moment, connection makes people feel better, but healing is a much larger issue. It means fundamental biological/neurobiological change that a person knows deeply and fundamentally -- leading to a more joyous existence.  For clinicians, bornforjoy.com, gives clear guidelines for diagnosing and treating the chronic neuropsychiatric disorders that result from childhood hurt.  This information is in the Science section.  Moreover, without healing these neuropsychiatric disorders, adrenalin-mediated neuro-endocrine-immunological stress that underlies addictions as well as the physical disorders so well documented in the ACE studies -- that adrenalin-mediated stress remains a constant threat to physical health.

"how can knowing the details of my client's ACE score improve my care to the client? …"

Compassionately listening to a patient's brief narrative creates a connection which helps to dissolve the alienation they feel about what has happened to them. Creating that connection has healing power.

Randall,

       The ACE score is a valuable tool in that it alerts us to look for "pathology" (i.e., Did the adverse childhood experiences cause damage? If so, what damage?).  My own work (detailed on my website bornforjoy.com) was with neuropsychiatric patients with serious life-long symptoms who -- when I took the all-important medical history -- told me of damaging childhood experiences. I learned from them.  First, how the experiences linked with adult psychiatric symptoms (3 distinct syndromes) and, then, how to treat those syndromes.  And treatable they are.  (Smoking, to address your specific question, allows immediate relief for agitated, depressed patients unable to get relief any other way.)

       The website includes a "health and healing" essay -- dense -- on how to understand our culture's hurting children but, more important to your question, The Science section, details 1) how to diagnose the syndromes using a modified medical H&P, then how to treat them.  The statistics are solid, and I think you'll find the supporting information (specifically detailing how to adjust 2 simple, straightforward medications) helpful.  Let me know if you have any problem accessing the information.  Sara Stalman

Dr. Clarke's answer below is certainly one I agree with.  I'd go down the same path with the observation that there is a Public Health Paradox wherein certain common public health problems are indeed that, but are often also solutions for the person involved, and few people are likely to give up their solution, particularly at the behest of someone who has no idea what is going on.  

For instance, everyone knows that the demonized 'crystal meth' (methamphetamine in crystalline form as opposed to being ground into a powder) is a major street drug in the US.  Interestingly, no one seems to remember that the first prescription antidepressant successfully introduced in the US in 1940 by Burroughs-Wellcone was methamphetamine.  It held that position for the next 18 years until the introduction of tricyclic antidepressants like Elavil.  Does it mean anything that the most commonly sold street drug has recognized antidepressant properties?  One thing it means is that it's a lot easier to say, "My kid is on drugs because of that dealer on the block" than it is to say, "My kid's buying antidepressants on the street."  

In that vein, one might then wonder WHY the kid is depressed.  Thus, the relevance of knowing the ACE Score as the lead-in to knowing what adverse childhood experiences were the antecedents to depression.  Equally important is not being misled by the presence of imbalances in brain chemicals that are associated with depression.  These are not causal.  They are essential intermediary steps in the expression of depression as a natural response to certain life experiences (that are generally not recognized for reasons of shame, secrecy, and social taboos).  

Effective treatment commonly depends on understanding what the core problem is, and not mistaking the most obvious manifestation for the essence of the problem. A more comfortable explanation of this point is an analogy to house fires.  In a house fire, the most obvious manifestation is the smoke billowing out.  If one did not understand the relevance of smoke to fire, one might think that the smoke was the essence of the problem.  After all, we know that people die of smoke inhalation.  Following that logic, one might conclude that the proper treatment for house fires would be large fans to blow the smoke away - except the house now burns down faster, and soon home owners flee the treatment.  Indeed, flight from treatment is common in addiction programs.

Thus, in treating many common problems like the various addictions or obesity, it is important to know what has led to their existence.  Our traditional approach to treatment of these problems has centered on getting rid of their disturbing aspects to other people, concealed by platitudes like, "Don't you know it's bad for you."  We enter a difficult game playing with half a deck, comfortably unaware of the personal benefits to the individual involved.  For a heavy smoker, lung cancer is twenty years away, but the psychoactive benefits of nicotine in terms of its anti-anxiety effects are twenty seconds away from inhalation.  Most of us have some sense that, if the screws are on tight enough, we will sell out the future to gain current relief.  If we really want to be effectively helpful, it is generally important to understand the core issues involved, not just their most obvious symptoms.  We no longer accept Fever as a diagnosis.  We want to know 'Fever due to What' so we can treat the 'What'.

Dr Reitz and I are colleagues and I have lectured twice on this subject at the CFHA meetings.  He raises the key question about ACES: what is the benefit to a patient of knowing this information?

The benefit, which can be considerable, derives from relieving the long-term psycho-social consequences of ACEs.  The two most fundamentally important of these consequences are low self-esteem and unrecognized anger about the ACEs.  A helpful initial approach to the first is to point out to the ACE survivor that a hero in our society is someone who has overcome a difficult mental or physical challenge for a good cause.  ACE survivors have done exactly that.  If they can view themselves in these terms they will move toward a reversal of the low self-esteem that is the most common legacy of ACEs.  This is of fundamental importance in reversing many of the negative health and social behaviors common in ACE survivors.

A helpful initial approach to the unrecognized anger is to ask the ACE survivor to imagine a child they care about growing up exactly as the survivor did.  (ACE survivors often struggle to recognize the magnitude of the difficulty they endured as children, until they imagine it happening to a child they know).  Then, when they feel ready, I ask them to write a letter (rarely mailed) to the person(s) who mistreated them, expressing their memories and emotions as completely as they can.

After these initial steps, counseling with a therapist who has interest and expertise in helping adult ACE survivors is an obvious follow-up.  

My experience with the above is based on detailed interviews with over 4000 ACE survivors referred to me for medically unexplained symptoms or refractory functional syndromes.  Not only did these typically improve in response to the above but I often noticed improvement in substance abuse (including tobacco), eating disorders, depression, anxiety and willingness to move on from dysfunctional personal relationships.  Self-care skills also tend to improve substantially.

A group of experts in treating the long-term somatic consequences of ACEs has collectively created the Psychophysiologic Disorders Association (PPDA).  Our website www.ppdassociation.org is due to launch in about a month (subject to delay of course).  We are offering a one day conference to teach treatment techniques (primarily aimed at mental health professionals but all are welcome) on Saturday, Oct 6, 2012 at the New York Academy of Medicine, co-sponsored by NYU.  (Registration will be via the website.)  There is also much more information in Chapter 3 of my book which you can read more about at www.stressillness.com.  (All earnings from the book and from my speaking fees are donated to the PPDA which is a 501c3 non-profit.)

Hi, Leslie -- I'm at the "Futures of Violence" conference in SF. Both Drs. Vincent Felitti and Bob Block were on a panel this morning, and will be this afternoon, too. I'll find them and ask them to answer your question.

You might also want to join the Primary Prevention of ACEs group or connect with its members -- one of them might know someone who's interested in answering, too.

Cheers, Jane

[I tried to post this on Friday, but it wouldn't upload....here it is, on Sunday, the day after the conference ended. Nevertheless, I'll ask Vincent and Bob to comment, if they haven't seen this already. It would be great if people could post their answers here. I'm sure there are others who'd like to know the answers to Dr. Reitz's questions, too!