[Ed. note: This post is in response to Dr. Jeoff Gordon's post about the American College of Preventive Medicine's position statement on ACEs.]
Responding with, and on behalf of, my co-authors Kevin Sherin, MD MBA MPH and David Niebuhr, MD MPH MSc.
Dr. Gordon, thank you for starting a conversation about our Open Access paper which includes the ACPM Position Statement on ACEs. We agree 100% that a national priority is preventing, mitigating, and treating childhood maltreatment as well as all forms of adversity across the socioecological spectrum. We also agree that the science of trauma and healing is a key part of medical education and practice. In fact, our paper begins, ends, and makes many points along the way to emphasize exactly that. It is intended to be a call to action. Here are some examples.
“Adverse childhood experiences (ACE) profoundly affect health and well-being across the lifespan1, contributing to significant morbidity and mortality2, and present opportunities to enhance prevention, mitigation, and treatment frameworks and strategies.3 Evidence is emerging that ACEs are both a cause and a consequence of health disparities.” 4,5
“…the high prevalence of ACEs and evidence of their deleterious effects onmorbidity and mortality as well as healthcare utilization and costs make ACEs a worthy target for prevention and mitigation strategies.” 2,6,7,9
“Health professionals have an ethical and moral responsibility to respond to health needs based on the best available evidence. ACPM accepts this responsibility and calls for evidence-based population and clinical measures to prevent and mitigate childhood adversity and trauma, as well as ongoing program evaluation and research that will either support or refute current position statements.”
The evidence-informed ACPM recommendations summarized below also align with the priorities you raise and are consistent with the recommendations of other professional and governmental organizations (AAP, AAFP, AHA, ASTHO, CDC, and USPHSTF). ACPM recommends:
- Population level surveys and research for ACEs and protective factors (e.g., positive childhood experiences) as well as for lifestyle, behavioral factors, and social drivers of health, such as CDC’s BRFSS.
- Sensitive trauma inquiry to explore adversity, trauma, and positive childhood experiences such as supportive relationships in adults/families/children in the context of therapeutic relationships and shared decision-making.
- Training all health care teams about the impact of childhood experiences on health across the lifespan and putting protocols and systems in place which support evidence-based trauma-informed, resiliency-informed, healing-centered care and referral for other indicated behavioral and social services, such as perinatal home-visiting and parenting programs.
- Public and private payer and health plan incentives for universal precautions, a trauma-informed approach, and appropriate evidence-based trauma-specific treatment for individuals with a history of childhood trauma and adversity
- Supporting state and county level initiatives to reach Healthy People 2030 goals to improve the health and well-being of children with evidence-based resources so children get timely developmental screenings, recommended health care services, as well as family, school, and neighborhood-level interventions, such as home visitation programs and parental interventions
- Funding research about prevention, mitigation, and treatment of adversity and trauma as well as about protective factors and positive childhood experiences that support development of health and resilience. This research may include development, implementation, and assessment of validated and generalizable assessment instruments as well as longitudinal intervention studies with a variety of study designs
- Conducting rigorous evaluation of full spectrum trauma-informed care implementation efforts as well as of effective trauma specific interventions to treat patients with a history of significant trauma and adversity
Our review methodology included an umbrella review of systematic reviews along with a review of governmental and professional society recommendations. We integrated the findings from these two reviews as much as possible. Please note that an umbrella review is a review of systematic reviews, not a meta-analysis. We acknowledge that our review had limitations: 8 year time period, English language-only studies, some, but not all, databases, etc. While we agree that there are promising single studies, such as the examples you raise and others (guaranteed income programs, home monitoring rather than incarceration of parents, and more), single studies were not eligible for inclusion in our research design. We did, however, note positive findings or positive trends from our umbrella review whenever they existed, and we raised other promising examples in our discussion. Below are some of our conclusions.
“While there are some encouraging findings from these studies, the current evidence is too limited to draw firm conclusions about the benefits of primary care (e.g., pediatric and maternal-child health) or public health (community nursing and social services) approaches to prevent adverse child experiences based on the heterogeneity of strategies and outcomes reviewed.”
“School-based mental health promotion programs had a clearly positive impact and yielded improvements in student resilience and individual protective factors, such as increased frequency of use of coping skills, reduction in internalizing behaviors, and improved self-efficacy in post-assessment studies.32 Nonetheless, there appears to be limited evidence for the effectiveness of most of the interventions studied for children and young people who have experienced childhood adversity. The strongest evidence is for the effectiveness of CBT for mental health outcomes in children who have been sexually abused. The evidence on other interventions and populations is less clear, but there are positive findings.”31
Unfortunately, most of the studies were rated low or critically low quality, which means that we as a public health and preventive medicine community , in addition to as a nation, must prioritize well-designed implementation and evaluation of enhanced protective factors and prevention and mitigation of adversity.
The only place it appears we have differences is in relation to ACE screening in the individual clinical encounter. While we did not recommend ACE screening in individual patient encounters, we did not recommend not thinking about or talking about childhood experiences with individual patients. Instead we advocated for a Universal Precautions approach and/or Sensitive Trauma Inquiry in the context of positive relationships and shared decision-making. Below is the position of the authors and many, many other researchers, including Robert Anda, David Finkelhor, Craig McEwen, Kat Ford and more, based on the available evidence.
“Along with other experts, the authors are concerned that ACE scores may be misappropriated as a screening or diagnostic tool to infer individual client risk and misapplied in treatment algorithms that inappropriately assign population level risk for health outcomes from epidemiologic studies to individuals. Such assumptions ignore the limitations of the ACE score. Routine ACE screening may also retraumatize individual patients and clients who are not yet ready to disclose their personal histories of adversity. Therefore, programs that promote ACE screening and treatment of individuals with high scores should receive the same rigorous and systematic review of the evidence of their effectiveness according to the standards applied to other screening programs by the U.S. Preventive Services Task Force (USPSTF).”
We welcome the opportunity to discuss more and hope you’ll take another look at the manuscript. We look forward to working together on our mutual goal of enhancing positive experiences and preventing, mitigating, and treating the consequences of childhood adversity for all.
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