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Response to Jeoff Gordon about the American College of Preventive Medicine statement about ACEs

[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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I very much appreciate Dr. Stillerman's thoughtful response, as well as the work of her and her co-authors to advance PACEs awareness in the health care system (How cool is it that one of the authors is a PACEs Connection member?!?!). I furthermore appreciate the ongoing discussion here on the PACEs Connection forum, started by Craig McEwen's post on ACPM's recommendations, then spurred by Dr. Gordon's response. I hope to respectfully add to the conversation and apologize in advance for my lack of brevity. I'm largely writing this in hopes Dr. Stillerman reads it, as I both value her insight and (frankly) am lobbying here. I actually want to steer away from the topic of to screen with the ACE Questionnaire or not. It's definitely an important issue, though I think tends to turn the debate into an all or none scenario that I feel distracts us from the main goal. I used to use the Questionnaire a lot, but don't use it now. I found that it served as a great conversation starter for PACEs, and I've now evolved into starting that conversation other ways. To be clear, I'm definitely all for the Questionnaire, but feel that the main point is that we need to be addressing PACEs with all patients, however it's done.

Here, I instead want to specifically focus on the topic of how to better get the medical community engaged in addressing PACEs. This is of personal interest to me, as I'm a general internist who has worked in primary care all of my 22-year career. Despite all these years in medicine (re: I'm old), I didn't become aware of ACEs until 4-5 years ago. As a shameful example of the problem we're up against, it was a patient of mine who brought the emerging PACEs science to my attention, and not the NEJM, JAMA, ABIM, USPSTF, or other leaders of medical education and policy. I'll give the AAP credit for having published a statement on ACES 10 or so years ago, but as an adult medicine doc, this didn't enter into my world. I'll add that 4 years ago, when I brought up ACEs to the Chief of Pediatrics for the very large medical group I worked for at the time, he admitted that he had not heard of ACEs.

The patient who first educated me caught my attention because her complicated health issues had significantly improved through her own doing, and not from anything I (traditional medicine) had offered her. Being very curious as to what her secret was, I took her advice and read "The Body Keeps the Score" and watched Dr. Nadine Burke Harris' TED Talk. Armed with this new information and perspective, and my fascination with neuroscience's recent understanding of the pathophysiology of chronic stress, my clinical approach slowly started to change. However, it wasn't until 6 months later, when I had the inspiration to start using the ACE Questionnaire, that things really shifted. I'll never forget the ensuing, deeply meaningful conversation with my first patient who took the Questionnaire (she had 9 ACEs), sparking the epiphany that almost every health issue we primary care clinicians encounter is rooted in early life adversity and the behaviors people cultivate to deal with these traumas and after affects. I soon mentioned my eye-opening clinical experiences to a colleague, who then started screening some of his patients, and he had the same revelation. Everything now made so much sense to us that we naively assumed once we brought this to the attention of our medical group administrators and physician partners, they'd all "get it", too. Unfortunately, we were way off base and, with rare exceptions, what we pitched didn't resonate with other docs.

4 years have passed and my obsession with PACEs burns as strong as ever. I have no doubt that the patients I serve have benefitted from my now trauma-informed clinical approach, and I'm much less burned out than I was 5 years ago. I realize that this "n of 1" isn't evidence-based enough to prompt the ACPM to quickly revise their recommendations, but I also know that I'm not along among physicians and APCs who "get it", and that we need to be the Johnny Appleseeds who spread PACEs awareness. I'm guessing that Dr. Stillerman and her co-authors share my obsession and that this fueled their efforts on the ACPM paper. So, how do we get our enormous beast of a health care system aligned with us? Dr. Burke Harris created wonderful momentum in California, showing that it is possible to move the needle. But it took the governor of the 5th largest economy in the world to wield his power in order to put her in a position to make change.

ACPM's recommendations, while largely in favor of advancing PACEs, are disappointing because they were made playing within the confines and rules of our medical culture (I'm mainly referring to physicians here). This culture is dominated by a thirst for evidence-based medicine and is, like our society's culture, generally uncomfortable addressing emotional health. I appreciate how an evidence-based approach took modern medicine out of the era of leeches and snake oil, into one where therapeutics have largely been safe and effective, but it seems like our medical culture has now become shackled to a need to be evidence-based. Every review article/lecture is expected to cite evidence supporting treatments, insurance companies deny treatment coverage that isn't evidence-based, and some medical groups base physician compensation on value (evidence) based care. Then there's the whole discussion on how medical culture's obsession with double-blind placebo studies, along with a reliance on pharmacologic treatments and shortened appointment times, have taken the humanity out of our profession.

We burned-out, change-resistant docs generally won't consider altering our practice styles unless there is an A or B rated recommendation from the powers that be, such as the USPSTF. Furthermore, it's going to be a long, long while before sufficient interest develops, momentum builds, studies are funded, time for studies elapses, PACE-supporting studies get published, debates/discussions occur, policy gets put in place, and then individual clinician practices adapt before the rubber finally hits the road and meaningful change takes place. We shouldn't and can't wait this long. There is harm - tremendous harm - in doing nothing.

In the case of ACPM's paper, the favorable recommendations get deflated by numerous caveats that use the usual medical-speak, such as "Despite limitations in the heterogeneity and quality of the published systemic reviews...", and "...require further implementation research", and "Prerequisite health system development is required...", and "...must have protocols and systems in place which support...healing-centered care."

To the overworked physician or health care administrator perusing through the ACPM recommendations, I fear that they will be underwhelmed by how the recommendations are presented, then quickly jump to the conclusion that addressing PACEs requires way too much infrastructure implementation and isn't ready for prime time. Also, I suspect that discomfort addressing childhood trauma will be used as further rationalization by the reader to take a pass on learning more about PACEs, and instead seek the familiarity of "real medicine", such as how best to update diabetes management protocols, or if heart failure patients should be on an SGLT2 inhibitor.

While a multipronged approach is necessary, I think that a key strategic intervention to effectively encourage physician engagement in PACEs is to get the editors of major medical journals to understand the importance of them. One challenge here, as recently alluded to by Dr. Gordon in a different thread, is that if you're not a clinician practicing in the trenches, you're less likely to understand the powerful, healing moments that can happen in the exam room when PACEs are addressed. It feels like medical journals are more interested in what's happening in the research lab than the exam room. This barrier aside, if editors truly understood that ACEs are at the root of most health problems and that a paradigm shift is in order, they would then publish studies, recommendation statements, and editorials that legitimize PACEs to the medical community.

This is undoubtedly a tall task. I've failed thus far and have the declined Letters to the Editor to prove it. Recognizing that I'm a lowly, community primary care doc who doesn't have an administrative title or PhD next to my name, a big motivation for writing this rambling response is to encourage Dr. Stillerman and her co-authors, who have their foot in the door, to try to get even more attention from the editors they have access to. And if they do, that they hopefully would be moved to use stronger, more forceful language than was used in the ACPM paper. They could feel empowered by knowing they're speaking for people affected by trauma (all of us), and maybe even infuse some passion and emotion (humanity) into their statements. This issue is of unique, paramount importance and is not just a discussion on what the best colon cancer screening test is. We gotta turn it up a few notches to get the attention PACEs needs.

Thanks for reading, and I welcome other perspectives, insights, and ideas.

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