David Clarke, MD; Elliott Schulman, MD; David McCollum, MD;
and Vincent Felitti, MD
Adverse childhood experiences (ACEs) pose significant negative health risks for millions of people. Hopefully, new approaches for addressing the long-term consequences of ACEs in the health care setting can mitigate their impact on medically unexplained symptoms, chronic conditions, and unhealthy behaviors. Despite the importance of ACEs to long-term health, there is little existing research on screening, case finding, and initial steps clinicians should use after discovering that a patient has a significant ACE history. This section presents some clinical approaches that were developed and found useful by the authors who are clinicians who have sought to integrate ACE information into their patient care for many years.
A validated questionnaire1 completed in private may facilitate more standardized history-taking of a patient’s ACEs. It is important to be aware that some ACE survivors fail to recognize ACEs impacts and may minimize or even deny childhood adversity (at least initially) unless asked about their early life in a detailed yet compassionate manner. One example of a question that has shown practical value for uncovering ACEs in these patients is “How would you feel if you learned that a child you care about was growing up exactly as you did?” Amnesia for childhood experiences is also a common indicator of early childhood trauma.
Once a health care provider ascertains that ACEs are present in a patient’s history, the provider should begin to evaluate whether the ACEs produced deleterious effects on the patient’s life. For instance, Dr. Felitti suggests saying, “I see on the questionnaire that ….,” then follow up with, “Can you tell me how that has affected you later in life and how often you think about those experiences now?”
In some cases, ACEs-associated symptoms may be ameliorated by asking patients about their past history, listening carefully to their life stories, and allowing them to share the stresses and fears in a way that is safe and non-judgmental. In doing so, these patients can leave the office visit feeling still accepted as a human being.
Some experts have advocated for use of the original 10-item ACE survey as a means to explore possible childhood trauma. The original ACE survey was developed and used as a research tool to explore the relationships between ACEs and health consequences. It is neither a comprehensive nor a diagnostic clinical tool. Research has demonstrated that additional stressors such as being the victim of bullying or racism and being exposed to community violence are equally or more traumatic than some of the original ACEs. Embedding the ACEs and other stressors into an expanded medical history questionnaire such as the Kaiser “Health Appraisal Questionnaire”1 or sensitive inquiry may be a better approach. Examples of questions that the authors have found useful are:
- “How well do you remember your childhood?”
- “Are there things that happened to you when you were a child that shouldn’t have happened to you or anyone?”
- “Would you like your children to grow up as you did?”
- “Sometimes we feel guilty about things that happened to us in the past. Are you feeling any sense of guilt or shame?”
When clinicians perceive an ACE-related medical problem in a patient, they can often reframe it as an adaptation or solution from the patient's perspective. (Examples are methamphetamine’s anti-depressant effects, the reduction in unwanted sexual attention experienced by the obese, and the immediate psychoactive benefits of inhaled nicotine.) With this change in perspective, the trauma-informed mindset conveys acceptance and compassion. Patients can be reassured that “the ACEs were not your fault,” “It is not all in your head,” and “You are experiencing a normal response to abnormal life experiences in childhood. Help exists for that.”
By knowing a patient’s childhood history of these experiences, providers can focus efforts to promote healthier lifestyle or relieve functional symptoms. Attending to the root problem and not to the patient’s adaptation to the problem allows providers to address the “fire” rather than merely the “smoke.” In addition, the higher-quality clinician-patient relationship arising from this approach is itself therapeutic.
Another helpful initial approach for communicating with the ACE survivor is to point out 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. Hearing a health professional describe heroism in these terms helps ACE survivors begin to reverse the low self-esteem and guilt that they commonly feel. This reversal is a key step in ACE survivors’ overcoming many negative health and social behaviors.2
Many ACE survivors harbor substantial negative emotions surrounding their early lives. However, they also spent their childhood learning to avoid emotions in order to survive. Consequently, they often do not consciously recognize their anger, fear, or grief. Even though these memories may be partially or completely repressed, they may be expressed somatically as physical symptoms. Asking the ACE survivor to imagine a child they care about growing up exactly as the survivor did can increase conscious awareness of these emotions. Then, when they feel ready, speaking to a trauma-informed counselor, writing a letter (rarely mailed) to the person(s) who mistreated them, or autobiographical journaling3 may help relieve functional illness by converting somatic manifestations of emotion into verbal expression.
Most evidence-based psychological trauma treatments require referral to mental health professionals trained in those specific treatments, but there are a few evidence-based treatments that can be provided in a healthcare outpatient setting. For example, Eye Movement Desensitization and Reprocessing (EMDR) has established training, certification, and empirical support. It can be used in a health care outpatient setting. Properly trained healthcare professionals can use EMDR to treat patients with trauma symptoms related to ACEs.4
Because a large number of patients are reluctant to consult a mental health clinician for a physical symptom, the first author (Clarke) provides group lectures on stress and illness.6 Recommending community resources—such as Adult Survivors of Abuse, Adult Children of Alcoholics, and the United Kingdom-based National Association for People Abused as Children—can be a useful first step to introduce key concepts and encourage further healing. Many mental health professionals lack experience with patients whose most prominent ACE manifestation is one or more physical symptoms. Fortunately, resources are increasingly available that enable successful application of the clinician’s prior training and experience.2,6,7,8,9,10 Providing these and other resources to patients may improve their understanding of the relationship between early traumatic experiences and their current health and symptoms. For those patients with clearly disabling psychological symptoms and psychiatric disorders, referral to trauma-informed mental health services is indicated.
Healthcare providers’ initial screening and response to ACEs is beginning to receive needed attention. New methods, research findings and innovative approaches for meeting these challenges will likely soon emerge.
References and Resources
- Centers for Disease Control and Prevention. ACE Study questionnaire.
- Clarke D. They Can’t Find Anything Wrong!
- Pennebaker, James. Web site, video and the books Opening Up and Writing to Heal.
- Shapiro F. The Role of Eye Movement Desensitization and Reprocessing (EMDR) Therapy in Medicine: Addressing the Psychological and Physical Symptoms Stemming from Adverse Life Experiences. Perm J. 2014;18(1):71-7.
- Stress and Illness workshops and lectures. Scroll down to find two annotated powerpoint files. Click on each to download.
- Psychophysiologic Disorders Association (PPDA)
- Schubiner, Howard, MD. Unlearn Your Pain
- Karr-Morse. R. Scared Sick: The Role of Childhood Trauma in Adult Disease.
- Kirkengen, AL. The Lived Experience of Violation. National Center for Trauma-Informed Care.
- Kirkengen, AL. Inscribed Bodies—Health Impact of Childhood Sexual Abuse.
© 2015 by Academy on Violence and Abuse
