using the intersection of genetics, prenatal exposure ... · addressing aces in primary care using...
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Addressing ACES in Primary Care
Using the Intersection of Genetics, Prenatal exposure, & toxic traumatic stress to implementIntegrated Trauma-Informed Primary Care
Mark A. Sloane, DO, FACOP, FAAPKalamazoo, MI
8 November 2019
Western Michigan UniversityChildren’s Trauma Assessment Center
My Journey
Let’s start with two words
What
If
What if…
…A 10-Question Screening Assessment….
…could add 20 years to your patient’s life?
Do I have your attention yet?
10 Questions…
…That could also change your life!
How is that possible?
Stay tuned!
Adverse Childhood Experiences Study (ACES)
Anda / Felitti 1998
(We will talk about ACES details shortly)
Full Disclosure…these questions are very personal and can
trigger emotional feelings in the audience…
But…they must be asked!!!
Universal ACES screening is the ultimate goal!
But let’s return to your office…
We will start with 5 personal questions
During your first 18 years of life…
Emotional Abuse
…Did a parent (or other adult in your house) often swear at you, insult you,
put you down or humiliate you?
Physical Abuse
…Did a parent / other adult often push, grab, slap, or throw something at
you?...or hit you hard enough to leave marks?
Sexual Abuse
Did an adult (or a person at least 5 years older) ever touch or fondle you
or have you touch their body in a sexual way…or…
…attempt or actually have oral, anal, or
vaginal intercourse with you?
Emotional Neglect
Did you often feel that no one in your family loved you or thought you were special?...
...or your family didn’t look out for each other, feel close to each other, or support each other?
Physical Neglect
Did you often feel that you didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you?...or…
…your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
Now…here are 5 Family Questions…
Parental Divorce / Separation
Were your parents ever separated or divorced ?
Domestic Violence Exposure
Was your mother / stepmother often pushed, grabbed, slapped, or had something thrown at her?…or…
…sometimes/often was kicked, bitten, hit with a fist or something very hard?
Substance Use Exposure
Did you live with anyone who was a problem drinker / alcoholic or
who used street drugs?
Mental Illness Exposure
Was a household member depressed, mentally ill, or did a
household member attempt suicide?
Incarceration Exposure
Did a household member go to prison?
Ok…wow…that was heavy!!
Please stay with me…
These questions may seem quite intrusive for a routine
primary care office visit…
I’m certain that many/all of you are now thinking about the
reasons you won’t be able to ask these…
Hi Pandora…Is that your box?
But….these questions must be asked!
A main issue that primary care currently faces is
how to ask them!
But let’s first ask why we should ask them?
The main reason we should ask is the crux of ACES…
…Childhood trauma makes you sick
Chronic debilitating illness in the USA is a trauma issue
It impacts each & every specialty
Intergenerational TraumaThe key to explaining ACES
• The family secret…Too many secrets• The family legacy• “In the ‘hood, we call it the curse”• 4-5 generations of sexual abuse is not
uncommon• Family medicine is positioned well to
address this
Trauma is the the single greatest public health issue
we face currently
Let’s now briefly look at whywe should ask…AKA traumatic
impact…
Trauma: What we currently know
• Trauma is about science…not the latest fad…• Trauma is insidiously woven into the fabric
of modern society• Many critical trauma connections:
– Trauma - Mental Health– Trauma – School Failure– Trauma – Juvenile Justice / Adult DOC– Trauma – Substance Use / Abuse– Trauma – Physical Health– Trauma – Public Health
What is trauma?
• Overwhelming event or events that render a child helpless &/or powerless, creating a ongoing threat of harm and/or loss.
• Internalization of the traumatic experience that continues to impact perception of self, others, world, and development.
Complex Traumatic StressThe Event vs the Impact
• Early relational trauma (sequential/simultaneous)– Neglect -Physical -Emotional/Psychological– Sexual -DV exposure -Impaired caregiver
• 38 % of WMU CTAC referrals have FASD/ARND (n=1535)…but this is changing…
• Combined ND impact: Trauma + FASD/ARND• Not limited to foster kids (? to PCP: “When is
your trauma moment?”)– Teen: “Too much $ / too little time with my Dad”
Traumatic functional impact is clearly staggering…yet…
…Trauma is not sufficient…
…to explain complex behavioral issues that you all deal with on
a daily basis across the lifespan…
So…here is a graphic series to help you think bigger…
We like to call this…
Embracing Complexity
TraumaPrenatal
Drug/Alcohol Exposure
Genetics / Epigenetics
MULTI-ANGLEBRAIN IMPACT
Genetics Lens
Trauma
Prenatal Drug/Alcohol
Exposure
Genetics / Epigenetics
Must Be Bipolar or
Complex ADHD
Trauma
Prenatal Drug/Alcohol
Exposure
Genetics / Epigenetics
Must be a crack/meth baby
or FASD
Prenatal Lens
Trauma Lens
Prenatal Drug/Alcohol
Exposure
Genetics / Epigenetics
Must Be ComplexTrauma
Trauma
Integrated Lens
Prenatal
Drug/Alcohol Exposure
Genetics / Epigenetics
ALL of These Must be
Considered and Addressed
Trauma
Ok…let’s talk about some ACES details…
Types of Stress National Scientific Council on the Developing Child (2005)
Traumatic Stress & the Child’s Developing Brain
• Early and ongoing toxic traumatic stress to the developing brain results in: – Physical / neuroplastic brain changes that:
•Cause functional impairment•Contribute to problematic behaviors •Contribute to developmental delays•Impact on child & adult physical healthè
Toxic Traumatic Stress & the Child’s Developing Brain
• Research reveals a strong link between all types of child abuse /neglect and the subsequent development of psychiatric illness in adulthood
• ACES link child traumatic stress with variety of child/adult physical illness
VJ Felitti, MD
Vincent Felitti, MDGodfather of ACES
The Origin of ACES:Back to the future
• Vince Felitti, MD Internist in San Diego• Kaiser-Permanente Director of Preventive
Medicine• Was developing wellness programs to improve
outcomes for chronic conditions…obesity• Noted that program failures had a abnormally
high % of adverse childhood conditions (based on a screening psycho-social questionnaire required by K-P)
Setting the ToneAdverse Childhood Experiences Study
• CDC dismissed his initial research data (n=386)• CDC was concerned that primary care
physicians would be overwhelmed after asking the ACES questions
• Dr F then collaborated with Robert Anda, MD (CDC medical epidemiologist) to help with the study design and the data processing
• Offered ACES to 26,000 patients in San Diego• 17,000 completed ACES
The Origin of ACES:Back to the future
• Middle class San Diego sample (26-94 yrs)– “You and me”
• Retrospective and prospective landmark study– Counterintuitive data: ”This simply can’t be true”
• Dr Anda wept when he saw the initial data analysis
• Broad resistance continues despite overwhelming data…medical systems are so glacial!
The Origin of ACES:Back to the future
• ACE Score: Think of it like a cholesterol level for childhood trauma
• Range: 0-10
• 1 point for each type of adverse childhood experience (equally weighted)
ACE Questionnaire
• Emotional abuse• Physical abuse• Sexual abuse• Emotional neglect• Physical neglect
• Family separation/divorce• Domestic violence• Parental mental illness /
suicide attempt• Family member drug use• Family member
incarcerated
The Origin of ACES:Original sample
• ACE Score % of ACES population:– 0 33%– 1 26%– 2 16%– 3 10%– 4 6%– 5 5%– 6 6%
The Origin of ACES:Back to the future
• ACE study participants:– Emotional Abuse: 10%– Physical Abuse: 26%– Sexual Abuse: 21%– Emotional Neglect: 15%– Physical Neglect: 10%– Mom treated violently 13%– Parent with MH issues 20%– Parent with SUD 28%– Parental divorce: 24%
The Origin of ACES:Back to the future
• An ACE score of 4 is the “tipping point”:
– 2X smoking risk– 12X suicide attempt risk– 7X alcoholic risk– 10X injected street drug risk
Profound impact of 6 ACES
• 20 years less life expectancy
• 4600% increase in parenteral street drug use
Impact of ACESStrong & graded fashion as ACE ñ’s
• Alcoholism / Abuse• COPD• Depression• Fetal death• Health-related QOL• Illicit drug use• Ischemic Heart Disease• Liver Disease• Risk for IPV• Multiple sexual partners
• STI• Smoking• Suicide Attempts• Unintended pregnancy• Early initiation of smoking• Early initiation of sexual
activity• Adolescent pregnancy
Adverse Childhood Experiences Study (ACES)Pyramid of Doom!
Felitti et al. 1998;
ACES Update
• 28 internists in San Diego worked under Dr F• They evaluated 440,000 new patients in 8
years for a complete physical exam• All competed ACE questionnaires• The positive ACE responses were handled the
same way– “How has this affected you as an adult”
• The docs were trained to quietly listen
ACES Update
• The patients were relieved that they had told someone
• “No doctor has ever asked”• They did not feel judged• 35% decrease in pain-related office visits
the year after the complete physical exam• They were now ready for trauma therapy
– Medical hypnosis– EMDR
“If child abuse and neglect were to disappear today, the DSM would shrink to a pamphlet within two
generations” John Briere 1992
ACES: The Best Case for Early Prevention & Treatment of
Complex Trauma & Prenatal Exposure
So…how do we climb this massive trauma/ACES mountain?…
We do it together……one step at a time!!
My Current Trauma Consulting LifeBoard Certified Cat Herder
Strengthening Connections between:• Primary Care• Health Dept• Schools• Mental / Behavioral Health• Child Welfare• Legal / Court System
Primary Care & ACES Screening Implementation
• Uniform approach has not yet materialized• Don’t wait for someone else to tell you how to
do this in your office• Screening process has to be office-wide• Patients will not freak out (OK on occasion they
may get emotional)• ACES study found home completion was well
accepted (prior to a routine well visit)• But…this approach will miss many patients…
Primary Care & ACES Screening Implementation
• You can test the ACES Screening waters but…– …Eventually you have to jump in
• You can start with a small pilot of a well defined patient population
• Anonymous ACES model (Center for Youth Wellness)
• Feedback from these pilot participants can be instrumental as you scale up– Consider having focus groups– Include ACES in office wellness programs
Anonymous ACES ScreeningBarriers to implementation
• Our extensive experience with ACES underreporting
• System distrust is primary factor– Linear correlation with family risk of trauma
• Major issue for folks involved with child welfare / CMH / court systems– CPS investigations– Family Drug Court
• CTAC answers: unique trauma screener→
WMU CTAC Trauma Screening Instruments
• 3 versions (0-5y, 6-18y, Adult)– >10,000 in our database (multiple sources)
• ACES plus Behaviors model– Interview plus records review– Behavior section can be used to measure progress
• MDHHS now mandates this is every county– Total score of 11: MDHHS trauma assessment– CMH / court systems also using
• WMU CTAC Schools-Primary Care pilots– Group setting is ideal
Primary Care & ACES Screening Implementation• You do need to have a system in place to
answer questions / concerns that will emerge while/after the patient/parent completes ACES questionnaire– Written office ACES policy is needed– A community helpline can be helpful– Integrated behavioral health staff will be
invaluable– Establishing ACES referral system is essential
Primary Care & ACES Screening Implementation
• Knowing your patients/parents ACE score should impact your clinical decision-making
• Imagine: each patient/parent has their ACE score projected above their head as a ACES hologram
• All PCP staff will have increased empathy when they remember the ACE score especially during behavioral outbursts or after patient has been involved in the legal system
Trauma-informed Care (TIC)
• This is coming to your office…like it or not• Fed / state agencies are struggling with the
enormity of this• We must avoid linear thinking here• Building 3-D resiliency is the only chance
we have to accomplish TIC• Creative collaboration with all community
partners is not optional…it is essential!
Trauma-informed Care (TIC)
• Each community needs to construct a customized comprehensive local ACES plan
• PCPs need to be at that planning table!– Medical representation must be more than
just hospital / medical administration
Innovative Models Emerging
• Physician Training (Medical students / residents)– Michigan AAP– Authority Health
• Interdisciplinary models– CMU-Med Interdisciplinary Center for
Community Health and Wellness• ACE Initiative – Michigan• WMU CTAC Trauma-informed Schools Pilots
Thank you for your attention!
www.wmich.edu/traumacenter