Dr. Vincent Felitti, father of the seminal Adverse Childhood Experience (ACE) study that has informed so much of State of Opportunity’s reporting and recently this NPR series, was recently in Michigan for a conference on how adverse childhood experiences affect health. Fewer than 50 people showed up to hear him speak, and only five of them were doctors. That this number thrilled Dr. Tina Hahn – an Alpena pediatrician who coordinated Felitti’s visit – has less to say about the importance of Felitti's work and more to say about how behind the ball Michigan is in recognizing that.
Hahn says it’s been an uphill battle to get people, especially doctors, to recognize the connection between trauma and health. Other Midwestern states (Wisconsin, Iowa, and Minnesota, to name a few) began surveying people for ACEs many years ago, while Michigan just started. Michigan's doctors aren't alone in questioning this approach to medicine.
A refresher: ACEs are "adverse childhood experiences." Things like child abuse, living with a parent who has a mental illness, and being separated from a parent. High ACE scores have an incredible impact on a person's health, an impact that Felitti says is "hard to believe." The ACE study found that someone with an ACE score of 6 or higher, for example, is 46 times more likely to become an intravenous drug user than someone without that score.
Hahn is one physician who believes in the power of ACE. She's been using the ACE survey in her practice for seven years and sees it as part of her job. “As a pediatrician, I don’t just prevent infectious diseases by giving vaccines," she says. "I also prevent the negative health outcomes of ACEs by educating parents about the effects of adverse childhood experiences.”
Hahn first learned about the ACE study back in 2004. She thought, “Wow — now the field is going to move. Physicians will now be able to understand why preventing adversity in childhood is so important.”
That hasn’t happened. The majority of doctors in Michigan aren’t asking ACE questions, says Hahn. But they should be, especially because kids in Michigan have higher ACE scores than the national average. About 50% of all Michigan kids experience one or more adverse family experiences each year.
Both Hahn and Felitti think doctors are in the perfect position to educate people about how adversity affects their health. Doctors should already get a psychosocial history, which Felitti and Hahn argue should include ten additional questions to account for ACEs. Felitti suggests giving patients a questionnaire to fill out at home to do this, which is exactly what Hahn does.
Doctors aren’t asking these questions for a variety of reasons, says Felitti. Some of those are a lack of training, no way to bill for it, and not wanting to "open Pandora’s box".
For her part, Hahn thinks physicians worried that talking about ACEs will take too much time should know research shows subsequent office visits actually go down by 35% after talking about their experiences. Felitti attributes this to the power of acceptance. He says that when people tell someone important to them about the trauma they've lived through, like a doctor, it removes some of the shame, and stress, they carry from those experiences.
About 80% of the kids Hahn cares for with common kid complaints like stomachaches and symptoms of ADHD can actually be traced back to adverse childhood experiences, she says. Hahn worries if doctors don’t understand trauma and adversity, they will come to a wrong diagnosis. Or, prescribe psychotropic drugs kids don’t need for a condition they don’t have.
Is trauma something that can be recovered from?
Felitti says mostly, “but the efforts required to do that are major and not commonly accessible … particularly because the basis of the problem is not commonly recognized.”
The basis of the problem is the way kids are taught not to talk about their “family secrets.” This makes people more resistant to sharing their experiences and asking for help.
Poverty, Hahn says, can make things worse. Felitti agrees. Kids with more economic advantage have higher rates of child health, largely because they can get the resources they need. For poor kids with high ACE scores, resources are much more limited. The original ACE study involved employed, insured middle- to upper-class adults. Felitti says if the results were as bad as they were on the upper end, “it can’t get much better on the lower end.”
How will we know when information about adverse childhood experiences is really sinking in?
“When everyone knows what an ACE score is,” says Hahn. Not just doctors – everyone. "This is the biggest public health problem the United States is facing."
By the end of the conference, two doctors agreed to start screening for ACEs in their practice. For advocates like Hahn, that's a start.