Using the Intersection of Genetics, Prenatal exposure ... · Addressing ACES in Primary Care Using...

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…

…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


Must Be Bipolar or

Complex ADHD

Trauma


Exposure


Must be a crack/meth baby

or FASD

Prenatal Lens

Trauma Lens


Exposure


Must Be ComplexTrauma

Trauma

Integrated Lens

Prenatal

Drug/Alcohol Exposure


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


• 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!


• 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%


• 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%


• 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…


• 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


• 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!

[email protected]

www.wmich.edu/traumacenter

mailto:[email protected]

http://www.wmich.edu/traumacenter

Using the Intersection of Genetics, Prenatal exposure ... · Addressing ACES in Primary Care Using...

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