Every day in internal medicine, we see the pain and enduring consequences of mental illness; we are taught early in training about mental health screenings and treatment, critical to addressing our patients’ needs. While mental illness is at least partially genetic, we are learning that many environmental factors also play a role in the development of mental health. Exploring and understanding these environmental factors, such as childhood events that increase the risk of mental health problems, can provide important context to ongoing and future mental illness, yet clinicians, including physicians and advanced practice providers, rarely discuss them with their patients.
Adverse childhood experiences (ACEs) are defined as potentially traumatic events that occur in childhood, such as experiencing violence, living with adults with substance use or mental illness, parental incarceration, or food insecurity.1 These events are unfortunately commonplace—in one study, 61% of adults reported experiencing at least one ACE, and 1 in 6 reported experiencing four or more types of ACEs, classifying them as “high risk” for toxic stress.2 Data shows that being exposed to four or more ACEs increases the risk of chronic disease development compared to exposure to one ACE, suggesting a direct correlation between number of ACEs and toxic stress. Women and minorities are more likely to have exposure to four or more ACEs,1 leading to further inequity. These events can affect whole communities, and with the significant economic and health impacts of the COVID-19 pandemic, the current generation of children are likely to have even more exposure to adverse events.
ACEs have a significant impact on long-term health, likely related to altered gene expression, as well as changes in immune and organ function,3 and place patients at high risk of chronic medical co-morbidities, including pregnancy complications, heart disease, COPD, mental illness, and substance use in adulthood.2 Studies have shown that those with four or more ACEs have five-fold increased odds of depression and were at increased risk of heavy alcohol use, obesity, COPD, unemployment,2 and violence victimization and perpetration.1 Traumatic exposures as a child are hypothesized to affect brain development, decision-making, and ability to cope with stress. A lack of stability and healthy relationships in childhood can cause difficulty establishing secure relationships in the future; ACEs may subsequently become intergenerational, with the lasting impact of trauma extending from parents to their children. By increasing the risk of mental illness in adulthood, it can also generate new adverse experiences for the next generation of children. Additionally, ACEs deepen socioeconomic barriers for survivors and consequently affect their social determinants of health, such as resources for food, jobs and income, and education.
Due to their significant prevalence and role in future health, ACEs have become an important topic of discussion within Pediatrics, with a focus on both preventing adverse experiences and mitigating their effects. In our experiences as Internal Medicine-Pediatrics physicians, however, these conversations have not frequently extended to include adult clinicians. While the childhood events a patient experienced are obviously not preventable once a patient is an adult, ACEs can still affect ongoing mental and physical well-being, and screening for ACEs can shape ongoing care. Screening tools (typically 10 questions) for adults and recommended clinical workflow are available to clinicians through the Center for Health Care Strategies and ACEs Aware (https://www.acesaware.org/resources/). Exposure to one of the ten surveyed ACEs results in a positive screen. Patients with exposure to 1-3 ACEs are considered at “intermediate risk” for toxic stress, and should be provided with anticipatory guidance regarding ACEs and their possible consequences. Also, protective factors against toxic stress (e.g., developing supportive interpersonal relationships, stable employment, completion of education, and connection to their community) should be discussed. Patients with exposure to four or more ACEs are at “high risk” for toxic stress, and the patient should be linked to supportive services if amenable and evaluated for health conditions associated with toxic stress.
The most common concerns regarding screening are time commitment, patient and clinician discomfort, and how to best implement this into a busy clinical practice. Most research shows that patients are comfortable with self-administered surveys and that positive ACEs screening usually takes less than five minutes to discuss.4 ACEs screening can be used in conjunction with more commonly used screens for mental health illness such as the Patient Health Questionnaire (PHQ-2 or PHQ-9). Studies have also shown that most patients felt discussing ACEs improved their relationship with their clinician, and clinicians reported increased empathy for their patients after discussion of ACEs.4 Providing trauma-informed care education using the 4C (Calm, Contain, Care, and Cope) framework5 to all staff and clinicians may serve as a guide to improve comfort in acknowledging and responding to ACEs during screening. Trauma-informed care recognizes the impact of trauma on ongoing functioning and helps the provider to respond in an empathetic way without causing ongoing trauma. This includes helping providers to address distorted beliefs related to a history of trauma, discussion of available resources for those with a history of trauma, and avoidance of re-traumatization.
Given their significant impact on adult health, it is critical for clinicians to screen for ACEs and intervene in those at increased risk. As Med-Peds physicians, we have often seen the intergenerational effects of trauma, and how surviving ACEs can shape a patient’s experience. ACEs can normalize substance use, cause difficulty handling new stressors, and devalue the benefits of stable interpersonal relationships. But helping a patient acknowledge these traumas and critically analyze how they affect their response, can create an open dialogue between the patient and provider to discuss ways to move forward with healthier lifestyles. From our practice, for example, an adult patient who presents with multiple chronic conditions that were poorly controlled (related to medication non-adherence) engaged with us in a discussion of how growing up, she had no stable relationships with adults due to being raised mostly in foster homes. This provided context for previous encounters: her distrust of authority figures had carried into her adult life, affecting her relationships with her physicians. Upon discussing this openly with her, she reframed her relationships with her physicians to be about self-empowerment – rather than authority — and we were then able to form a truly therapeutic relationship.
Identification of risk factors for substance use or mental health disorders can help clinicians connect their patients to resources earlier and prevent propagating trauma through multiple generations. Through screening, we can connect patients with mental health resources earlier to benefit whole families, not just individuals. It is important that clinicians who choose to implement ACEs screening feel prepared to address these conversations in a trauma-informed manner and refer patients to appropriate mental health resources. Much like a thorough family history or review of systems, identification of ACEs can provide important context for understanding our patients’ and their families’ perspectives on their mental health, medical co-morbidities, and the socioeconomic implications of these conditions—and assist clinicians in halting the cycle of this long-lasting inequity.
- Centers for Disease Control and Prevention. Adverse childhood experiences (ACEs). https://www.cdc.gov/violenceprevention/aces/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fviolenceprevention%2Facestudy%2Findex.html. Published April 3, 2020. Accessed July 15, 2021.
- Merrick MT, Ford DC, Ports KA, et al. Vital signs: Estimated proportion of adult health problems attributable to adverse childhood experiences and implications for prevention—25 States, 2015–2017. Morbidity and Mortality Weekly Report. 2019;68(44):999-1005.
- Jiang S, Postovit L, Cattaneo A, et al. Epigenetic modifications in stress response genes associated with childhood trauma. Front Psychiatry. 2019;10:808. Published November 8, 2019. doi:10.3389/fpsyt.2019.00808.
- Rariden C, SmithBattle L, Yoo JH, et al. Screening for adverse childhood experiences: Literature review and practice implications. J Nurse Pract. 2021;17(1):98-104. doi:10.1016/j.nurpra.2020.08.002.
- Barnhill J, Fisher JW, Gerber MR, et al. Moving towards healing-centered engagement: What trauma-informed care can teach us about burnout and healing in the workplace. SGIM Forum.
Clinical Practice, Health Equity, Medical Education, SGIM, Social Determinants of Health, Wellness
Dr. D’Amico (Rachel.D’Amico@nationwidechildrens.org) is a fourth-year Internal Medicine-Pediatrics resident, The Ohio State University/Nationwide Children’s Hospital. Dr. DeSalvo (Jennifer.Desalvo2@nationwidechildrens.org) is a third-year Internal Medicine-Pediatrics resident, The Ohio State University & Nationwide Children’s Hospital. Dr. Pilapil (email@example.com) is an associate professor of internal medicine and pediatrics, Zucker School of Medicine at Hofstra/Northwell. Dr. Mixter (firstname.lastname@example.org) is an assistant professor of internal medicine and pediatrics, Johns Hopkins University School of Medicine. Dr. Hart (Laura.Hart@nationwidechildrens.org) is an assistant professor of pediatrics and adjunct assistant professor of internal medicine at Nationwide Children’s Hospital/The Ohio State University College of Medicine.
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