Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Adverse childhood experiences: Can government policy reduce trauma?

Ariane Marie-Mitchell, MD, PhD, MPH
Conditions
October 23, 2022
39 Shares
Share
Tweet
Share

One of the most radical implications of the literature on early childhood trauma is that abuse needs to be eliminated from all of our relationships: our families, teachers, colleagues, and government. When government leaders create a new policy, they can proceed in a way that disempowers constituents, or they can proceed in a way that fosters dialogue and shared decision-making. Ironically, the development and implementation of California’s policy to address childhood trauma provides an example of leadership with good intentions but execution that was neither trauma-informed nor evidence-based.

Many states have developed or are developing public health policies to reduce adverse childhood experiences (ACEs). The original ACE study defined ACEs as child abuse and neglect, plus parental separation or divorce, a household member with a mental illness or substance abuse problem, domestic violence, and incarceration of a household member. This study found that the accumulation of ACEs was linearly associated with an increased risk of medical problems in adulthood, including mental illness, substance abuse, sexually transmitted infections, cardiovascular disease, liver disease, pulmonary disease, and cancer. Numerous studies have corroborated the finding that ACEs are associated with an increased risk of medical problems and psychosocial problems such as school failure and homelessness. Thus, there are good reasons for states to take action, but what action to take is less clear, given gaps in evidence.

A trauma-informed approach to creating state policy would empower constituents by considering both public feedback and the latest scientific evidence such that the resulting policy is viewed as coming “from us” and justified rather than something that is being “done to us” and questionable. California solicited public input through the AB340 Task Force on Trauma and later public commentary. However, the policy that was implemented ignored AB340 recommendations to allow provider choice of a tool for ACE screening, despite the fact that no tool had (or has) such extensive evidence for validity that a state policy is justified in determining reimbursement based upon the use of that tool only. There was also no formal response to public concerns about the use of an ACE score to differentiate patient risk, which various authors have noted can result in potential harms, including misdiagnosis, unnecessary anxiety, and inappropriate use of community resources with unclear benefits. It is not clear why California chose this approach. My best guess is that the simplicity of giving providers a number (ACE score) was appealing, as was the idea of having pediatric patients throughout California use the same tool (a strategy that might be justifiable after best practice is determined).

Advocates of the current California ACEs policy point to population-level research which shows a clear linear association between more ACEs and more health problems, and therefore they argue that there is enough evidence for using an ACE score in clinical practice. But to translate population studies into clinical practice for the purpose of screening generally healthy patients, individual-level research is needed on the psychometric properties of a screening tool. Population-level research shows that increases in ACEs are statistically significantly associated with group mean health problems. But an individual patient does not care about a group mean; they want to know about their own risk. A recent study evaluated whether an individual’s ACE score predicted the risk of poor health outcomes for that same individual. This study found an ACE score was associated with increases in group means for later health problems but was barely above chance (not much better than flipping a coin) in predicting an individual’s risk of health problems. This is not surprising since an ACE score by itself does not factor in resilience and protective factors that reduce the impact of ACEs. Focusing on an ACE score also misses a key opportunity in pediatric practice: preventing ACEs.

There is an alternative approach to incorporating information about ACEs into pediatric practice. This is to screen for specific ACEs (e.g. parent divorce or mental health problem), and this approach may explain more variance in outcomes than the use of a total ACE score. Consideration of specific ACEs by pediatricians is consistent with a biopsychosocial model aimed at promoting optimal child development through healthy parent-child relationships. Suppose patient care focuses on response to specific ACEs. In that case, potential harms of using an ACE score are unlikely because the goal is to understand the family context and address specific risk factors, not to make a diagnosis based upon a total score. Furthermore, patient counseling and education can be tailored to specific family needs rather than a number that has been evaluated in population-level but not individual-level research.

While more health care research is often needed, governments do not have to wait for the completion of research to set policies to promote public health. Governments can proceed with policies so long as these are justified based on current evidence and developed through shared decision-making with the public. Regarding addressing ACEs through pediatric practice and in consideration of current evidence to date, I suggest that state policy on ACEs:

  1. Recommend that pediatricians screen for specific ACEs (not a total ACE score).
  2. Provide an algorithm for management and related training focused on managing specific ACEs with and without associated child symptoms.
  3. Allow for reimbursement based upon the use of any tool that includes specific ACEs.

A policy that allows provider choice of tools and workflow supports provider autonomy and response to patient preferences while encouraging clinical innovation and research to determine best practices.

California’s new leadership on ACEs has an opportunity to amend the current ACEs policy, and other states have an opportunity to learn from related scientific and public discourse before implementing their own policies on ACEs. Arguably, all government action should be justified based on evidence and respectful of the perspectives of constituents. However, this is particularly important for policies about ending childhood trauma since the process of policymaking in and of itself provides an opportunity for modeling how to create healthy relationships throughout our society.

Ariane Marie-Mitchell is a preventive medicine physician.

Image credit: Shutterstock.com

Prev

Institutionalized racism in psychiatry: a doctor's experience

October 23, 2022 Kevin 1
…
Next

A cancer patient's last wish [PODCAST]

October 23, 2022 Kevin 0
…

Tagged as: Pediatrics, Psychiatry

Post navigation

< Previous Post
Institutionalized racism in psychiatry: a doctor's experience
Next Post >
A cancer patient's last wish [PODCAST]

Related Posts

  • Why is trauma activation so expensive?

    Skeptical Scalpel, MD
  • The crippling health effects of another government shutdown

    Alani Gregory, MD
  • Both markets and the government are needed to fix health care

    Matthew Hahn, MD
  • 5 things America can do today to reduce gun deaths

    Megan L. Ranney, MD, MPH
  • What would an optimal government-run health care system look like?

    Taylor J. Christensen, MD
  • Why is age only a concern regarding surgeons, and not government officials?

    Brian C. Joondeph, MD

More in Conditions

  • Maximize sleep efficiency with stimulus control

    Pedram Navab, DO
  • The endless waves of chronic illness

    Michele Luckenbaugh
  • Surviving and thriving after life’s most difficult moments

    Rebecca Fogg, MBA
  • The surprising power of Play-Doh in pediatric care: How it’s bringing families together

    Alexander Rakowsky, MD
  • Lazarus: the dead man brought back to life

    William Lynes, MD
  • The psychoanalytic hammer: lessons in listening and patient-centered care

    Greg Smith, MD
  • Most Popular

  • Past Week

    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • It’s time for C-suite to contract directly with physicians for part-time work

      Aaron Morgenstein, MD & Corinne Sundar Rao, MD | Physician
    • The struggle to fill emergency medicine residency spots: Exploring the factors behind the unfilled match

      Katrina Gipson, MD, MPH | Physician
    • What is driving physicians to the edge of despair?

      Edward T. Creagan, MD | Physician
    • Beyond the disease: the power of empathy in health care

      Nana Dadzie Ghansah, MD | Physician
    • The psychoanalytic hammer: lessons in listening and patient-centered care

      Greg Smith, MD | Conditions
  • Past 6 Months

    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • The vital importance of climate change education in medical schools

      Helen Kim, MD | Policy
    • The fight for reproductive health: Why medication abortion matters

      Catherine Hennessey, MD | Physician
    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
    • The Titanic sinking: a metaphor for the impending collapse of medicine

      Aaron Morgenstein, MD & Corinne Sundar Rao, MD & Shreekant Vasudhev, MD | Physician
  • Recent Posts

    • Maximize sleep efficiency with stimulus control

      Pedram Navab, DO | Conditions
    • The Iranian diaspora’s fight for liberty: Overcoming challenges in the largest women’s rights movement of our century

      Montreh Tavakkoli, MD | Physician
    • Surviving clinical rounds: tips and tales from a pediatric hematologist-oncologist [PODCAST]

      The Podcast by KevinMD | Podcast
    • The harmful effects of shaming patients for self-education

      Maryanna Barrett, MD | Physician
    • The power of self-appreciation: Why physicians need to start acknowledging their own contributions

      Wendy Schofer, MD | Physician
    • The endless waves of chronic illness

      Michele Luckenbaugh | Conditions

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 1 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • How Many Steps a Day Keep the Grim Reaper at Bay?
  • RA in Remission? Stopping DMARDs May Be OK
  • Masking Still Required in About Half of Medical Offices, Poll Finds
  • Drug Shortage Leads to Firing Squads; FTC Non-compete Backlash; Illegal Laughing Gas
  • Abortion Is Not Murder in the Eyes of the Law

Meeting Coverage

  • Children Do Well With Fewer Opiates After Surgery
  • Advances in Diagnosis and Management of Severe Cutaneous Adverse Reactions
  • Orismilast Clears Skin in Moderate-to-Severe Psoriasis
  • New Combinations Promising in Advanced Urothelial Carcinoma
  • No Survival Benefit With CRT Versus Chemo for Locally Advanced Endometrial Cancer
  • Most Popular

  • Past Week

    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • It’s time for C-suite to contract directly with physicians for part-time work

      Aaron Morgenstein, MD & Corinne Sundar Rao, MD | Physician
    • The struggle to fill emergency medicine residency spots: Exploring the factors behind the unfilled match

      Katrina Gipson, MD, MPH | Physician
    • What is driving physicians to the edge of despair?

      Edward T. Creagan, MD | Physician
    • Beyond the disease: the power of empathy in health care

      Nana Dadzie Ghansah, MD | Physician
    • The psychoanalytic hammer: lessons in listening and patient-centered care

      Greg Smith, MD | Conditions
  • Past 6 Months

    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • The vital importance of climate change education in medical schools

      Helen Kim, MD | Policy
    • The fight for reproductive health: Why medication abortion matters

      Catherine Hennessey, MD | Physician
    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
    • The Titanic sinking: a metaphor for the impending collapse of medicine

      Aaron Morgenstein, MD & Corinne Sundar Rao, MD & Shreekant Vasudhev, MD | Physician
  • Recent Posts

    • Maximize sleep efficiency with stimulus control

      Pedram Navab, DO | Conditions
    • The Iranian diaspora’s fight for liberty: Overcoming challenges in the largest women’s rights movement of our century

      Montreh Tavakkoli, MD | Physician
    • Surviving clinical rounds: tips and tales from a pediatric hematologist-oncologist [PODCAST]

      The Podcast by KevinMD | Podcast
    • The harmful effects of shaming patients for self-education

      Maryanna Barrett, MD | Physician
    • The power of self-appreciation: Why physicians need to start acknowledging their own contributions

      Wendy Schofer, MD | Physician
    • The endless waves of chronic illness

      Michele Luckenbaugh | Conditions

MedPage Today Professional

An Everyday Health Property Medpage Today iMedicalApps
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Adverse childhood experiences: Can government policy reduce trauma?
1 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...