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In this episode, we speak with Ariane Marie-Mitchell, a preventive medicine physician who discusses the impact of adverse childhood experiences (ACEs) on health and development. She discusses the challenges of using a clinical tool to diagnose patients with high ACEs, and the limitations of the current policy approach in addressing this public health crisis. She also shares her insights on the concept of creating a trauma-informed government, and the importance of engaging with stakeholders and using evidence-based policies in addressing the effects of early life stressors on individuals and communities. Join us as we explore the potential of government policy in reducing trauma and promoting health and wellbeing.

Ariane Marie-Mitchell is a preventive medicine physician.

She shares her story and discusses her KevinMD article, “Adverse childhood experiences: Can government policy reduce trauma?”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show is Ariane Marie-Mitchell. She’s a preventive medicine physician. Her KevinMD article is titled “Adverse childhood experiences: Can government policy reduce trauma?” Ariane, welcome to the show.

Ariane Marie-Mitchell: Thank you. It’s a pleasure to be here.

Kevin Pho: We’ll get into your article in a little bit. First off, briefly share your story and journey to where you are today.

Ariane Marie-Mitchell: Sure. I actually remember writing my college essay about my interest in mind-body relationships. I knew that our experiences and how we think about those experiences can affect our health, and I wanted to know more about how that happens. Stanford had a human biology major, which at the time was pretty unique and seemed like a pretty perfect way to study interactions between psychology, culture, and human health.

After college, I worked as a research assistant doing brain imaging and neuropsych testing. I definitely learned a lot doing that, but one of the things I learned was that I wanted to get a little closer to real-life stories and maybe help some people along the way. So I ended up enrolling in the MD-PhD program at USC, where my graduate work was in epidemiology and my dissertation was on biopsychosocial mechanisms of major depression.

From there, I went to residency, and I wanted to keep my focus on disease prevention. So I ended up doing an internship in pediatrics and a residency program in preventive medicine. The best part of that residency was a rotation that I did with the U.S. Preventive Services Task Force, an experience that continues to influence my understanding of the type of evidence needed to justify clinical preventive services.

I learned about the CDC study on adverse childhood experiences while I was working as a postdoc in preventive cardiology. It occurred to me that measuring ACEs in pediatric practice could lead to disease prevention, and that became the basis of the research that I am continuing as a faculty member at Loma Linda University.

Kevin Pho: All right. We’ll talk about that in a little bit, but one part of your story that caught my attention was your work with the U.S. Preventive Services Task Force. I’m a primary care physician myself, so obviously I’m very familiar with those guidelines. What was it like to work there?

Ariane Marie-Mitchell: Well, it was fun to be in D.C. My residency program was in Rochester, New York, so it was a pretty big deal. I had kids at home, and to go to D.C. was a big deal. It was very interesting to meet the people who were doing the work behind these guidelines. A lot of it was not necessarily very exciting. It was literally poring through the literature and sitting at a computer. But the best part was actually getting a chance to be part of one of their meetings where primary care physicians were invited. The members of the task force presented their data, and there was discussion about how we interpret this and all the subtleties of it, and some lobbying for different perspectives.

Kevin Pho: Take us into that room. I’ve always wondered, what was it like during those discussions?

Ariane Marie-Mitchell: Gosh. Well, I guess I haven’t sat in Congress, but I imagine it’s kind of similar: a lot of really smart, intelligent people, a lot of very opinionated people based on their practice experiences, but also a real commitment to making sure that we’re using the time wisely. There’s this opportunity that happens in primary care where a patient comes in and they really have not a lot of time with that primary care physician, and there’s a real awareness that we want to use that time wisely, and we want to use the dollars that we spend on prevention to make sure that it definitely helps.

Another really key focus is that we want to make sure to not do harm. So there’s a very acute understanding that sometimes, with good intentions, we may actually end up doing harm. And so it’s worth looking at that before making a recommendation for everybody to do a particular screening or other preventive service.

Kevin Pho: All right, let’s talk about your KevinMD article titled “Adverse childhood experiences: Can government policy reduce trauma?” How did this article come about?

Ariane Marie-Mitchell: Sure. Well, it came about in part because of the work that I was doing on ACEs. I actually got invited to be part of the conversation before California implemented their policy on ACEs. But then I watched as the policy got developed behind closed doors. It didn’t really follow what we had recommended. And I saw the public discourse when the policy came out. There were a lot of people who were upset about the idea of using an ACE score. They were upset about the recommendation for pediatricians to use a specific tool. And as I was watching this happening, I felt a lot of anger and frustration about the situation.

Kevin Pho: A little bit of context before we talk about some of the controversies: What was proposed? Just a little bit of background context for those listeners who may not be familiar with the discussion.

Ariane Marie-Mitchell: Yes. Well, first maybe I should define ACEs, or adverse childhood experiences. That refers to family-level risk factors: child maltreatment, any type of abuse or neglect, as well as household risk factors like a parent who’s divorced or is struggling with a mental health or substance use problem. So that’s what was trying to be addressed. There’s a lot of literature that has come out to date where they’ve done population-level studies and shown that when there’s an accumulation of early-life stressors, that puts that individual at higher risk for health problems. So this policy was about trying to address that public health crisis.

The policy that they came up with, though, was that in the case of pediatricians, they need to use a specific tool, and based on that tool, they give that patient a diagnosis of high or low ACEs. And if they do that, then they get paid for using that tool and making that diagnosis.

Kevin Pho: And if they score high on this tool, what happens next? What are pediatricians supposed to do?

Ariane Marie-Mitchell: Well, there’s a clinical algorithm, and there’s some education, a 2-hour training that’s given by the state, but it’s not really specific about what you do.

Kevin Pho: All right. And what are your thoughts on this policy?

Ariane Marie-Mitchell: What I was writing about, I would say, is a big idea, and then there’s a specific example. The policy on ACEs is the specific example, but the bigger idea that I was writing about is this idea of creating a trauma-informed government. The idea of being trauma-informed comes from the literature on ACEs and resilience. While ACEs are about ending abuse in the home, being trauma-informed is about ending abuse in our society, whether that’s in our schools, the places that we work, or our government. That big idea sounds good, but how to go about it is a little more complicated.

There are principles to guide being trauma-informed, one of which is understanding the biology of stress and how we can use that to change our own behavior and our response to others. Other key principles are promoting safety in our relationships and being collaborative, such that we minimize rather than play into power differences, right? So when the government creates policy in a trauma-informed way, they purposely engage in dialogue with a range of stakeholders, and whatever policy they come up with should be justified based on the evidence to date. In that way, that policy feels like something that is coming from us and is justified, rather than being done to us and being questionable.

So that’s the big idea that I’m really passionate about, because I think the idea of trauma-informed government is really key to creating a healthy democracy. In the paper, though, I talk about the specific example of this California policy on ACEs, where I think the government had good intentions, but they did not use a trauma-informed process, and they ignored the lack of evidence to create a policy on ACEs.

Kevin Pho: When you talk about the government becoming more trauma-informed, if you were totally in charge of policy, how would you do that? How would you make them more trauma-informed?

Ariane Marie-Mitchell: Yes. I think key to that is this idea of transparency, right? I think a lot of times there is engagement with the public. In this example, there was a task force that was set up to provide advice about how to respond to ACEs and what kind of policy to create. But when the actual policy was created, that happened behind closed doors. I don’t know who was involved in the decisions, but it basically ignored the recommendations. So ideally, there would be transparency about the approach and the reasoning. We’re never going to get to 100 percent agreement on something, but at least if there’s dialogue, that will help promote trust.

The other key thing that I think is important, especially for health care policies, is that the policy be at least evidence-based or evidence-informed, right? So if there’s a lack of evidence, which there often is, and there is often more research needed, at least the policy matches what we do and don’t know.

Kevin Pho: If the government was trauma-informed, how would that have changed the recommendations that could have come out?

Ariane Marie-Mitchell: Right. As I kind of go through in the article, first of all, we don’t have the evidence to date to recommend a specific tool. In fact, that task force that I referred to recommended that physician practices have the choice of their approach to asking about ACEs. That would be the first change. The second specific change: Right now, the policy asks us to create a score and make a diagnosis based upon that score, and that’s not really justified. So I recommend instead this idea of asking about specific ACEs so that we understand the family context, and we can use that specific information to address family needs.

Kevin Pho: Can you speculate why the government did what they did?

Ariane Marie-Mitchell: I think there were a lot of people who were passionate about the topic of ACEs, and they also wanted to create something that seemed simple so that it could be widely implemented. The idea of having physicians just calculate a score and respond to a number, I think, has a simplicity to it that is appealing. But the reality of the experience of ACEs is that they are complicated. If you take two families reporting a child with an ACE score of four, the circumstances and the situation around that family are complicated. There may be different ACEs involved, the child may have different degrees of resilience in their lives, and different degrees of health care symptoms. So, I mean, it’s just really not something that can be boiled down to a score successfully.

Kevin Pho: What kind of unintended consequences do you see from this approach? You went into a little bit of a story where sometimes ACEs cannot be boiled down into a score. What are some of the unintended consequences that may arise?

Ariane Marie-Mitchell: The concern is that if we focus on a score, first of all, there’s misdiagnosis. We may be raising somebody’s anxiety about their child. There’s this idea of toxic stress, which in itself is complicated, because we don’t have a gold-standard measure of toxic stress. But there’s this assumption that when we use a score and we see higher ACEs, there’s the presence of toxic stress, which we don’t actually know is the case for that particular patient. So in talking about this idea of toxic stress with families, we may be misinforming them. We may be missing folks who do in fact have stressful circumstances but don’t report them. And then we may be inappropriately allocating resources to families who do report concerns and missing other families who don’t report concerns.

Another thing is that, in terms of the current policy, I think because it is very prescriptive and it’s telling physicians how to go about this, it doesn’t necessarily engage physicians in making their own choices and working with their families about their own approach to asking about ACEs. Just as an example of that, in our practice, we developed an approach that works well for us because it’s integrated into the well-child care visits that we do, and a key part of what we’re asking about is actually risk for ACEs. I think that is something that’s overlooked in the current California policy, because they’re using a tool which is only asking about exposure to ACEs. But pediatricians have the opportunity both to prevent ACEs from happening and to mitigate the impact when that happens. So I think that’s an important area.

Kevin Pho: Where do you see the path going forward? Do you see any way to introduce some of the nuance and complexity that you’re talking about, or is this pretty much going to be the way it is?

Ariane Marie-Mitchell: No. This is how the policy currently is in California. I know other states around the country are making their own decisions about how they want to respond to ACEs, and I hope that they will consider some of the story that I shared in this article. I think California, too, has an opportunity to revise the policy and make it line up better with what we do and don’t know to date, and in so doing, empower their patients and physician partners so that we can in fact improve outcomes for families. That is what we want.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Ariane Marie-Mitchell: Absolutely. There are a lot of people trying to influence how health care is done. Insurance plans and state and federal governments are at the top of the list, and I get that. But I think that in the process of trying to get to the outcome that we want, it is important to take the time to partner with the people involved in getting that outcome. If it’s an educational policy, we would want to partner with teachers as well as students and parents. For a health care policy, we have to make sure to engage the health care staff and providers as well as patients and families. If we do that, that will earn their trust and engagement, which will be so critical to the success of whatever policy we’re implementing.

It also means paying attention to the evidence that we have to date to make sure that our policies are informed by the evidence and justified. I think that all government action should be trauma-informed, but particularly policies about ACEs, since how we go about ending abuse is pivotal to our ability to actually succeed in ending abuse.

Kevin Pho: Thank you so much for sharing your story, time, and insight. Thanks again for being on the show.

Ariane Marie-Mitchell: Thank you.