A Primary Care Approach to Adverse Childhood Experiences
Am Fam Physician. 2020 Jul 1;102(1):55-57.
A 41-year-old long-time patient presented with concerns about irritability, depression, and anxiety after getting into another fight with her mother-in-law. The patient was concerned that her symptoms were getting worse, and she was worried about lacking control over her emotions and behavior. She commented that she has been easily upset when perceiving that others are disrespecting her. The patient shared that she has experienced similar conflicts with others since childhood. When asked to share more about her past, she talked about severe depression brought on by childhood physical and sexual abuse. When asked whether these past experiences might be contributing to her current difficulties, the patient was unsure how the two were related.
How do adverse childhood experiences effect a patient's health and well-being, and what is the role of family physicians in addressing them?
Adverse childhood experiences are defined as childhood exposure to various forms of abuse and household dysfunction, including psychological abuse, physical abuse, sexual abuse, substance abuse, mental illness, domestic violence, and criminal behavior. The landmark study (conducted in 1998 and reprinted in 2019) to assess the prevalence of adverse childhood experiences in adults and their association with adult health risk behaviors and adverse health outcomes was conducted in primary care.1 Of the 9,508 respondents, more than one-half of adults reported at least one adverse childhood experience, and one-fourth reported two or more. Compared with those who had no adverse childhood experiences, individuals who experienced four or more adverse childhood experiences were four to 12 times more likely to have unhealthy drinking, drug abuse, depression, and suicide attempts and were two to four times more likely to smoke, rate their health as poor, and have had 50 or more sex partners or a sexually transmitted disease. Furthermore, exposure to adverse childhood experiences was associated with greater rates of ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease.1 These findings have been replicated,2–4 and adverse childhood experiences have received national attention from the American Academy of Pediatrics5 and Centers for Disease Control and Prevention.6
IDENTIFYING ADVERSE CHILDHOOD EXPERIENCES
The U.S. Preventive Services Task Force does not have a recommendation about screening for adverse childhood experiences but does recommend screening for adverse childhood experience–related sequalae such as intimate partner violence, depression, sexually transmitted infections, unhealthy alcohol use, drug use, poor diet, and sedentary lifestyle.7 Similarly, Bright Futures does not have a recommendation to screen for adverse childhood experiences but recommends that physicians ask questions when there is a concern about children and adolescents being exposed to family violence and substance abuse.5 FPM provides a helpful review of adverse childhood experience screening tools.8
Clinical scenarios for physicians to potentially identify adverse childhood experiences include patients mentioning exposure to those experiences during history taking, physicians suspecting and asking about adverse childhood experiences, and observing real-time exposure to adverse childhood experiences in children when managing a parent's mental health needs or unhealthy behaviors.
If an adverse childhood experience is suspected, physicians should ask whether the patient has experienced various categories of events; ask an overarching question such as whether the patient has ever experienced an event that was frightening, including abuse, domestic violence, or parental substance abuse; or administer an adverse childhood experience questionnaire (https://www.ajpmonline.org/article/S0749-3797(98)00017-8/fulltext).1,9 When adverse childhood experiences are disclosed, it can be helpful to ask patients to describe their thoughts and feelings about the traumatic event at the time it occurred, throughout their lives, and currently. Follow-up questions should include how patients think adverse childhood experience–related events have affected them and how their thoughts about the experience might have changed over time.
MANAGEMENT OF ADVERSE CHILDHOOD EXPERIENCES IN PRIMARY CARE
Once adverse childhood experiences have
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Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous. Send scenarios to firstname.lastname@example.org. Materials are edited to retain confidentiality.
This series is coordinated by Caroline Wellbery, MD, associate deputy editor.
A collection of Curbside Consultation published in AFP is available at https://www.aafp.org/afp/curbside.
Please send scenarios to Caroline Wellbery, MD, at email@example.com. Materials are edited to retain confidentiality.
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