Curbside Consultation

A Primary Care Approach to Adverse Childhood Experiences

 

Am Fam Physician. 2020 Jul 1;102(1):55-57.

Case Scenario

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?

Commentary

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,24 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

Address correspondence to Jennifer Hinesley, PsyD, LCP, at jennifer.hinesley@vcuhealth.org. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14(4):245–258....

2. Wade R Jr, Cronholm PF, Fein JA, et al. Household and community-level adverse childhood experiences and adult health outcomes in a diverse urban population. Child Abuse Negl. 2016;52:135–145.

3. Hughes K, Bellis MA, Hardcastle KA, et al. The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. Lancet Public Health. 2017;2(8):e356–e366.

4. Bellis MA, Hughes K, Ford K, et al. Life course health consequences and associated annual costs of adverse childhood experiences across Europe and North America: a systematic review and meta-analysis. Lancet Public Health. 2019;4(10):e517–e528.

5. American Academy of Pediatrics. Bright Futures guidelines and pocket guide. Accessed October 9, 2019. https://brightfutures.aap.org/materials-and-tools/guidelines-and-pocket-guide/Pages/default.aspx

6. Centers for Disease Control and Prevention. Violence prevention: adverse childhood experiences (ACEs). Updated April 3, 2020. Accessed April 30, 2020. https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/index.html

7. Krist AH, Davidson KW, Ngo-Metzger Q. What evidence do we need before recommending routine screening for social determinants of health? Am Fam Physician. 2019;99(10):602–605. Accessed April 6, 2020. https://www.aafp.org/afp/2019/0515/p602.html

8. FPM. Screening for childhood trauma history. January 24, 2020. Accessed April 3, 2020. https://aafp.org/journals/fpm/blogs/inpractice/entry/screen_for_aces.html

9. Ford DC, Merrick MT, Parks SE, et al. Examination of the factorial structure of adverse childhood experiences and recommendations for three subscale scores. Psychol Violence. 2014;4(4):432–444.

10. Prins A, Bovin MJ, Smolenski DJ, et al. The primary care PTSD screen for DSM-5 (PC-PTSD-5): development and evaluation within a veteran primary care sample. J Gen Intern Med. 2016;31(10):1206–1211.

11. Spoont MR, Williams JW Jr, Kehle-Forbes S, et al. Does this patient have posttraumatic stress disorder?: rational clinical examination systematic review [published correction appears in JAMA. 2016;315(1):90]. JAMA. 2015;314(5):501–510.

12. Korotana LM, Dobson KS, Pusch D, et al. A review of primary care interventions to improve health outcomes in adult survivors of adverse childhood experiences. Clin Psychol Rev. 2016;46:59–90.

13. Monson CM, Schnurr PP, Resick PA, et al. Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. J Consult Clin Psychol. 2006;74(5):898–907.

14. Resick PA, Nishith P, Weaver TL, et al. A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. J Consult Clin Psychol. 2002;70(4):867–879.

15. Iverson KM, Gradus JL, Resick PA, et al. Cognitive-behavioral therapy for PTSD and depression symptoms reduces risk for future intimate partner violence among interpersonal trauma survivors. J Consult Clin Psychol. 2011;79(2):193–202.

16. Stein DJ, Ipser JC, Seedat S. Pharmacotherapy for post traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2006;(1):CD002795.

17. Khachatryan D, Groll D, Booij L, et al. Prazosin for treating sleep disturbances in adults with posttraumatic stress disorder: a systematic review and meta-analysis of randomized controlled trials. Gen Hosp Psychiatry. 2016;39:46–52.

18. Krystal JH, Rosenheck RA, Cramer JA, et al.; Veterans Affairs Cooperative Study No. 504 Group. Adjunctive risperidone treatment for antidepressant-resistant symptoms of chronic military service-related PTSD: a randomized trial. JAMA. 2011;306(5):493–502.

19. Ravi A, Little V. Providing trauma-informed care. Am Fam Physician. 2017;95(10):655–657. Accessed April 6, 2020. https://www.aafp.org/afp/2017/0515/p655.html

Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous. Send scenarios to afpjournal@aafp.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 afpjournal@aafp.org. Materials are edited to retain confidentiality.

 

 

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