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,^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 been identified, physicians should assess for related sequelae. This includes determining whether the patient is at risk for further trauma, has undiagnosed mental health conditions (e.g., posttraumatic stress disorder [PTSD], anxiety, depression, suicidal ideation), and is engaging in unhealthy behaviors, including substance use. PTSD is a common manifestation of adverse childhood experiences and can be assessed using the Primary Care PTSD Screen^10,11 (Table 1).

Treatment regimens should address the patient's identified adverse childhood experience–related sequelae and may include a combination of counseling, medications, referral to specialists and community resources, and longitudinal support and follow-up. Collaborating with a multidisciplinary team to manage these complex, time-intensive matters is recommended. Symptoms and behaviors may be refractory, so it is often necessary to switch or combine treatments. For patients who are pregnant or have children, physicians may want to consider the potential risk of adverse childhood experiences being passed to the next generation. Parents are often motivated to pursue their own treatment and change unhealthy behaviors that can cause adverse childhood experiences in an effort to protect their children and to improve the parent-child relationship. Depending on circumstances, children and family members may also benefit from concurrent treatment.

First-line treatment for the mental health sequalae of adverse childhood experiences includes a combination of trauma-focused psychotherapy and medications. Cognitive behavior therapy has the most evidence of benefit.¹² It aims to modify problematic patterns of thinking and behavior by addressing negative or irrational beliefs. Cognitive behavior therapy has been shown to improve symptoms of depression and PTSD, to reduce risky behaviors, and to foster healthier responses to future adverse events.¹² Cognitive processing therapy, which helps patients learn how to modify and challenge unhelpful beliefs related to trauma, can also help adults with a history of childhood physical or sexual abuse. Cognitive processing therapy has evidence for reducing symptoms of PTSD, depression, anxiety, shame, and guilt.^13–15 Cognitive behavior therapy and cognitive processing therapy can be delivered individually or in group settings. Availability of these services can be a challenge based on the number of credentialed therapists, expense, and disparities in accessing face-to-face therapy for some underserved and under-resourced rural and low-income communities.

Serotonin reuptake inhibitors are a reasonable first-line medication if symptoms warrant.¹⁶ There are fewer studies assessing the effectiveness of serotonin-norepinephrine reuptake inhibitors. Prazosin (Minipress) is recommended for patients with significant sleep disturbance, including nightmares.¹⁷ Randomized clinical trials provide some evidence of effectiveness for second-generation antipsychotics (as monotherapy or augmenting serotonin reuptake inhibitors).¹⁸ If effective, medications should be continued for at least six to 12 months to prevent relapse or recurrence.

PREVENTING ADVERSE CHILDHOOD EXPERIENCES

Adverse childhood experiences can be prevented by supporting safe, stable, and nurturing relationships and environments.⁶ Strategies to build these relationships and environments include home visits for pregnant women and families, new parent training programs (especially for teens), intimate partner violence prevention by teaching healthy and safe relationship skills, teen pregnancy prevention programs, mental health and substance abuse treatment, high-quality child care, and income support for lower income families. Family physicians can play an important role by identifying patients who would benefit from programs to prevent adverse childhood experiences and by advocating for their community to build and maintain necessary supports and services.

APPROACH TO CARE

Physicians are encouraged to discuss adverse childhood experience–related concerns with patients in a timely fashion, using similar principles as those that apply to trauma-informed care.¹⁹ Providing sensitive and responsive care to the patient in the case scenario requires the use of empathic listening, reflection, and a nonjudgmental and supportive stance and allowing the patient to disclose at her own pace. Maintaining confidentiality is essential, especially because the alleged abuser may also be a patient. Addressing adverse childhood experiences can be difficult, and collaboration with a multidisciplinary team is important. Finally, safety, crisis planning, pharmacotherapy, and/or a referral to a mental health specialist may be warranted. Family physicians are well poised to help identify, treat, and prevent adverse childhood experiences. Doing so can improve the health and well-being of their patients and community.