• FPs Are Best Equipped to Tackle Adverse Childhood Experiences

    Quick quiz: Which of the following is not associated with exposure to adverse childhood experiences, also known as ACEs?

    Heartbreaking, conceptual photo of son beaten by his own father

    A) Heart disease
    B) Cancer
    C) Chronic lung disease
    D) Obesity
    E) Parkinson's disease

    The answer: All of the above conditions have been closely associated with ACEs except Parkinson's disease, but a recent study suggests that even Parkinson's disease may be mediated by exposure to ACEs.

    We know that childhood trauma is a devastating experience that can impact mental health; we are also increasingly learning of its insidious effects on the body. Although it might not be surprising that childhood trauma and lifestyle/behavioral issues may be connected to poor long-term health outcomes, people may not realize that ACEs also have been directly linked to many chronic conditions, including asthma, eczema and even Alzheimer's disease.

    When family physicians ponder how to go upstream to address the social determinants of health, it's worth noting that ACEs are about as far up the river that one can swim. ACEs are a far-reaching public health issue implicated in at least five of the 10 leading causes of death. In a groundbreaking study published in 1998 in the American Journal of Preventive Medicine, responses from 9,500 adults showed how prevalent ACEs are in communities and how they impact health. Subsequent investigations have added to the evidence supporting a dose-response relationship between exposure to ACEs and the risk for chronic disease later in life. The public health implications are troublesome and enormous, considering that about 61% of adults report exposure to at least one ACE and one in six adults has been exposed to four or more.

    What exactly is an adverse childhood experience? An ACE is a potentially traumatic event experienced or witnessed in childhood. The 1998 investigation of ACEs studied traumas such as physical, emotional and sexual abuse; physical and emotional neglect; household dysfunction, including parental mental illness, an incarcerated relative, a mother treated violently and household substance abuse; and not being raised by both biological parents. Further study has shown that violence in the community, discrimination, bullying, death of a parent or guardian, or separation from a caregiver to foster care or migration are also forms of ACEs. Like many of the social determinants of health, ACEs disproportionately impact women and racial and ethnic minorities.

    Evidence suggests that ACEs disrupt normal brain development and alter the body's response to stress by altering the hypothalamic-pituitary-adrenal axis. The lifelong effects on behavioral responses to stress, on mental health and on physiology facilitate a path toward chronic disease and accelerated aging. ACEs are literally poisonous to the body and, in fact, are referred to as a form of toxic stress. Like air pollution and lead, ACEs are poisoning our communities and contributing to the chronic disease we see in our clinics.

    The good news is that recognizing exposure to ACEs early in childhood and intervening appropriately can mitigate the impacts on development and physiology and lead to better outcomes among children exposed to ACEs. In adults, recognition of their own childhood exposure to ACEs can be empowering.

    One of my patients, an adult survivor of childhood sexual abuse, expressed relief when he found out his history of trauma influenced his current health, and he subsequently became more engaged in his care for HIV infection. This kind of knowledge can help facilitate engagement with mental health resources and, most importantly, may motivate parents to learn skills to break the intergenerational cycle of transmitting ACEs from parent to child.

    If ACEs are so prevalent in our communities and have an outsized impact on the development of chronic disease, what would happen to our communities if we invested in a large, coordinated response to fight them?

    I have been excited to see my state take on this pervasive public health issue. California Gov. Gavin Newsom last year appointed Nadine Burke Harris, M.D., M.P.H., an expert on ACEs and advocate for a public health response to childhood trauma, as the first surgeon general of California. In his budget for 2020-21, Newsom recently proposed spending $10 million to raise public awareness of ACEs. This is in addition to the $45 million already earmarked in 2019-20 to reimburse physicians who screen for ACEs in children and adults covered by Medi-Cal, California's Medicaid program, and $50 million to train clinicians about ACEs and to help their patients with positive screening results. This public health initiative is groundbreaking.

    I represent the California AFP on the California Surgeon General's Trauma-Informed Primary Care Implementation Advisory Committee -- a group of stakeholders from private and public health systems, physician specialty organizations, academia, community organizations, and government agencies who are providing input on the surgeon general's plan. I was struck by how questions that have been raised reflect the many silos in medicine: How do we get obstetricians involved to prevent the transmission of toxic stress during pregnancy? How do we make sure the patient gets mental health care? How do we engage the patient's family?

    This is Family Medicine 101; this is our bread and butter. The value family physicians place on meeting the health needs of our patients, whatever they are, makes us uniquely qualified within medicine to address the impact of ACEs.

    Family physicians have helped patients deal with adversity and its complications since our inception as a specialty, for we have always intuitively addressed not just the disease but also the context in which our patients live. Now there is a name for one of these sources of trauma -- adverse childhood experiences -- with a growing body of science behind it. ACEs have captured the attention of our colleagues in other specialties and, if California is any indicator, they will also get the attention of the public. Now is the time for family physicians to call for more research on screening for and treating ACEs and to lead our health systems, our communities, and federal and state governments in tackling an upstream problem that impacts our patients so powerfully.

    Dr. Burke Harris set an ambitious goal of reducing ACEs by half in a generation. I am delighted by the magnitude of her resolve. To achieve this, our health system will need to engage patients, their families and their communities at every stage of life. In my view, there is no better physician to do that than a family physician.

    Brent Sugimoto, M.D., M.P.H., A.A.H.I.V.S., is the new physician member of the AAFP Board of Directors. You can follow him on Twitter @BrenticusMD.


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