RVTS registrars, supervisors, medical educators and staff recently gathered in Sydney for a 5 day face to face workshop. The workshop is always a highlight for everyone involved – it’s a time to master new skills and techniques, consider new ideas, meet new people and generally have fun while learning.
In one of the sessions, we discussed interventions for Adverse Childhood Experiences (ACE). This isn’t a new concept, but it was new to a lot of us who hadn’t considered it before. Initial studies on adverse childhood experiences done in the USA in 1995 found an association between adverse childhood experiences and health and social problems across the lifespan. Since then, there have been many international studies, increasing our understanding of the effects of adverse childhood experiences. The research considered ten stressful or traumatic experiences prior to the age of 18 years.
The ACE questionnaire has ten questions which ask about exposure to three categories of trauma: abuse, neglect and family dysfunction. You can review an example of the ACE questionnaire here.
An ACE score above four is significant, as people are more likely to have:
- depression – 460 times more likely
- Alcoholism – seven-fold increase
- Cancer – twice the risk
- Emphysema – four times more likely
ACE scores above six were associated with a 30-fold increase in attempted suicide.
Through the work that has been done, we now understand that:
- ACEs are common and a score of four and above are significant
- High ACEs in childhood increases cortisol production which changes brain structure, disrupts neurodevelopment and can change epigenetic markers
- These changes in epigenetic markers alter gene function and have a powerful impact on physical and mental health for a lifetime
- Importantly, these gene alterations alter the genetics of future generations
- Childhood stress and trauma has a long-lasting impact on thinking, interacting and learning
- High ACE scores are strongly associated with smoking, alcohol and drug abuse, severe obesity, depression, heart disease, cancer, chronic lung disease and shortened lifespan
- There is a dose-response between the number of ACEs and health risks
During the workshop session, we all realised that ACEs were common in our communities where we work, and we focussed on what we could do to assist patients who had been exposed to ACE.
These are some points from the small group discussion:
- Prevention is important: identify those at risk and refer for parenting support and assistance
- Identify patients who had been exposed to ACE by asking them to complete the questionnaire
- Educate patients on the long-term effects of ACE, but also educate them about strategies to decrease the effects by:
- Promoting positive relationships (e.g. refer to Social and Emotional Wellbeing / community groups)
- Regular physical exercise
- Stress-reduction practices – mindfulness, meditation, art, music
- Referring to programmes in the community that:
- Support victims/survivors of trauma to regain a sense of control over their daily lives and actively involve them in the healing journey
- Support safe relationship building as a means of promoting healing and recovery.
- build executive function and self-regulation skills
- Facilitate supportive adult-child relationships
- Build a sense of self-efficacy and perceived control
- Provide opportunities to strengthen adaptive skills and self-regulatory capacities
- Are sources of cultural traditions, hope and faith.
High ACE scores do increase the risk of poor health outcomes, but, just as having an increased risk of diabetes doesn’t mean you’ll definitely get diabetes, having an increased risk because of ACE does not mean you’ll definitely have poorer health. With positive interventions, it is possible to change the outcomes.
It’s important that we as GPs understand the impact of trauma on individuals and groups so that we can work towards creating environments in which patients feel physically and emotionally safe. Being mindful of our actions and words, employing culturally competent staff and adopting practices that acknowledge and demonstrate compassion.
Sometimes, the best thing we can do as GPs is to simply be there: be reliable, be attentive, be caring and supportive. And this is what we do well as GPs.
If the idea of ACEs is new to you, you may find the references and resources below helpful to gain more understanding of this important health risk.
Many thanks to Dr Lorri Hopkins for introducing ACEs to us, and assisting with the writing of this post.
Front Cell Neurosci. (2012; 6: 18.) Epigenetic effects of stress and corticosteroids in the brainhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3329877/
Dialogues Clin Neurosci. (2014 Sep) Lifetime stress experience: transgenerational epigenetics and germ cell programminghttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4214173/
Epigenetic effects of stress and corticosteroids in the brainhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3329877/
Lifetime stress experience: transgenerational epigenetics and germ cell programminghttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4214173/