ACEs

A few days ago, Victo Dolore posted a piece titled Quagmire in which she discussed being at a loss in dealing with an obese patient. No approach that she had tried seemed to connect with the patient about the need to lose weight. This communication problem sent her on a quest for other possible approaches that might work, a quest that eventually led to a post on another blog, ACEsTooHigh, titled The Adverse Childhood Experiences Study — the largest, most important public health study you never heard of — began in an obesity clinic. The ACES post reports on work carried out by Dr. Vincent Felitti and Dr. Robert Anda. Dr. Felitti noticed that patients in his obesity clinic would lose 100 pounds or more and then drop out just when they were making real progress, and he wondered why.

Studying 250 of his own patients he uncovered a strong connection between obesity and what have since been called Adverse Childhood Experiences, ACEs. ACEs include events such as abuse and neglect, violence in the home—abuse of mother or siblings, violence in the neighborhood that a child has witnessed, alcoholic of drug-addicted parents, or a parent that has been in jail. And, obesity wasn’t the only problem connected with ACEs. Other adult problems, such as alcohol or drug abuse, depression, criminal activity, and even diseases such as COPD, IBS, and fibromyalgia are much more likely in adults with non-zero ACE scores, and increasingly likely as the ACE score increases. After having some surprising difficulty getting his peers to believe his results, Dr. Felitti, together with Dr. Anda and others, conducted a much larger study involving over 17,000 patients.

The article has some stunning stats in it (you should read it). Perhaps the most surprising to me was the possibility of long delayed effects (decades in some cases) of childhood trauma and of ongoing trauma having the effect of permanent changes in brain structure as a result of toxic changes in brain chemistry. I’m not in any health care field, so I’m sure that I think I know more than I really do, but I found those effects surprising.

I also found stunning the quotation from a rape victim ‘Overweight is overlooked, and that’s the way I need to be.’ According to the article, she had gained over 100 pounds in the year after she was raped, and the weight gain appeared to be a (semi-)conscious protective measure against being raped again.

I was led to read more from the ACEsTooHigh blog and followed some links to other sites. One that was particularly interesting dealt with Trauma-Informed Care (TIC). It was a power-point presentation by Tim Turner from the Substance Abuse and Mental Health Services Administration (view it here) that had a list of what is TIC and what isn’t. My first impression was “that sounds pretty good—what do I have to do to be treated that way?”

So, what about the treatment of adults? Not knowing anything about toxic stress, I went looking for more information on the network–not the best way to search for scientific results, I realize, but a good place to find an overview or pointers to more scientific results. What are the effects of toxic stress on adults, and can what has been learned about treating children be applied to adults. I thought I would find information about how adults are being treated to alleviate the effects of stress, or at least find information on PTSD as a result of stress. Nada. Maybe I gave up too easily or was guilty of Google Incorrectness, but I found only one site, and that was about how to deal with a micromanager. Good stuff, I suppose, but “watch funny movies and get some exercise” wasn’t what I was after.

There doesn’t seem to be much to read, so we’ll have to resort to MSU (making stuff up). Let’s do a little thought experiment. Suppose that we applied the general principals of TIC (which distill down to things such as basic respect, asking what the patient wants, trying to be collaborative instead of authoritarian, involving patients in their care) to residents in nursing homes. Could that do something to lessen or even reverse what seems to be an almost universal revulsion for nursing homes? Could it make them feel less like warehouses or places of incarceration? (The only thing my mother ever said about the way we cared for her was “Don’t put me in a nursing home.” She lived in an Assisted Living Facility at the time, and her experience was that people had a medical event of some kind, were trucked off to the hospital, sent to a nursing home, and never heard of again. To her, a nursing home was a death sentence.) Do your own thought experiment and tell us what you learned.

Let’s try one more thought experiment. What if we had Trauma-Informed Policing? (I know you haven’t looked at that power-point yet. You better go do that before trying this one.) For this experiment, suppose that we have already reversed the current fad of militarizing police departments and gotten that toxic idea out of our systems.

If you have gotten this far, you should go back and read those other posts now. Then report the results of your thought experiments. Happy experimentation.

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4 thoughts on “ACEs

  1. I love the TIC slides. Thanks for sharing that! Don’t focus on “what is wrong with you, but rather what happened to you.” For a bit I wanted to do psychiatry. Then I spent time at state hospitals and the horror there was just too much for me to bear. TIC should be the norm across all medical care. Trauma Informed Policing is something I will have to chew on for a bit, though…

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    • There is a lot in those slides. You have picked out one of the most crucial parts–the idea of reframing the whole attitude towards care. Is a long term stay in a nursing home medical care that includes housing, or is it a housing option that includes medical care? Is the purpose of policing “to protect and serve” as it says on many, many police cars across the country, or is it to keep people in line? Can we reframe policing to make it more equitable, less violent, and, at the same time, more effective? The phrase “Trauma-Informed Policing” was an attempt to stretch the TIC idea to a larger arena than health care. Not a particularly good descriptor for what that kind of policing would look like.

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  2. I’m thinking that “trauma” is probably a spectrum thing, depending not only on the objective event that occurs, but also the extent to which an individual’s psyche is disrupted by a given event. There are some folks, I think, who have what must be a hereditary resilience . . .

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    • You must be right about that. Trauma doesn’t come in discrete chunks, so it must be (at least almost) continuous. Some folks are more resilient just like some folks have a higher threshold of pain. Where ACEs are concerned, there is also the effect of having seen too much, where you become inured to further assaults and each one has a smaller effect.

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