Adverse Childhood Experiences: How the ACE Tool Can Improve Care in Family Practice

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1 Adverse Childhood Experiences: How the ACE Tool Can Improve Care in Family Practice William Watson, MD, FCFP Seema Bhandarkar, NP, MPH Katie Sussman, MSW, RSW Ashley King, MSW, RSW. With thanks to Esme Fuller-Thompson, Andree Schuler, and Rick Glazier May 24, 2018

2 Acknowledgement We would like to begin by acknowledging that the land on which we gather is the traditional territory of the Haudenosaunee, and most recently, the territory of the Mississaugas of the New Credit First Nation. The territory was the subject of the Dish With One Spoon Wampum Belt Covenant, an agreement between the Iroquois Confederacy and the Ojibwe and allied nations to peaceably share and care for the resources around the Great Lakes.

Ashley King MSW, RSW Program: FMF Toronto Nov 15/18

3 Faculty/Presenter Disclosure Faculty: Bill Watson, MD, FCFP; Seema Bhandarkar, NP; Katie Sussman MSW, RSW; Ashley King MSW, RSW Program: FMF Toronto Nov 15/18 Relationships with commercial interests: No relationships to declare 3

4 Disclosure of Commercial Support This program has received no commercial financial support This program has received no commercial inkind support 4

5 N/A Mitigating Potential Bias

6 Speaker Bios Dr. Watson is a Staff Physician at St. Michael s Hospital Family Practice Unit and an Associate Professor, Department of Family and Community Medicine, University of Toronto. Seema Bhandarkar is a Nurse Practitioner at St. Michael s Family Practice Unit and adjunct lecturer at the University of Toronto Bloomberg School of Nursing. Katie Sussman is a registered social worker at St. Michael s Hospital Family Practice Unit and an adjunct lecturer at University of Toronto Factor-Inwentash School of Social Work. Ashley King is a social worker at St. Michael s Hospital Family Health Team and Adjunct Lecturer, Factor-Inwentash School of Social Work, University of Toronto.

7 Objectives Interpret the evidence and the effects of adverse childhood experiences (ACE) on health Apply how knowledge of adverse childhood experiences in our patients can be used in family practice Explore strategies to provide trauma-informed care and specific interventions for individuals with high ACE scores

8 Meet Marcus Marcus is a 45 year old burly, tattooed man. He visits frequently complaining of pain and claims you are doing nothing for him. When he appears at the office your heart sinks. He is a single dad with 2 kids and he is very close to one son. This relationship motivated him to end his criminal activities. Unfortunately, he has chronic pain that started in his back, spread to his arms and legs, and now is everywhere. No treatment has been effective. He has become a loner, experiences anxiety and insomnia, and cannot maintain functional relationships. After struggling with his care for months, you finally take the time to ask him about his life. He is surprised, as he has never been asked about his upbringing. He was abused as a child, left home at age 14, lived on the streets, and worked as a labourer before joining street gangs. You ask him to do the ACE tool-his score is 8/10

9 Case Reflection As a family physician, what would be your next steps in supporting Marcus? How would you begin your assessment?

10 ACES: What Are They?

11 ACE Assessment Tool 1) Previous studies have developed the ACE survey which consists of 10 questions relating to childhood trauma: o Five are personal: physical abuse, verbal abuse, sexual abuse, physical neglect and emotional neglect. o Five are related to other family members: a parent who is an alcoholic, a mother who is a victim of domestic violence, a family member in jail, a family member diagnosed with mental illness, and the disappearance of a parent through divorce, death or abandonment. An ACE score of greater than four is associated with a significantly higher risk of health problems later in life (i.e. obesity, smoking, depression, suicide attempts, illicit drug use, heart disease and cancer) (Felliti, 1998).

12 Marcus ACE Score

13 ACE s Exist! CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) study: One of the sample of over participants Almost two thirds of the study participants at least one ACE One in Five reporting three or more ACES Study findings repeatedly reveal a graded doseresponse relationship between ACES and negative health and well being across lifespan

14 Why Bother? ACES impact more than just childhood have psychosocial impacts throughout the lifespan Correlated with physical, mental health, and chronic ailments: Alcoholism and alcohol abuse Chronic obstructive pulmonary disease Depression Fetal death Health-related quality of life Illicit drug use Ischemic heart disease Liver disease Poor work performance Financial stress Risk for intimate partner violence Multiple sexual partners Sexually transmitted diseases Smoking Suicide attempts Unintended pregnancies Early initiation of smoking Early initiation of sexual activity Adolescent pregnancy Risk for sexual violence Poor academic achievement Positive Correlation with the social determinants of health (Glowa, 2016)

15 Screening for ACEs: Primum Non Nocere Dozens of Kaiser Permanente pediatricians in Northern California screening three-year-olds for ACEs, ACE Blog. Nov 14, 2017 If you don t screen for it, and you don t look for it, you ll never find it, but it has more health impacts than you imagine

16 Possible Barriers to Assessing ACE: Physician Despite the correlation between mental, physical, and chronic ailments, research shows primary care practitioners are hesitant to assess and inquire about trauma Practitioner discomfort is related to a variety of factors, including: o Sensitive Nature of Topic and Brief Interaction o Lack of Trauma Informed Training o Limited Knowledge of Community and Support Services (Green et al., 2011)

17 Possible Barriers to Assessing ACE: Patient Before we ask: 1) what are the effective interventions and responses we need to have in place to offer to those with positive ACE screening 2) what are the potential negative outcomes and costs to screening that need to be buffered in any effective screening regime 3) what exactly should we be screening for? (Child Abuse Negl Aug 4. pii: S (17) doi: /j.chiabu [Epub ahead of print] )

18 Health Impact

19 Prevalence

20 The ACE Pyramid CDC.gov 2017

21 Possible Benefits in Assessing ACE: Patient ACE study suggests the need to screen routinely for adverse childhood experiences in all patients; to have an awareness of the relevance of adverse childhood experiences to intractable conditions and problem patients ; and to have a sense of appropriate approaches to treatment that need to be devised for each case. Analysis of a 125,000-patient cohort where such comprehensive biopsychosocial screening routinely was used showed a 35% reduction in doctor office visits (DOVs) during the following year. (Felliti, 2004)

22 St. Michaels Hospital Academic Family Objectives: Health Team: Pilot Study 1) Obtain an understanding of the prevalence of ACE within the Family Practice Unit. 2) To identify if interventions are needed to mitigate effects of ACE on health outcomes. 3) Begin to evaluate the feasibility of implementing an ACE screening tool in primary care clinics.

23 Results Of the fifty responses collected: o 38% had an ACE score greater 2 o 28% having an ACE score greater than 4 Both Male and Females scores averaged 2 (s = 3)

24 Returning To Marcus After this conversation, your rapport changes dramatically. You start to talk about the link between chronic pain and childhood trauma. He is open to this conversation and gradually visits less often, although you still see him regularly. When he visits, you listen to him with care, and when you discuss the need to wean him off the narcotics he has been prescribed, he is willing to participate despite his persistent pain. Now you both smile when you greet each other, and you are surprised to discover that you look forward to seeing him.

25 What can I do? Trauma Informed Care A strengths-based delivery approach grounding in understanding of and responsiveness of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and creates opportunities for survivors to rebuild a sense of control and empowerment (National Centre For Trauma Informed Care)

26 Principles of Trauma Informed Care

27 Trauma Informed Primary Care

28 Trauma informed Primary Care: Screening Screening for trauma, normalizing experience: We know that there is a direct relationship between traumatic experiences and a person s physical health; have you ever had a chance to explore these? Ask about trauma and needs prior to/and throughout procedures Discuss procedure and possible concerns, encouraging them to do what is comfortable (i.e. asking patient to disrobe, explaining procedure prior to pap, prior to DRE ) Certain procedures can be difficult for individuals, the steps involve.would you be okay with this?

29 Trauma informed Primary Care: Environment Increase training, awareness, and understanding of trauma and possible impacts and health outcomes Create a safe and secure environment (i.e. trauma resources in waiting room, posters inviting people to access supports, remaining consistent with time) Inviting opportunity for feedback i.e. patient advisory group

30 Trauma informed Primary Care: Response Power of Language shifting from a deficit perspective to a strengths-based perspective Can I ask what happened? vs. What is wrong? Tell me about a time vs. Did you experience this y/n You feel now is not the right time for this intervention vs. Not compliant Validation and Empathy I am sorry this happened to you, that must have been quite difficult. You were able to overcome so much Offer choice and trauma informed resources

31 The Question is not what s the matter with you, but.

32 Summary/ Recommendations ACEs are present in family practice Better screening for ACE scores, using it as a predictive tool when assessing both primary care and mental health ailments. Implement more trauma-informed care, possibly accessing training for clinic staff, enhancing client care, clinician capacity, and overall quality of care. Increase use of allied health for interventions (i.e. individual and/or group therapy), forming partnerships with community agencies to increase capacity, recognizing the impact such intervention may have on primary ailments.

33 Administer ACE Tool Score >4 Score < 4 Validate and Educate of ACE Scores Provide counseling resources if interested Ask if interested in further discussion either this visit or follow up If No IF YES -Ask about experience -Validate strengths -Check in at later date -Provide resources for social work, counseling, and/or trauma groups -Inquire about supports If Yes -Provide resources for social work, counseling, and/or trauma groups -If severe symptoms of anxiety/depression, offer medication or psychiatry referral

34 Ask, Assess and Educate According to research (Felliti 1998 & Glowa, 2016).: ACE score is correlated with increased long-term, chronic physical and mental health problems Note: Score of 1 or greater indicates ACEs Higher Correlation with poor health outcomes with score of 4 or higher Create Trauma Informed Environment Create environment characterized by physical and emotional safety Acknowledge and identiy impacts of trauma Recognize and validate strengths Educate and offer choice Educate on Recources Crisis Resources Social Work Support External Longer Term Support Follow up in 3-6 months

35 Thank you Questions?

36 Please fill out your session evaluation now! FMF app Fmf.cfpc.ca Session #: T200 Session Name: Adverse Childhood experiences: identification and strategies for intervention YOUR FEEDBACK IS IMPORTANT TO US!

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