When Vermont State Legislator and physician Dr. George Till heard Dr. Vincent Felitti present the findings of the CDC’s Adverse Childhood Experiences Study at a conference in Vermont last October, he had an epiphany that resulted in a seismic shift in how he saw the world. The result: H. 762, The Adverse Childhood Experience Questionnaire, the first bill in any state in the nation that calls for integrating screening for adverse childhood experiences in health services, and for integrating the science of adverse childhood experiences into medical and health school curricula and continuing education.
That Vermont would be the first in the nation to address adverse childhood experiences so specifically in health care at a legislative level isn’t unusual. More than most states, Vermont is a “laboratory of change” for health care. It has embraced universal health care coverage for all Vermonters, and it passed the nation’s first comprehensive mental health and substance abuse parity law. (Washington State passed a law in 2011 to identify and promote innovate strategies, and develop a public-private partnership to support effective strategies, but it was not funded as anticipated. The Washington State ACEs Public-Private Initiative is currently evaluating five communities’ ACE activities.)
Vermont is also a state grappling with a number of social and health problems, including high rates of underage and binge drinking and a highly publicized drug-abuse crisis. A bright spotlight was shown on the state’s drug-related ills with Governor Shumlin’s single-issue state of the state address.
The ACE legislation came about as a result of the state’s activist traditions. Knowledge of the ACE Study had been percolating among people in several state-level departments. Essentially, the study links adverse childhood experiences with the adult onset of chronic mental health, physical health and social health issues. Other studies have shown short-term consequences in school-age children; ACEs are the best predictor for poor health and the second-best predictor for academic failure. Last year, says Kathy Hentcy, chronic disease prevention specialist at the Vermont Department of Health, the cross-agency group developed a consensus that the findings and implications of the ACE Study would be a focal point to convene diverse leaders from around the state for a series of meetings: a state-wide meeting, followed by a series of regional meetings. The goal was to plant seeds in communities around the state to examine the root causes of childhood trauma and find solutions.
The first meeting — VT ACE Conference: Improving Clinical Outcomes for Complex Patients — was where Till, a specialist in obstetrics and gynecology, had his epiphany. The conference was structured to encourage physicians, mental health experts, educators, state officials, legislators, corrections personnel, and others, to talk with each other and share ideas. The statewide conference set the stage for plans to be developed and implemented at the regional level. Hentcy says the high noise level of the breakout sessions reflected the energetic engagement among participants, some of whom, before the day was out, made immediate plans to meet locally.
Right after the meeting, Till and fellow legislator Mark Woodward, who also serves on the House Committee on Health Care, wrote and proposed H. 762, The Adverse Childhood Experience Questionnaire.
The initial draft was “pretty blunt but it certainly started a conversation,” says Till.
The bill takes measured but meaningful steps to address adverse childhood experiences (ACEs). The “Findings and Purpose” section carefully lays out the evidence related to ACEs and lists the many health conditions that accompany higher ACE scores. For example, a person with an ACE score of six or higher is 46 times more likely to abuse intravenous drugs. (For more information about ACE scores — see Got Your ACE Score?)
The key provisions of the bill are:
- The Director of the Blueprint for Health (a health care program that includes the majority of Vermonters) shall explore ways to implement two initiatives: 1) use of “an appropriate and voluntary screening tool containing questions on the ten categories of adverse childhood experiences, including consideration of patient privacy, appropriate training for providers using a screening tool, and increased per-member, per-month payments to incentivize use of an appropriate screening tool”; and (2) a pilot program in at least two interested counties using the Vermont Center for Children, Youth, and Families’ Vermont Family Based Approach to utilize a “family wellness coach” as part of the community health teams.
- The Commissioner of Health shall develop and implement a pilot program for primary schools in at least two interested schools districts throughout the state using the Vermont Center for Children, Youth and Families’ Vermont Family Based Approach.
- The Commissioner of Health shall designate a Director of Adverse Childhood Experience, Treatment, and Prevention within the Department who among other responsibilities will coordinate the implementation of services throughout the Department and will develop and implement programs, aimed at preventing and treating persons who experience trauma as a child.
- The University of Vermont College of Medicine and School of Nursing shall consider adding or expanding information to their curricula about the ACE Study and the impact of ACEs on lifelong health.
- Vermont Board of Medical Practice and the Vermont Medical Society Education and Research Foundation shall develop educational materials pertaining to the ACE Study, “including available resources and evidence-based interventions for physicians, physician assistants, and advance practice registered nurses.”
- The Department of Health is required to report to the Green Mountain Board (a body created by the legislature in 2011 to regulate health insurance rates and hospital budgets) on recommendations: to incorporate education, treatment and prevention of ACEs into the state’s medical practices and the Department of Health; on the availability of appropriate screening tools and evidence-based interventions; and on additional security protections for patients.
Days of testimony were taken and many concerns were addressed over the weeks before the Committee voted 9-2 to report the bill out of committee on March 14. The bill was referred to the Appropriations Committee, where it could either die or advance to the Senate Health and Welfare Committee. The “crossover” rules of the legislature put strict limits on timing so it will be known in a matter of days whether the bill makes it to the Senate.
A provision in the original bill was stricken early in the process that made Medicaid payments contingent upon the use of the ACE questionnaire. Taking a “carrot” rather than a “stick” approach — i.e., a trauma-informed rather than a punitive approach — the revised bill directs the Blueprint for Health to consider financial incentives, such as bonus payments, to encourage practitioners to ask ACE-related questions.
Fiscal concerns were also front and center in designing the legislation. According to Till, Dr. Jim Hudziak, director of the UVM Vermont Center for Children, Youth, and Families, who developed the center’s internationally-recognized Vermont Family Based Approach, offered the expertise and services of the center to help launch the pilots in community health teams and schools.
As the prime sponsor of the bill, Till worked hard to address his colleagues’ concerns. In the end, he was surprised that the vote was not unanimous. Lingering concerns were not entirely dispelled about providing adequate privacy safeguards and potentially harming patients by asking questions about trauma.
Testimony presented by the Vermont Psychological Association and a psychiatrist expressed the fear that patients would be re-traumatized by being asked questions about traumatic childhood experiences. Till said the data shows this fear is unwarranted — the ACE questionnaire was administered to 440,000 individuals at Kaiser Permanente in San Diego without a single crisis. In his own experience, patients appear to be relieved to be asked about early traumas. He pointed to the administration of the original ACE questionnaire to 17,000 individuals in San Diego where researchers were required to carry pagers 24 hours a day, seven days a week in the event that subjects had breakdowns when asked about trauma. Because no one ever asked for help, the beepers never beeped.
Because the evidence is crystal clear that traumatic childhood experiences impact health status and healthcare costs, the taboo around discussing these issues in a medical setting must be eliminated, notes Till. He says these types of questions must be asked with sensitivity and compassion — and it may take some patients a long time to feel they can answer them — but they need to be asked. These issues “must come out of the closet”, Till says, “so we can successfully manage the many chronic health conditions that stem from early childhood trauma.”(Felitti describes how he integrated ACEs screening in the Kaiser Health Appraisal Center.)
There are known evidence-based interventions that do help people who have experienced early trauma, says Till. Unfortunately, there is a wall between primary care and human services that, according to Till, must be broken down. The literature about evidence-based practices has been generated on the human services side of the wall and is unfamiliar to those on the medical side, he says. Till believes that a population health approach is needed as well as more tools to intervene earlier and prevent ACEs in the first place, e.g., by investing in parenting classes and training childcare providers. In the 15 years since the ACE Study researchers published the first paper, clinical trails are needed but have not been done that build on the findings of the original ACE Study, according to Till.
While Felitti was in Vermont, he presented the ACE Study findings, which he co-authored with Dr. Robert Anda, at Grand Rounds at Fletcher Allen Health Care. Till says that as a physician he was embarrassed that he had not previously heard of the ACE Study before Felitti’s visit. He asked other physicians, including a few who had recently graduated from medical school and were now in residencies, if they knew about the ACE Study; they almost uniformly said they did not, he notes. Physicians such as Jeffrey Brenner, MacArthur Foundation genius award winner and chief executive of Camden Coalition of Health Care Providers in New Jersey, and Steve Mann, a Vermont family physician, have spoken out about the value of the ACE Study and the need to address toxic stress in the primary care setting.
Hentcy said that the introduction of ACE concepts in primary care is the best way to reach the largest number of people, citing research that shows 90 percent of people visit a primary care physician, many on an annual basis. Primary care also provides the opportunity to address the multi-generational aspects of health and to take a holistic approach where physical health and mental health are treated together.
Awareness of the ACE Study and its implications continues to grow across many fields. In a speech earlier this year, one leader in mental health, former U.S. Representative from Rhode Island, Patrick Kennedy, said, “We have learned about the far-reaching effects of adverse childhood experiences, not just on mental health, but on overall health, and we are now beginning to see real measures communities can take to reduce the trauma too many children experience.”
The word is spreading in other state legislatures as well. ACEsConnection and ACEsTooHigh founder and editor, Jane Stevens, will be testifying at a California Select Committee field hearing April 4th on trauma-informed care, and commenting on solutions and innovations in schools and other settings. She will share the forum with legislators, foundation officials, and other experts including Dr. Christina Bethell (who also presented at the Vermont ACE conference).
These are hopeful signs that the long gestation period for the ACE Study and concepts is ending and a new period of solution-focused activity is accelerating. Certainly that is the case in Vermont.
A series of follow-up regional meetings — in April and May — will continue the planning and problem-solving in all 12 state health districts. The meetings will be held in hospitals and police departments — the largest local venues to accommodate community participation — so that everyone who wants to attend will be able to, says Hentcy.