The most important thing I didn’t learn about in medical school: Adverse childhood experiences

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Dr. Nancy Hardt

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The most important thing I didn’t learn in medical school is about adverse childhood experiences, also known as ACEs.

To be sure, if I had understood them then the way I do now, I would have been a better and more compassionate physician. Importantly, I would have avoided lots of mistakes.

What kind of mistakes, you ask?

I was pretty much a failure taking care of smokers, drinkers, drug addicts, and morbidly obese people. People who were chronically depressed or in chronic pain were not helped by me either.

I never understood that addictions to food, drugs, alcohol, and cigarettes, are imperfect solutions to the effects of toxic stress resulting from adverse childhood experiences. Toxic stress sets up pathways in the brains of traumatized children, pathways which persist into adulthood. We don’t outgrow these pathways, so as we get older, we try “home remedies” to treat them.

My mistake was to try over and over to get people to “give up” cigarettes, alcohol, pills, or overeating without addressing the reasons these things provide comfort. I was never taught that the stress receptors in our brain that are soothed by these substances are set up in early childhood. Our early experiences create memories which become structural realities in our brains. To try to address chronic pain with pills simply compounds the problem by adding a new one: addiction.

I failed to find out what kind of pain people were facing.  I was not taught to ask the right questions. The ACEs questions.

Drs. Vince Felitti and Rob Anda found the connection between adverse childhood experiences and chronic illness in adults during research on insured middle class people. When I learned this, I became intrigued. Could this information help me understand health disparities better?

Indeed, it did, leading my career away from caring for one patient at a time and towards caring for people. Lots of people. A neighborhood of people, a community of people.

I learned that there is hope accompanying learning about ACEs in our community.

Resilience can overcome the effects of toxic stress. As adults, we can’t undo the early childhood trauma we experienced. But, our ability to develop resilience starts in early childhood and never goes away.

We can develop resilience in ourselves, and we can help others develop it in themselves.

In fact, if you suffered ACEs as a child and are living an adult life free of addiction and chronic illness, you have someone to thank for it. Someone helped foster your resilience.

Our understanding of ACEs and the developmental effects of them have revolutionized the way communities think about young children.  Investments in pre-school education, health care for children, and addressing behavior problems in school have been found to be not only wise but enriching. Yes, community money spent early saves enough to make a community prosper later.

A lot is happening in Gainesville and Alachua County, where I live, to avoid trauma in pre-kindergarten children and their families. Gainesville4All teams are addressing important social structures and supports for young children, Peace4Gainesville is enhancing systems understanding of adverse childhood experiences and resilience, Partnership for Strong Families is providing supports to vulnerable families, and our County Commission is poised to make significant strategic investments in preschool children.

For older children, Alachua County Schools are coordinating with law enforcement to reduce disproportionate contact of minority youth with juvenile justice, and the River Phoenix Center for Peacebuilding is fostering reconciliation and enhancing resilience in those experiencing trauma.

This month, our local papers, the Gainesville Sun and the Guardian launch a multipart series about ACEs science and how people and organizations are integrating trauma-informed and resilience-building practices based on ACEs science. Join us on this journey to learn about toxic stress and the power of resilience to overcome it.

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Dr. Nancy Hardt is Professor Emerita, University of Florida College of Medicine. She was featured in an NPR story, A Sheriff and a Doctor Team Up to Map Childhood Trauma, in 2015. 

9 responses

  1. How many reading this, at age 12-15, would have gained strength and self-confidence to make better life decisions, if junior and senior high public schools offered classes in family law and criminal law? Both would address domestic violence. Thoughts?

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  2. So what specific actions can one take to do this “We can develop resilience in ourselves, and we can help others develop it in themselves.”

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  3. I read your article on ACE and was surprised I’d never heard of it before. I’m almost 70 now and had it existed in my youth I would have been identified as ACE. Regardless I went on to work within society helped along by a very limited group of people but only after I had removed myself from what had become unimaginable violence. My father was a very violent man, probably suffered from PTSD from WWII and Korea and used me as his punching bag at a very young age. It wasn’t until my 50th birthday that I realized that there was nothing I could have done to deserve having my face smashed into a table top, my teeth knocked out and my nose broken so many times I lost count. It was the reason I ran at a very young age. So I believe to be successful with a program for ACE you have to remove the child from the cause and you have to convince the child that there isn’t anything they could have done to deserve their abuse and you must convince them they were abused in the first place. In my generation I wouldn’t have recognized abuse if you’d stamped it on my forehead. Any real success at being normal I attribute to people like Phyllis Betts family, they welcomed me into their home not realizing at the time that I lived in a .25 a day hotel down-town and survived by working at a hamburger place. I had befriended one of Phyllis friends and that’s how I was introduced and ultimately accepted. I joined the Army as soon as I was old enough but always kept in contact with the Betts, seeing them each time I returned from Vietnam, there were many returns because I spent nearly 4 years there (it was another accepting family). I have always attributed my acceptance with the Betts and one other family as the reason I have some kind of normalcy in my life. I’m also a diagnosed and 70% disabled PTSD veteran, so in someways it continues. I raised two sons who’s Dad had PTSD but I was aware enough not to use physical violence but I was far from the perfect parent. ACE seems like a good awareness but you have to remove the child from the situation and you have to convince the child they are not the cause (biggest part)… being self aware goes a long way.

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    • Thank you for posting this, Dan. These words — So I believe to be successful with a program for ACE you have to remove the child from the cause and you have to convince the child that there isn’t anything they could have done to deserve their abuse and you must convince them they were abused in the first place. — are so true.
      If a child is lucky, removing the child from the cause might be educating the parent about his or her own ACEs so that they’ll stop passing that on. Sometimes that works, sometimes it doesn’t. Your sons certainly benefited from your self-awareness. I’m glad you’re healing.

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  4. So true!! I wish my physicians would have recognized in me that I was in extreme emotional pain when I was extremely underweight and going to the doctor all the time which was just for someone to pay attention to me. I also got pregnant at 17 so I could get married and escape my extremely abusive mother only to marry someone who was extremely emotionally abusive. My poor children paid the price but now they are in their late 30’s and doing well. I also became a workaholic mother and am now trying to make up for lost time which is almost impossible.

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