Would pregnant women participate in surveys from their doctors asking them about whether they had experienced trauma in their childhood? In surveying moms-to-be at two Northern California Kaiser sites, clinicians discovered that the women were receptive to filling out an adverse childhood experiences (ACE) survey, according to a study that was published earlier this year in the Journal of Women’s Health.
In fact, researchers found out that the vast majority of pregnant women — 91 percent of the 375 women— were “very or somewhat comfortable,” filling out the ACE survey. Even more, 93 percent, said that they were comfortable talking about the results with their doctors. The women were surveyed from March through June 2016 at Kaiser Permanente clinics in Antioch and Richmond, CA.
ACE refers to the groundbreaking CDC/Kaiser Permanente Adverse Childhood Experiences Study that tied 10 types of childhood trauma, including living with an alcoholic family member or experiencing verbal abuse from a parent, to a host of health consequences. (Got Your ACE Score?)
The higher the number of ACEs that people have, researchers learned, markedly increases their risk for poor health outcomes, as well as social and economic consequences. Having four ACEs, for example, nearly doubles a person’s risk for heart disease and cancer, raises the risk of attempted suicides by 1200 percent and alcoholism by 700 percent.
The study, first published in 1998, emerged with a growing body of ACEs science that includes: how trauma affects the brain; how toxic stress has epigenetic effects from one generation to the next; how toxic stress from trauma results in short- and long-term health consequences; and how appropriate supports can build resilience and heal the harmful effects of toxic stress from ACEs. (ACEs Science 101.)
What really stood out for Dr. Carey Watson, one of the authors of the study, was the number of patients who felt strongly that their doctors should ask them about their ACEs. Around 85 percent of the participants “strongly or somewhat strongly agreed” that doctors should ask their patients about ACEs.
“it was really, really eye opening to me,” she said. “I was used to screening patients for ACEs, but I wasn’t sure how they would feel about it later.”
Researchers also screened patients for how resilient they are in coping with adversity using the Connor Davidson resilience screening scale. “We were interested in framing the conversation with patients in a way that might be more empowering or positive,” Watson noted. (Interpreting how patients’ resilience and ACE scores translate to health outcomes is the focus of an upcoming study by Watson and her peers.)
But Watson and her colleagues were also well aware that beyond their patients, they really needed to understand how their fellow physicians would feel about screening their prenatal patients about their ACEs. Would they find it acceptable, they wondered? Watson said that she was well aware that many of her colleagues were reticent about asking their patients about childhood trauma, wondering if a conversation would “open up a can of worms,” as Watson put it. That worry, said Watson, was perfectly understandable.
“This is a very foreign concept and uncomfortable for providers. It was not anything that any of my colleagues learned about in medical school,” Watson said.
A pre-pilot survey of clinicians showed they had “moderate” concerns about ACEs screening. After the pilot, which included training in trauma-informed care – how to talk in a sensitive manner to patients — their confidence and knowledge around ACEs screening increased.
“The fact that they felt, ‘yeah, we could totally do this,’ was a dramatic difference from where we started from.”
Unsurprisingly, one issue that clinicians agreed on, according to the study, was the need to ensure that resources and referrals for follow up for patients who were screened for ACES were firmly in place.
In surveying clinicians after the pilot, researchers learned that among the key reasons clinicians were comfortable with ACEs screening was that it was incorporated well into their workflow, including how they flagged patients for follow-up in the electronic health record, and because they were also screening for resilience.
“I think it would have been very difficult to have ACEs [screening] without the resiliency score, because then you wouldn’t have known what their coping mechanisms, and coping ability would be. We can’t change the trauma—the trauma is done. But the resilience piece, the coping piece, is the piece we can work on,” wrote one clinician in a survey that was quoted in the study article.
To Watson, the reason for taking the first steps in finding out pregnant women’s response was clear and goes to the very core of her work as the physician site lead at Kaiser Antioch’s Family Violence Prevention Program, and why she says she’s so interested in ACEs science.
“I already knew that people who were experiencing violence or witnessing family violence when they were children were more likely to experience intimate partner violence or become perpetrators of family violence, “she said. Witnessing a mother being physically abused is one of the 10 ACEs, along with experiencing physical, verbal or sexual abuse; experiencing physical or emotional neglect; living with a family member who’s depressed or diagnosed with other mental illness; living with a family member who’s addicted to alcohol or some other substance; having a family member who’s incarcerated; and losing a parent to separation, divorce or other reason.
Subsequent to the ACE Study, other ACE surveys have expanded the types of ACEs to include racism, witnessing a sibling being abused, witnessing violence outside the home, witnessing a father being abused by a mother, being bullied by a peer or adult, involvement with the foster care system, living in a war zone, living in an unsafe neighborhood, losing a family member to deportation, etc.
The ACE Study clearly shows that men and women who have high ACE scores (four or more) are more likely to perpetrate domestic violence, as well as be victims of domestic violence. The survey of the pregnant women showed that 54% reported 0 ACEs, 28% reported 1–2 ACEs, and 18% reported more than three.
In this study, which she oversaw at the Kaiser Antioch campus, Watson was able to begin zeroing in on an all-consuming idea: “What if we talk to expectant parents about ACEs and give them the support they need to help them heal from ACEs and help prevent that intergenerational cycle?”
Obstetricians, the journal article explains, are uniquely positioned to help break the “transgenerational cycle of ACEs,” by educating their patients about the health harms that ACEs can cause and giving them support and referrals, if necessary.
Watson has heard feedback from her patients that leads her to believe that she and her colleagues are on the right track.
“I’ve had some patients who said ‘This has always been on my mind. I’ve been afraid for my own children, because of their experiences in the world, because of high ACEs. But I’ve never known who to talk to about this or where to get help. I’m grateful to start the conversation.’”
In fact, because of their patients’ positive response to ACEs screening, Kaiser Antioch decided to continue screening patients and began again in April 2018. They’re looking at mental health, preterm birth, breast feeding rates, and substance use as they relate to patients’ ACEs and resilience.
“This is a learning time and it may be that we decide to expand or adjust based on continued learning,” Watson notes. “At this point we plan to continue indefinitely.”