Screening for adverse childhood experiences in integrative healthcare settings

By Julie Luzarraga

Adverse childhood experiences (ACEs) refers to different types of abuse, neglect, and other trauma a person experienced as a child. The Centers for Disease Control and Prevention (CDC) and Kaiser Permanente conducted a study examining the connection between such negative experience and health in 17,000 Health Maintenance Organization members. The results showed links between adverse childhood experiences and risky health behavior, psychological issues, chronic illnesses, and mortality.  Furthermore, the study showed a dose-responsive trend. The higher the ACEs score, the more likely a person was to have experienced compromised health, difficulty regulating emotion, and high-risk health behaviors. 

The growing emphasis on incorporating screening into healthcare settings aligns with the integrative healthcare approach to treating the whole person. Knowing that resilience, emotional-regulation, and positive health behavior can be learned, integrative healthcare providers need to know when a high ACEs score maybe contributing to a patient’s health and wellness. There are several steps to implementing the use of ACEs screening in your practice.

Trauma is more common than most practitioners think, and the chances are high that regardless of where you practice, a large percentage of patients you treat have experienced trauma at some point in their lives. In the CDC study, almost two-thirds of study participants reported at least one ACE, and more than one in five reported three or more ACEs. Knowing your patient’s ACEs score can dramatically impact diagnosis and treatment planning. 

Incorporating ACEs score into working diagnosis may lead a provider to look more closely at comorbid substance abuse and mental health issues. Diagnosis may become more complicated, but it will also enrich the treatment plan. Looking through a trauma-competent lens recognizes the complicated factors of trauma, illness, health, and prevention. Someone who grows up with multiple adverse experiences such as witnessing or experiencing violence and neglect will likely have fewer coping skills and difficulty regulating emotions. Interventions then may include earlier health behavior coaching, relaxation skills, cognitive behavioral therapy, and other treatments that will support increased resilience. 

Understanding the context of presenting symptoms through a trauma-competent lens will inform the patient-provider relationship and communication. Adults who have experienced significant trauma can be easily triggered, interpreting situations as threatening. Being a patient is a vulnerable position for many trauma survivors who have often had difficulty with intimate relationships. Late cancelations, missed appointments, and frequent emergency room visits or crisis calls should be seen as a patient’s difficulty with self-regulation versus other shaming interpretations. 

When we know a patient has a high ACEs score and we can appreciate the difficulty, we can help support them in their healthcare journey. When I see patients with trauma histories, part of my initial appointment with them includes creating safety for them in the relationship. I tell them that they may feel anxious or worried at some point and either be afraid to call the clinic or maybe even not want to come to their appointment. I then encourage them to call or come anyway but tell me about it. I also give them permission to not talk about things so that they remember that they have control of how they share their stories. 

Implementing screening of ACEs into your practice has many benefits when it is done thoughtfully with a plan for how you will screen and use the information. Providers should receive training in trauma-competent care, have a process in place for how the information is shared, and have a collaborative team to refer to when appropriate. In my experience, most patients are grateful when asked about their ACEs, but how they are asked and how often they are asked are defining factors in their perception. 

In our integrative healthcare clinic, a patient may have a new appointment with a primary care provider, an acupuncturist, a therapist, a psychiatric medicine provider, or any number of healthcare providers. One provider asking about ACEs feels validating, however multiple providers asking the same questions could potentially trigger a patient and feel invasive. Our policy is to have the ACEs screening in the shared chart and noted so that any provider working with the patient can see that it has been asked.

Additionally, trauma-competent practice is to ask permission to administer the questionnaire and explain why. Trauma survivors experienced negative events that they had no control over and made no sense; things were done to them. Trauma-competent healthcare providers work with patients and educate on why so that there is less fear and anxiety. When assessing someone’s ACEs, I first ask if I can ask the questions and explain why I would like to ask. I share that we now know the higher your score the more likely you are to experience other health issues, have difficulty with changing health behaviors, and regulating mood. When I explain this, I find most patients are relieved and willing to answer the questions without feeling shamed.

Once it is established that a patient has a higher ACEs score, there are multiple resources we can introduce to further support patients. Depending on the patient and their unique situation, support groups or shared healthcare appointments are great ways to help create community and added support. Evidence-based treatments like cognitive behavioral therapy and mindfulness-based stress reduction therapy are helpful additions to a patient’s treatment plan.  Particularly when the trauma is significant, team members should get permission to communicate with each other and create a collaborative treatment plan. For many trauma survivors, life was chaotic and confusing. Clear communication and treatment plans that complement versus contradict will help patients be more successful and engaged in their care.

Up until recently, trauma has been a taboo topic in our society.  Unfortunately, it is a significant part of many people’s lived experience. When we neglect to learn about that part it can be detrimental to the patient and frustrating for the provider. As integrative healthcare providers, we need to be developing thoughtful processes for incorporating this into our practice so that we are continuing to fully understand our patients and their unique experiences.