Season 2, Episode 8: ACEs Adverse Childhood Experiences

There are countless factors that engage in the bigger picture of a patient's health, notably Adverse Childhood Experiences, or ACEs. Dr. Joshua Gettinger talks with Dr. Amy Santin, to reveal a myriad of statistics that demonstrate the emphasis on early childhood experiences and how their background can affect a patients’ health long term. We hope you enjoy this illuminating episode! 

TED Talk: 

 “How Childhood Trauma Affects Health Across a Lifetime,” Dr. Nadine Burke Harris https://www.ted.com/talks/nadine_burke_harris_how_childhood_trauma_affects_health_across_a_lifetime?language=en

 Book:   

The Deepest Well: Healing the Long-Term Effects of Childhood Trauma and Adversity, by Dr. Nadine Burke Harris

 Methods to Assess Adverse Childhood Experiences of Children and Families: Toward Approaches to Promote Child Well-being in Policy and Practice, Academic Pediatrics, Dr. Christina Bethell, et al   https://www.academicpedsjnl.net/article/S1876-2859(17)30324-8/fulltext

 Positive Childhood Experiences and Adult Mental and Relational Health in a Statewide Sample: Associations Across Adverse Childhood Experiences Levels, JAMA Pediatrics, Dr. Christina Bethell, et al   https://jamanetwork.com/journals/jamapediatrics/fullarticle/2749336

 The Data behind Adverse Childhood Experiences (ACEs) and Resilience, Dr. Christina Bethell, https://bhdp.sccgov.org/sites/g/files/exjcpb716/files/t2-data-behind-aces-and-resilience-10-20-16.pdf

 PACEs Connection: 

 https://www.pacesconnection.com/

Please provide feedback here:
https://redcap.mahec.net/redcap/surveys/?s=XTM8T3RPNK 

Transcript

Intro [00:01]: Hi everyone, and welcome or welcome back to just us before birth and beyond. We're so glad to have you here with us today. My name is Katlyn, and I have been a nurse in Western North Carolina for the last 10 years, and I'm also one of the hosts of this podcast, and I'm here to introduce our episode for today. So, today's episode is on adverse childhood experiences or ACEs, as you will hear it referred to often in the episode. And I am really excited about this one. So, in that episode, we cover what ACEs are, and what adverse childhood experiences mean. Our hosts talk a little bit about how to screen for ACEs and whether or not we even should be screening for ACEs and how do we move forward thinking about how trauma or adverse childhood experiences affect our patients and how should it then affect the way we care for our patients. It's a really good episode, with a lot of rich information. Our guest, Dr. Godinger, is just fantastic and very passionate about this topic, and it really comes through in the episode. So, we hope you enjoy it, and without further ado, here we go.

Amy Stanton [01:20]: Good morning everyone, this is Amy Stanton. I am a family medicine faculty member at the May Heck Family Medicine Residency Program in Asheville. I'm also the lead family medicine champion for the maternal health innovation program. I am extremely honored today to have a special guest, Dr. Josh Godinger, who is going to talk with us about adverse childhood experiences. We are very grateful to have you here today. Josh, would you care to introduce yourself?

Dr. Josh Godinger [01:53]: Yeah, my name is Josh Godinger. I am a faculty member of the Family Medicine Residency at May Heck in Asheville, North Carolina. I came here about 11 years ago after 33 years as a small-town family doc in east Tennessee, and I became very engaged in children's mental health and brought this passion to Asheville. When I came here 11 years ago, one of the first things I did was to take advantage of the fact that the position of behavioral health champion in the residency was open and I became, I've been the behavioral health champion in the residency for the last 11 years.

Amy Stanton [02:37]: That's wonderful, Josh. I can't think of a better person to come and speak to us about ACEs. You and I were talking recently about, you asked me what was your epiphany moment around ACEs and I said to you that I had never heard of it until you came and joined our faculty and then I heard about it a lot at faculty meetings, every faculty meeting in didactic session, and I say that with the utmost affection and respect, but it really helped transform the way that I think about a lot of my patients. So, can you share with us what your epiphany moment was around ACEs?

Dr. Josh Godinger [03:20]: I'm happy to actually, it was a pivotal moment in my life. I came here again in 2012 and the ACE study had actually been published 14 years earlier, and even though I'd been working in children's mental health for decades, I hadn't heard of the ACE study When I came here by chance, the American Public Health Association mid-year meeting was in Charlotte, North Carolina, and I met Gabby Harris, who was the head of the Buncombe County Public Health Department and told her that I was interested in children's mental health and she told me, oh, you have to talk to Melissa Baker. Melissa at that time was shepherding a community effort called Innovative Approaches, and one of their projects was working on ACEs, and she said to me, have you heard of the ACE study? And I hadn't, I had seen personally practicing in a small town over and over again, the ravages that ACEs did on my children's patients.

And also, it became obvious to me after a few years that if I saw adults with premature morbidity that were, were sick beyond what they should have been at their age, they were often all too often due to things that had happened to them in childhood, and sometimes leading to behavioral changes, but sometimes just seemed to take its toll on them. So, again, it didn't take long for me to appreciate the significance of the study and I was happy to join the community project and learn more and more over those first years of practice in Asheville, so, that was my introduction to ACEs.

Amy Stanton [05:01]: Yeah, thank you for sharing that and we appreciate your introducing it to our practice. So, since we have a broad audience here, could you spend a few minutes telling us about the ACE study and what that is?

Dr. Josh Godinger [05:18]: Yeah, the bottom line that the ACE study showed in 1998 in San Diego, California was that adverse childhood experiences are pervasive and very common, and the second obvious conclusion from the study was that ACEs have serious adverse effects on mental health and physical health throughout a person's life cycle. I'd like to talk about the study as a story. I'd like to tell the story of the ACE study because I think it sticks better, and also I think even listeners who are familiar with it may not have heard some aspects of this. It all began several years before 1998 with an obesity researcher at Kaiser Permanente in San Diego who stumbled on the following story. He had a patient in his obesity clinic who had been highly successful over the course of about 15 months. She lost 200 pounds from 350 pounds to 150, and all of a sudden started to gain weight more rapidly than she had lost it.

And when Dr. Felidi asked her about what was going on, he told him that she was sleep eating, she'd wake up in the morning and the kitchen would be ravaged, and nobody had been there and he hadn't heard anything like that, and when he asked her why three months ago what happened the week that one of her coworkers finding her more attractive at 150 pounds asked her out for a date, and at that point she became flooded with memories of the sexual assaults that her grandfather had perpetrated on her from the ages of 12 to 16. Felidi didn't know what to make of that. He had the sense that incest was extremely unusual and probably wouldn't have done anything except a week later he heard an almost identical study and that was what launched him on this adventure. He did a case-control study matching a hundred people in his weight program, extremely obese people with a hundred non-obese people.

Dr. Josh Godinger [07:20]: And he found a little bit to his surprise, that childhood trauma seemed to be a common theme among the obese population, and he started to talk about it at academic presentations and nobody was listening. So, until one day, Dr. Robert Anda from the CDC, an epidemiologist was in the audience, and he said, oh, you need to do a population study, and they actually designed a population study, which was very..., How they brought it off. I don't exactly know, but over two years, they studied 17,000 adults coming to the Kaiser Permanente Health Center for their annual physical, and buried in all the questions that they had to answer about their health and what they were doing were these 10 questions about which of these categories of childhood adverse experiences happened to you before you were 18 years old, and there are basically three types that they asked about.

Dr. Josh Godinger [08:19]: And they were based on this case, what had popped up on his previous case study. The three types where you have any abuse as a child that's physical, mental, or emotional? Were you neglected as a child physically or emotionally? And did you have any of these five types of severe family dysfunction? A Parent in jail, a parent with mental health problems, a parent who is on alcohol or drugs, a parent who is just missing, death, abandonment, divorce, or were you a witness to domestic violence and you got a raw score from zero to 10?

The results were really astounding, what they showed is that almost two-thirds of people, about 60% had at least one significant adverse childhood experience, and about 15%, about one person in six or seven had a score of four or more. So, that was one thing that was astounding, the second thing is that there's a very clear correlation and it's virtually linear between any sort of medical problem that you want to ask about from behavioral health problems like depression to things like smoking and alcoholism, to even things that you wouldn't think would necessarily be related, let's say arthritis or something like that. There was a virtually linear relationship between your ACE score and how likely you were to have one of these medical problems.

Amy Stanton [09:56]: Yeah, that was going to be one of my questions because I think those of us in healthcare, whether we're pediatricians or primary care providers or other kinds of healthcare workers, I think anecdotally, without looking at studies or doing surveys, know how absolutely pervasive these problems are in our patient population, and so I was going to ask you, what are some of the links to some of the healthcare problems that we see down the road in adults that we see as family physicians?

Dr. Josh Godinger [10:27]: Yeah, and what some people said initially is, oh, sure. You know, if these things happen to you, you'll be more anxious and depressed and you'll be more likely to smoke and drink and use drugs. So, that all have an advert, but that's not actually the whole story. Even if you are correct, for example, for smoking, for how much people smoke, let's take people who don't smoke at all, they still have more, or people who smoke a pack a day, the incidence of chronic lung disease is higher according to your ACE score, and the other interesting thing I found is if you look at the more severe aspects of health problems later on, let's look at depression for example, and instead of looking at how often a population has been depressed, let's look at a marker for severe depression, suicide attempts. That relationship is no longer linear, it's not like a linear graph, it's an exponential graph. If you have an ACE score of six or more, there is a one in four chance you will try to kill yourself. Similarly, if you look at drug use, okay, there's a linear relationship. If you look at intravenous drug use, there's an exponential relationship. If you want to look at social problems, homelessness, strong relationship with your ACE score. So, it became clear that what happened to you as a kid has a lot to do with your health later on in life, and the question then became, so now what do we do about it?

Amy Stanton [11:57]: Yeah, those statistics are just astounding. It's really incredible. When you talk about someone's ACE score, can you tell us a little bit about what that means exactly to have an ACE score and how our practices, how would a provider clinician use an A score?

Dr. Josh Godinger [12:18]: Okay. To be honest with you, I no longer get a score a few years ago, actually in 2013, and again, reaffirmed in 2018, by the United States Task Force on Prevention, which is our bible of what, which preventive tests we should screen for said we don't have good evidence that screening for ACEs makes a difference, and at first I was shocked and felt dismayed that they were ignoring this very important determinant of health. But I've come to the realization that it makes more sense to use the kind of approach that we did when with HIV, where we now practice what we call universal precautions, very careful about needle sticks and stuff like that. If this is something that affects 60% of the population and if I know that the patient sitting across from me has more than a 50/50 chance of having at least one ace that's enough information.

This is an interesting public health tool. It's been called the most important public health study that you've never heard of. But I don't know that it means that much to screen an individual patient. The other reason, it might not mean that much to talk to an individual patient is it might not matter if they have a score of one or six, A score of one can, if it was severe trauma can be just as bad as somebody with a higher score who's put things in their place and done a lot of work and now is much more resilient. So, I don't know that we need to, knowing how pervasive these are, I don't think we need to screen for them. I think we just need to make sure that we have trauma-informed practices in all our settings, just like we do needle stick precautions, whether I know that the patient sitting across from me has been infected with HIV or not.

So, another point I'd like to make is that the science of the ACE study is now extremely solid. These questions have been asked in I think at least 28 states and maybe more, and the statistics always look exactly the same. About two-thirds of people have had at least one ACE and about one person in six or seven have had a score of four or higher. The other question that arises is, okay, but is that just a correlation or does the ACEs actually cause damage later in life? The science of neurodevelopment is proving more and more that the trauma that happens in early life has effects on you perhaps a lot more later than something that happens later in life. One good example is that the Danes find out when they were looking at soldiers from Denmark who'd been in Iraq that the ones who actually developed PTSD post-traumatic stress disorder, were almost always individuals who also had childhood trauma.

If you didn't have childhood trauma, have had the same wartime trauma, you didn't develop PTSD, and you can almost say it that broadly. Here's one more example of why you almost don't need to ask for a person's score. Early on, when MAHEC began to get very much involved with substance use medication-assisted treatment, and we were building our practice and disseminating knowledge about how to approach substance use disorder Zach White, our social worker, came to me after they enrolled their first maybe a hundred patients and said to me, I think I finally found a patient who's in our program who did not have a high A score. If you look at special populations, and it's been looked at in many places. For example, native American women incarcerated in New Mexico, they don't have a 60% incidence of at least one ACE score. They have a 60% incidence of sexual abuse as a child.

Amy Stanton [16:21]: Wow.

Dr. Josh Godinger [16:21]: If you look at young women, like in the juvenile penal system in New York City, they have their incidence of ACE scores is almost, I think 75, 80% of scores of three or four or more. So, we don't really need to prove anymore that the ACE study is solid science.

Amy Stanton [16:45]: Yeah, and it sounds like we don't need to measure it and do something with that exact number, which really resonates with me. I think I love the analogy of using universal precautions and just assuming that the patient before you have had some adverse experiences, and I know just the default of it without measuring it, that once you understand that, at least for me personally, it's allowed me to bring a lot more compassion to my care, and when teaching residents and medical students who understandably are frustrated that patients aren't following their recommendations, or they're engaging in self-destructive behaviors or destructive to other people, and being able to understand this and think about what happened to them as a child, and that's what's showing up in the exam room really helped me a lot as a clinician, and that's what I'm hearing you say is the power behind just being educated about spaces.

Dr. Josh Godinger [17:43]: It's very definitely a compassion enhancer, one of the principles of the Compassionate Schools movement out of the state of Washington is to try to get teachers to transition from saying what's wrong with this child. To say I'm wondering what's happening to this child, and that can be revolutionary in terms of getting a child who's acting out back into feeling like they're part of a community. But I want to say this is important actually. So, one of the important discoveries that happened after the original ACE study was recognizing more and more how ACEs impact communities that are already disadvantaged in other ways and that are affected by things that happened early in their life that were not part of the original 10 questionnaires. The original 10 questionnaires focused on things that were going on in your household. Subsequent questions have been added that have to do with what's been going on in your neighborhood and your community. Have you witnessed violence as a child? Have you experienced racial discrimination? And that's been an important addition to what we already knew about ACEs and their impact on individuals' lives.

Amy Stanton [19:08]: Yeah. Josh, it sounds like it is very important to get the word out to anyone who's involved with taking care of people about the importance of ACEs. What are your recommendations for how we can translate this knowledge into the practice that we do, whether it's prevention, treatment, or that sort of thing?

Dr. Josh Godinger [19:27]: Yeah, I, in preparing for this, I had an opportunity to reflect on that particular question. Where do we go from now? What would I suggest that people do? And I don't have an answer for everybody, but it started me thinking about what I've done and how this might inform other people's practices. I definitely believe in the Mantra Act locally and think globally, because my main sense is that every one of us working in the healthcare field and working in even alive fields like education, in fact, it's hard to imagine a field where this doesn't apply. The waitress in the restaurant needs to be aware of how this might affect the behavior of the client that she's waiting on. So, let me tell you a few of the things that I've done, and then what I'd like people to think about is, what can I do in my world?

Where are the places that I might have the most influence? The first one you've already touched on which is just educating people about the prevalence of trauma and how it affects people. There's still a lot of work to be done when we're interviewing residents. When I see a new third-year med student, I always ask them if they've heard of the ACE study.

Amy Stanton [20:52]: I know, you know.

Dr. Josh Godinger [20:54]: And no, but it's been interesting to me and a little baffling that I still get blank stares for med students, including people who are about to graduate more often than not. I think Huffington Post declaring this, the most important study that you've never heard of is still apparently right, and for all that's happened over the last years to change that, there are still major gaps. I love what you said about the way it affected your practice, because I think that's in our residency at least, I feel like it's pervasive.

I sometimes say my residents think that ACEs is a normal English word, which is not of course, but I think the fact that they, that they have internalized this so well does affect the way they perform as physicians, and that's what I would say. So, one of the things that people should be doing is spreading the knowledge of this. When we started the ACEs collaborative that I joined when I first came here, had public education as their first priority, and did work not only in the healthcare system but in the legal system with police, with the Department of Children's Services, and all the places where this was important. So, I would ask the listeners, okay, I told you what I did, what can you do? The second thing is, and this also has to do with what I just spoke about.

The second thing is we really need to connect. I'm going to actually read you a quote of Dr. Anda who's the epidemiologist, if you ever heard him speak. He's very emotional and passionate about this issue. He'll tell you that when he first saw the statistics coming in, he broke down in tears because he said; I didn't realize there was so much suffering in America. But here's a quote from what he said a hard look at the public health disaster calls for both the prevention and treatment of ACEs. This will require the integration of educational, criminal justice, healthcare, mental health, public health, and corporate systems that involves sharing of knowledge and resources that will replace the traditional fragmented approach to the burden of adverse childhood experiences in our society. None of us can do this ourselves, taking advantage of other agencies in the community that are aligned with this purpose, joining with them in collaborative efforts, and supporting things that are going on in areas that are not yours.

That's another thing I would invite for me. Much of my education about ACEs came from working with schools. So, stepping out of your silo into the wider world is another thing that I would invite people to do. The third thing I'll tell you about another project that I'm working on right now. I'm working with Dr. Christina Bethel, and I'll mention again later out of the Child and Adolescent Health Measurement Initiative at Johns Hopkins University on rethinking how we do Well Childcare. I'm a healthcare provider, I'm a family doc, and I do a lot of work with children. We touch virtually every child in America in the course of, particularly in the first two years of their life, and in the first five years before they start school, they may not have as many well-child visits as we would advocate for, but everybody has at least a few, and we're missing stuff. We're not approaching the things that are most important to families.

So, we're in the process of using a tool that Dr. Bethel has developed called the Well Visit Planner, to get people to do preparatory work before they come to see the doctor, which includes the developmental screening, which isn't happening by and large, asking about social determinants, which is now part of our mission, and also not just finding out what the concerns of the family are, but also asking what the child's strengths are, and if you've ever had the experience of doing a well-child visit and after the introduction saying, so what do you really like about this kid? The whole dynamic changes. People just brighten up and have a lot of things that they want to tell you and share. That's just one example of what we can do, and my sense is this gives us the opportunity to, as it were, move upstream. That is not to wait till the child is in bad trouble in high school or till they've already suffered a lot of things and are having impaired health as a young adult. But to really start to address things early and to support families and to partner with families in a way that might be helpful in lessening the incidence of ACEs, actually decreasing that, but also mitigating things that have already happened. Unfortunately, there are too many kids these days that have an ACE score of three or four when they are born.

Yeah. Yeah. That's so again, I would say think upstream. What can you do about intervening earlier before these things have had disastrous effects? And the last thing I would say is that I work in the healthcare system. We have a lot of dysfunction in the healthcare system. We have gaps in care, we have people with limited access to care, and if the healthcare system, in fact, let's put that in air quotes. If the healthcare air quote system is dysfunctional, the mental health system is even more in disarray, and if the mental health system in urban areas is in disarray, you can barely imagine what it's like in the rural areas where I practiced for 33 years. One of the other things I'm doing is trying to work on, we've got elaborate resources in mental health in May Heck now.

We've got a psychiatry department, we've got a public health department. There are interesting things going on in mental health in our internal medicine department, in our family medicine department, and in our OBGYN department. But we haven't been pulling together, and I'm still running across things that are going on elsewhere in our own institution that I didn't know about. I don't know how many of you all have heard of the collective impact model out of Stanford in 2011 that addresses, that's something that is very pertinent to the whole idea of doing something about very refractory system problems like dysfunction in the mental health system, tackling ACEs and actually doing something about it. So, pulling things together from disparate parts of the agencies. We're about to launch another collaborative effort to pull primary care and mental health, to have us all pulling in the same direction, aware of what each of the other is doing. So, that's another thing that I would challenge my listeners today to say, what can you do in this regard? Who else is around to help you? And what about your organization that could be working better? So, those are the points I wanted to make today, actually.

Amy Stanton [28:07]: Yeah, that's really wonderful, and I really love that mantra of think globally and act locally, and that's clearly like you're advocating for and what you've done. I just really want to thank you for doing your part, which has been so profound to me personally, our practice, and then what you're doing today, which is sharing it with a broader audience to discuss the importance of it. I just wanted to add for the listeners that there are some resources that Dr. Godinger has gotten together, and we'll be attaching them to the show notes so you can look at that. If you're interested in learning more about [Inaudible 28:47].

Dr. Josh Godinger [28:49]: Let me talk to you a little bit about the resources that Dr. Santon just mentioned. There are really only three, the first one is I'd like you all to be aware of two people who I think are the guiding lights of the current generation of ACE's work. The first is Dr. Nadine Burke Harris, who is just recently left her position as the Surgeon General of the state of California. Two of the things in her CV are a 15-minute TED talk that I still think is one of the best introductions to the whole subject of ACEs, and if you have someone who wants to learn about them, it's a good start. The second thing is she's written a book about ACEs called The Deepest, which has a lot of resources and comments in it.

The second person is Dr. Christina Bethel, who some years ago out of the Child, and Adolescent Health Measurement Initiative, which we call cami, called for a national agenda to address ACEs. She also got the Journal of Academic Pediatrics to do a supplement devoted to ACEs, and she's continuing to collect data not only on children's health morbidity but also on thriving. She, in fact, did another study which you can access about positive childhood experiences demonstrating something that I think is only common sense, namely that positive childhood experiences can in part compensate for ACEs, and the last thing is there's a very nice website called Paces Connection. They change their name from ACEs Connection to Paces Connection, which illustrates that ACEs are not a death sentence. Positive experiences, internal resiliency, and other things can compensate for that, and they now call themselves the paces connection. I think you may still have to get them to agree to take you on, but they'll send you periodic emails at whatever frequency you want about what's going on in the world of ACEs and what kind of research is going on. If you want to hear what's going on today, that's the best resource I know of.

Amy Stanton [30:59]: But thank you for your passionate advocacy. Before we always like to ask each of our guests what they're most grateful for about the work that we do.

Dr. Josh Godinger [31:10]: That's an easy question; the thing I'm most grateful for is for my patients. Every day I see examples of heroism, of overcoming things that are very difficult to them, that are inspiring and make me feel as if I need to work as hard as I can to match that. The second thing though, is being in Mahec, I get to work with some very wonderful colleagues who share this sense of purpose about making the world a better place. But the thing that has been particularly wonderful to experience is watching the group of new young doctors come through and have the opportunity to be part of mentoring them because they are, we have 12 residents every year, and I've been here 11 years, and without exception, they are intelligent, compassionate, caring, and really haven't lost that idealism that brought them to healthcare, to begin with. So, I feel that I've been very privileged to be a part of all these things.

Amy Stanton [32:24]: Thank you so much. I, it's a wrap.

Dr. Josh Godinger [32:28]: Thank you.

Outro [32:30]: I don't know about y'all, but I learned so much from Dr. Santon and Dr. Geer in this episode. Such good information, and really makes a difference in how we can think about approaching our patients and keeping the history of their life in perspective when we're caring for patients. It's just a great episode. Please remember everything discussed will be linked in the show notes below in the show notes. We also have a link to a survey. We would love your feedback on the podcast. How do you think we're doing? What could we improve on? There's also a question in the survey where you will have the opportunity to suggest topics for future episodes. We would love to hear what you all would be interested in us doing an episode on. And again, we just really appreciate your feedback. Also, don't forget to like to rate us five stars, and share with your network, and the other people with that you're working within this space. We would really love to get as many listeners as we can with our information, and we thank you so much for listening. Until next time.