Robert Maunder, Head of Research, Department of Psychiatry, Mount Sinai Hospital
Adverse Childhood Events And Trauma-Informed Care
Close relationships are critical to health. For children, those are relationships with parents, for adults the circle is wider—parents, partners, children and other loved ones. What happens in those relationships, the support and security that we provide for one another, and the stress and harm we do one another, are a powerful in?uence on the health of our bodies.
I’m going to be talking about childhood adversity, and I’m gonna I want to set the stage for I think other discussion that will come later, by really talking about the impact of early life adversity on physical health in general. Kind of across the board which is the work that I do. And I should just locate myself in that a little bit for you. So I’m an adult psychiatrist. So I come to this because the patients I see all have chronic physical disease and chronic pain syndromes. Sometimes syndromes have unexplained medical symptoms. So I see a lot of people with early childhood adversity, but I don’t have any expertise with children at all. My job is to show up 20 or 30 years too late. So I get support from my hospital for myself and for my work, and I get some royalties from books. So my grade 12 english teacher said tell me what you’re gonna tell me then tell it to me then tell me what you told me.
So what i’m gonna tell you is that adverse childhood experiences which are now often known as ACEs are very common, that they make people sick, that they interfere with healthcare, and where I can I’ll just speak a little bit specifically to HIV, although that’s not primarily where I practice. So let me talk about how common this is. This is a paper. This was the first emergence of child abuse as a medical problem. This was published in JAMA in 1962 by a pediatrician Dr. Henry Kemp, and he was describing the phenomenon of kids showing up in the emergency department with broken bones because they’d been beaten. And so he introduced this as something that deserved medical attention, and he tried to provide some guidance about how to recognize that on an x-ray, and otherwise grossly underestimated how common that phenomenon was.
One of the useful things he did though was that he recognized that it occurred in all facets of society, that essentially there was you couldn’t be rich and educated enough to be immune from that kind of early childhood adversity. So that was 62 and I want to link that to attitudes, to and evidence about smoking around the same time. Because I think we’re now with childhood adversity at about the same position that society and healthcare was in the 60s with respect to smoking. The evidence is in, we don’t need any more evidence, but we’re not doing anything about it. And that’s pretty much where we were in the 60s. It was really clear that smoking caused cancer even in the 50s that was known to some extent. It was a good 20 years before there was enough public policy and cultural change to do very much about lowering the rates of smoking. I think that’s where we are now with ACEs. So it’s about 20 years since talking about childhood adversity became known as ACEs.
It’s a it’s a good acronym. It’s easy to remember, and that came out of the work of Vincent Valetti and his colleagues, who did a huge study up to 20,000 people I think. In San Diego at Kaiser Permanente. And they surveyed their adult patients about what had happened to them during childhood and then started to look at correlations between that and various health outcomes. And this is the list of the original ACE items on their survey. So they asked people about 10 kinds of experience. Yes / No, these things happened to you while you were growing up or they didn’t, and then they just added up the number and that gave people an ACE score between 0 and 10. And that list of items is not magic and it’s a little bit dated. It’s a bit of it’s time, there are other things that should be on that list and that weren’t at the time, and I’ll speak to those a little bit.
But most of the epidemiological data about the impact of these on health, comes from a score of how many of those things happen to an adult before they were 18. So what they found in what has now been replicated in more robust studies in many places in the States and also in Canada, is that ACEs are very common. It’s actually the statistical norm to have experienced at least one ACE and that the more ACEs that you experience the fewer people there are, but there’s still quite a lot. And the more ACEs that people have experienced the greater risk they are of a variety of health outcomes. So these are some of the other items that you can add to the list. This is based on on evidence there are some others that you might want to add to the list but I wouldn’t argue against them.
But there’s been some additional work to see what other sorts of early life experience. If you look at that list in totality we’re talking about physical abuse, sexual abuse, emotional abuse, various kinds of neglect, violence within the home, having parents whose parenting ability is limited because of their own mental illness, or substance abuse, or because they’re away in jail, bullying, low socioeconomic status, parental death. Not doing well at school I never would have guessed but that showed up with the with the evidence and makes perfect sense. Like a lot of these do. Okay, so then there is quite a bit of evidence now that ACEs make people sick. This is data from the original ACE study showing these bars. The further they are to the to your right the the more ACEs people are reporting. And the more ACEs people report the greater their risk of ischemic heart disease, liver disease, respiratory disease, starting to smoke early, self-reported problem drinking, and this has been replicated and expanded in a ton of work since then, so there’s now really strong correlational evidence that ACEs are related to cardiovascular disease, to cancer, COPD, HIV, chronic pain, a longer list than that.
So there’s enough evidence that the American Heart Association came out with a scientific statement earlier this year to say that there’s substantial evidence that links childhood adversity to heart disease and stroke. There’s actually better evidence for the links between ACE and cardiovascular disease than most other health outcomes and it’s just because there’s been more research done. So that risk is up there with the risk of smoking on cardiovascular disease but it’s not recognized as such. And it’s not all correlational data now there’s, been longitudinal studies. So the more ACEs people have the greater the effect that it has on mortality. And I want to show you the links between early adversity and mental health. So I’ll just orient you because they were asking different questions in this survey. This is Canadian data this is Tracy Afifi and her colleagues at the University of Manitoba. And they used a really robust definition of a fairly severe physical abuse, sexual abuse, or exposure to violence at home. Which is virtually always violence against the child’s mother by her partner.
And what you can see is that the type of abuse that these adults are reporting about their childhood is gendered in terms of whether sexual abuse or physical abuse is more prominent. But the totals for any kind of abuse are actually quite similar. And it’s about 1 in 3. Which are just astounding numbers when you see them for the first time. Most people who see those numbers for the first time suspect that the research is wrong. But in fact those are reliable numbers and it’s the same that you find where ever you look for it. And this from the same study, is just looking at how much greater the likelihood is of experiencing various mental illnesses or substance abuse for people who’ve experienced physical abuse. That’s the blue bars, or sexual abuse, or exposure to intimate partner violence. And you can see that the risk is about doubled for depression, for anxiety, for alcohol use, other drug use and it’s substantially more for suicide. It’s up to six to eight times. And I won’t go all the way through this diagram but I want to make the point that we’re not just talking about correlations.
There’s enough evidence now that it’s pretty clear that we’re talking about causal pathways, but those causal pathways are really complicated because childhood adversity leads to a whole cascade of risk factors for health problems. So some of those are really kind of clear direct behavioral things like it’s more likely that you smoke, it’s more likely you have problem drinking, those things lead directly to chronic illnesses. But even after you account for all the behavioral changes there’s still more variance to explain, and some of that is explained by physiology. So changes in stress regulation, changes in inflammation, other physiological changes that are related to that early adversity. I’ll talk a little bit more about social determinants of health when I look at some of the other data, and more subtly but I think really importantly, the impact that early adversity has on the way that people use the healthcare system, because it actually interferes with the ability to trust and to seek help and to interact to tell your story in a way that invites people to give you help.
So through all of these effects childhood adversity increases the risk of physical illness, mental illness, and importantly how people look after their health, and interact with the healthcare system. So this is straightforward data from our own primary care clinic, just showing the increased likelihood of hazardous drinking, or body mass index over thirty five, or smoking for people who have experienced at least one ACE. And this this is a little bit more complicated. But it’s important, so I’ll just pause here for a second. This is data from our psychiatry department. So this is information that we collect. The first time people come into our department for an outpatient assessment and the psychiatrists after they’ve done their assessment fill out a checklist of various characteristics that the patients have. And what this is showing is the way that early adversity, that the psychiatrist has deemed to be currently significant, so it’s not just presence absence at this point, it’s whether this is an issue to be dealt with at the time of diagnosis and treatment, that it’s linked to a whole host of other characteristics that also increase the complexity of that person’s life, and of their getting care.
So it’s not just the one thing but those people with that significant early childhood adversity are substantially more likely to also be experiencing discrimination and stigma that’s interfering with their care. Recent harm to themselves, impulsivity, inadequate housing, poverty, having multiple psychiatric diagnosis, be experiencing shame, worthlessness, guilt, be interpersonally isolated, and to be experiencing more trauma as adults. So it’s not just one thing, it’s not just two things, it’s like all of these things. The Venn diagram of all of this kind of difficulty and complexity is a complicated Venn diagram where most of the people are at the middle, with all of these kind of overlapping risk factors. And this is from our family medicine clinic just showing how steep the curve is of increasing psychological distress as people are reporting more ACEs. These are people who have heart disease or have risk factors for heart disease. And this is a graph that comes from the States, from the Department of Health and Human Services, in the states where they tried to estimate the attributable risk for various adult health conditions that could be attributed to ACEs.
And so in this diagram the size of the black blob corresponds to how much of this condition can be attributed to ACE, and some of those blobs are very large but I would just emphasize how large the smaller ones are, so the impact on cardiovascular disease and cancer, about 25% of that risk is attributable to ACEs. So then the point that I like to make, especially when I’m talking to colleagues, so I bring this message to internal medicine or to family medicine where these links are really not appreciated very well, is that this kind of data tells us that ACEs are not just another part of medicine they’re actually at the core of medicine. Right. This is our job to be dealing with this. Okay, so I want to talk a little bit about health care. So not just about how ACEs make you sick but how they interfere with getting well. So this is a little bit of data from different studies that when you take it together kind of tells a story. So if you look at how ACEs are related to healthcare utilization, the more ACEs a person has the less likely they are to get routine preventive dental care.
And preventive dental care is taken as a kind of proxy for access to health care services, because by and large people who have good access to health care go to the dentist, and going to the dentist is one of the first things to go when people don’t have good access to health care. So that suggests that there’s like impediments to access but then when you look at utilization of various health care services, ACEs are actually associated with increased use, but increased use of the emergency department, increased use of unscheduled medical care, and with appointments with physicians that the physicians identify is being difficult. So interpersonally difficult, so it paints this picture of having limited access to healthcare, using the health care that’s available, but often using it in ways that are not scheduled, structured, not necessarily the most effective, and then when you’re there finding that those interactions are complicated right. And I don’t have the data here, but I can say for sure that when the physician is noticing that the interaction is difficult, so is the patient.
So we’ve surveyed Ontario physicians to ask them a number of things about ACEs, including if they ask their patients. So this is one of the things that came up earlier when Dr. Greene was asking, just the the emphasis on asking as the as an important intervention in itself. And what we found if you just look at the the big line, they’re the tallest bars. The tallest bars are the most common modal response that people of physicians of various specialties gave. So psychiatrists mostly say they always ask. Family physicians mostly say they ask when indicated. Whatever that means. But when I talk to individual family physicians they will acknowledge that when indicated is not all that often, so that it’s fair to presume they’re under estimating how often that’s a relevant issue and doctors of other specialties don’t ask. So I think right now like in terms of the kind of work we’re doing with our colleagues, our effort is just on encouraging people to ask. Identifying what the barriers are and trying to convince people that it doesn’t open up a whole can of worms, it just actually improves the quality of the conversation that you’re having with patients. So this is our little haiku that we built to try and tell that story as quickly as we can. That to treat, you need trust, and to trust a patient needs to feel safe, and to feel safe you need to be heard. This is another graph just to show this really steep curve.
The more ACEs a person is reporting the lower their quality of life. Just globally. Okay, so I can say a little bit about HIV, this is kind of like what I learned about HIV while I was preparing for this talk, because these are not my patients. So about half of people with HIV report childhood physical or sexual abuse, which is somewhere between 50 percent and double than in the general population. And all the percentages are a little bit of a moving target because they depend on you ask the question. In the OHTN cohort study of 1,400 people the prevalence of having any ACE was 71 percent, and our ACE question wasn’t a very good one. And it didn’t include sexual abuse, so the numbers probably higher than that. I’m not going to say very much about syndemics and intersectionality because there are so many people in the room that know so much more about it than I. But just to make the point that there’s higher prevalence of ACEs among certain subgroups and those subgroups are not mutually exclusive and so women with HIV are more likely to have acute stress disorders than men with HIV, they’re more likely to experience interpersonal violence than women without HIV. The prevalence of trauma and its consequences are increased in men who have sex with men, in indigenous people, and people who identify as African Caribbean Black, and sex workers, and the seriously mentally ill.
And I found a study that’s interesting how some of these factors relate to each other. There was a small study but they were looking at young Aboriginal men and women in Vancouver, and they found that there was more HIV in the women than in the men, but and when they dug a little deeper they found that it statistically that was entirely explained by the greater rates of sexual abuse in the women than in the men. And so like those are statistical stories but they’re not hard to translate down into personal stories or anything. I start to see how this works. I’ve totally lost track of time so you have to tell me when the hook is coming. This is from the OHTN cohort study as well, it’s just showing the link between the number of ACEs people have experienced and various measures of socioeconomic status. And this is actually not specific to HIV you would find a similar thing if you looked in in virtually any other population, but it’s so clear in this data that the more ACEs you have the less likely you are to have a post-secondary education to be employed or to have a livable income.
This is from that same study, so that the more ACEs people have the less likely they are to be adhering to antiretroviral treatment and the more likely they will have a detectable viral load. Just want to make the quick point. I think there’s lots of health care workers in the room. That there’s no us and them about this. We’re talking about something that in its most severe definition is present in about one in three people, and in it’s broader definition is present in about six of ten. So this is everybody. If we look at ACEs in health care workers, we find that the the rate of childhood abuse in hospital workers, and we’re only able to look at women because most the hospital workers are women, was around twenty three percent in this study with the definitions that we used. Which is pretty similar to the general population, definitely not lower. And when we looked at paramedics it was substantially higher.
So the the male paramedics had 35% same definitions and the female paramedics forty five percent. And when we looked at ongoing stresses in these healthcare workers life, in these pies the details don’t matter, the gist of it is the darker the shade of blue the more stressful events people are reporting in the last six months. And the people with ACE that’s a much bluer circle. So people who have experienced childhood adversity are continuing to experience more stress like their lives just continue to be complicated. Which relates to burnout. So we’re down to one minute, so I’m not going to tell you the stories but I’m gonna encourage you to go look at the stories, because hearing narratives from patients and about patients, I think gives us a much clearer idea of how this affects health and healthcare and how people work their way out of it.
So John Hunter and I, John’s who I do most of this work with, published a story in the Walrus that’s available online about a young man with hepatitis C and this kind of early life experience. And there’s an ongoing story in segments that’s been published on Medium.com by us, about a patient who I see in therapy, who has given consent for his story to be told. “The Damage I Am” is actually a phrase that he has used to describe himself to me, and if you’re interested I’d encourage you to look that up. And just a couple of resources, there’s lots of resources about how to ask about ACE but we put the original ace questionnaire online in a self scoring version that’s easy to use and it gives people their own score. It gives them a little paragraph about what that means and then invites them to print it off and bring it to their doctor if they want to. And we have another much broader self assessment kiosk so that people can go online and measure virtually anything they want about their mental health and some things about their physical health, and again get them scored and get a little information about what it means so that they can print it off for themselves or bring it to their doctor if they want. I’ll finish there [Applause]