In 1998, Dr. Vincent Felitti, Dr. Robert Anda, and colleagues published “Relationship of Childhood Abuse and Household Dysfunction to many of the Leading Causes of Death in Adults: The Adverse Childhood Experience (ACE) Study,” which set the stage for further research about this very important topic. It certainly influenced Dr. Nadine Burke Harris’ work in ACEs and in her 2018 book, The Deepest Well, she eloquently explores the long-term effects of childhood adversity while passionately writing about a physician’s role in addressing such issues. She states early in her book: “Most people intuitively understand that there’s a connection between trauma in childhood and risky behaviors…. But what most people don’t recognize is that there is a connection between early life adversity and well-known killers like heart disease and cancer” (39). Reading this book inspired me to think about my own education thus far as a medical student, particularly as it pertains to my exposure to the topic of ACEs.
I recall being introduced to the topic of ACES during a course called Generations, at the conclusion of the Foundations level of the Vermont Integrated Curriculum. In this course, we learn about different stages of life and the diseases that may be encountered at each stage. I remember being taught by psychiatrists about different mental health conditions that individuals may experience throughout their life. It was here where I first heard about ACES, albeit briefly. After Generations, I went on to take Step 1 and then began clinical rotations. In each rotation, I learned a lot about history taking, improving my physical exam skills, improving my ability to build differential diagnoses, and understanding next steps in diagnosis and treatment. However, when I reflect about my clerkship experience, it wasn’t until psychiatry that I again began to think about ACEs.
During my psychiatry rotation, I had the opportunity to work in child and adolescent psychiatry for three weeks. In learning more about ACEs, I began to understand how early experiences can impact children and adults, while appreciating different ways we can address sequelae.
I recently had the opportunity to work at a family medicine office in Vermont, where I observed an integrative medicine-trained doctor truly taking time getting to know her patients and understand their life stories, instead of only focusing on their disease. While I did not see her formally using the ACE questionnaire, her interactions with patients clearly reflected her appreciation of the ACE framework. Thinking about my clinical experiences, I wish I had spent more time with patients and the physician discussing childhood experiences and how they could be impacting a patient’s health today. Some patients who experienced sexual, emotional and physical abuse as children suffered from a range of issues including hypertension, extreme anxiety and depression. I inquired about their conditions and concerns, performed a physical exam, and discussed their medications. However, not once did I stop to make the connection that their conditions could be partially explained by the adversity faced during childhood. Likewise, at the time I saw these patients, some of their conditions were worsening after being well-controlled for many years. As I look back on these experiences, and after reading Dr. Burke Harris’ book, I understand that one of the reasons these conditions may have flared is that these patients were experiencing memories from their childhood – memories generated by recent events. I wish I talked more with these patients about notions of wellness, exercise, counseling, mindfulness, etc. and how focusing on these areas could improve their health more effectively, especially in controlling an acute flare.
Dr. Burke Harris proposes a framework for addressing the impacts that early adverse experiences can have on emotional and physical health. The framework consists of six pillars: exercise, nutrition, sleep, mindfulness, mental health awareness, and healthy relationships. The sooner these things are fostered and incorporated in an individual who’s experiencing(ed) adversity, the quicker his/ her body may ‘rewire’ itself and respond more adaptively to stress. These techniques are not ones that are done once and then one never has to worry about them again; they are techniques that are useful intervention and prevention strategies to use at any stage in life, especially when an event comes up that brings back memories of adversity and one’s body begins to react negatively. Yes, it is true that there is a place for medications and people may benefit from them, but there’s also a role for these other pillars of wellness and physicians should be aware of the evidence for their use.
Adverse childhood experiences and how they impact health is important for every physician to understand whether you are a primary care doctor, a psychiatrist, or an orthopedic surgeon. Reading Dr. Burke Harris’ book inspires me to advocate for change in the medical curriculum and the way current and future doctors practice medicine. We have an opportunity to integrate ACE education at every level of medical education, beginning with the first course of medical school, so future physicians can identify early, different causes for patient symptoms. Furthermore, there is additional opportunity to discuss, screen for and address ACEs at regular doctor visits, especially with primary care providers. Regardless of specialty, we all have a responsibility to understand what may be contributing to our patient’s health and associated outcomes. Thinking about the future of health care, one of the major ways we can promote health and effectively combat illness is to address childhood adverse experiences early and with intent.