Addressing adverse childhood experiences and their sequelae in primary care

- Kenny Lin, MD, MPH

In a recent editorial on the relationship between stress and chronic disease, Dr. Jennifer Middleton mentioned that adverse childhood experiences (ACEs), "such as physical or sexual abuse, witnessed domestic violence, loss or incarceration of a parent, and poverty," are associated with later development of diabetes, cardiovascular disease, asthma, and cancer. A 2019 report from the Centers for Disease Control and Prevention (CDC) found that 60% of U.S. adults surveyed from 2015 to 2017 had experienced at least one ACE, while 1 in 6 adults had experienced four or more. In addition, the CDC identified a dose-response relationship between number of ACEs and prevalence of health risk behaviors, socioeconomic challenges, and chronic health conditions.

In a Curbside Consultation in the July 1 issue of AFP, Drs. Jennifer Hinesley and Alex Krist discussed the primary care approach to a woman who presented with irritability, depression and anxiety and a history of childhood physical and sexual abuse. The U.S. Preventive Services Task Force (USPSTF) does not have a recommendation for screening for ACEs; however, a sample screening tool is available in a recent FPM article. In patients who disclose a history of ACEs, Drs. Hinesley and Krist suggested assessment for mental health conditions such as post-traumatic stress disorder and substance use disorders. For other health care needs, including preventive care, applying principles of trauma-informed care may reduce the risk of re-traumatization and increase patients' comfort.

Can screening for ACEs at well-child visits improve resilience and prevent future ACEs and associated toxic stress? Similarly, what types of interventions might help adults with a history of ACEs but no symptoms of related chronic issues? Dr. Krist previously wrote an AFP editorial about the necessary prerequisites for the USPSTF to recommend routine screening for social needs:

an accurate screening test to identify patients with the social need, an effective treatment to address the social need once identified, and evidence demonstrating a meaningful health outcome improvement for patients. We know that having a social need leads to poorer health. In some cases, we even know that screening identifies those with a need, but often we do not know what to do after we have identified the need.

Substituting "ACE" for "social need" highlights some potential problems with systematic identification of ACEs in primary care. As Dr. Thomas Campbell noted in a JAMA Viewpoint, the evidence is lacking that ACE-related clinical interventions in children or adults improve any health outcomes. It is possible that screening for ACEs might inadvertently cause harm by reducing trust between clinicians and patients or parents/guardians, or by erroneously labeling patients as "high risk" for future problems based on a high number of ACEs alone.