Beating the Odds with ACEs
Health-care professionals at OU-Tulsa are improving medical outcomes of patients affected by adverse childhood experiences.
A 50ish man can’t stop smoking or drinking alcohol even after years of various treatments.
A woman in her mid-30s believes she has a chronic disease, but all tests turn up negative. A successful 50-something woman develops inflammatory arthritis, back problems and heart disease with no family history of such health problems.
Such cases stump and frustrate health-care professionals using traditional medical approaches. The solution likely lies in the patients’ childhoods.
Since 2012, a group of researchers and practitioners in medicine and social work at the University of Oklahoma-Tulsa campus has been developing and training a curriculum around Adverse Childhood Experiences, known as ACEs. On campus, this includes integration into OU-Tulsa’s simulation center.
The model has gained a national reputation with demand for training dramatically increasing. It has appealed to graduate students, medical professionals and groups including teachers, counselors, law enforcement, attorneys and business groups.
Presentations at professional medical conferences attract standing-room-only crowds and usually result in frequent requests for materials. This popularity has led to the consideration of expanding into a university-supported center.
“What’s exciting is that Tulsa is leading the country in this,” says Dr. Martina Jelley, Julian Rothbaum Chair of Community Health Research and assistant dean for clinical research. “Nobody else has the simulation training on ACEs education in adults. And no one is doing training near the scale we are.
“National groups are interested in coming to Tulsa because they want to see what we’re doing. We’ve been asked about having a conference. It’s unique.”
The ACEs questionnaire was created in 1998 as a research tool by the Division of Violence Prevention at the Centers for Disease Control and Prevention in partnership with Kaiser Permanente. A study was conducted between 1995 and 1997 with more than 17,000 participants.
This landmark research has linked traumatic childhood experiences to negative adult health outcomes including disease, disability and early death. It found connections between those early events and risky behaviors like smoking and binge drinking.
The ACEs tool has 10 categories focused on household experiences ranging from divorce to sexual assaults. Researchers start seeing poor health outcomes at a score of four. At a score of six, life expectancy drops to age 60.
“Even though people may be successful in their career, their life has been affected by ACEs,” says Dr. Kim Coon, director of psychotherapy education in the OU Department of Psychiatry. “They may not have the emotional intelligence they need to continue to succeed, or they will have problems with family or have problems interacting with colleagues.
“The ACEs are going to come out one way or the other. With ACEs, it’s not just psychological. It’s not just psychiatry. It’s not just depression, mood, anxiety and trauma. There are all kinds of physical ailments that come out of ACEs.”
At OU-Tulsa, an interdisciplinary team formed to see how significant childhood experiences impact existing, local patients at its primary health-care clinics and to find ways to address the consequences. The findings, which are still being published, revealed that the average adult patient ACEs score in Tulsa was much higher than the national average.
This may not be surprising considering Oklahoma’s ranking in health and social outcomes: No. 1 in female and overall incarceration, No. 2 in teen birth rates, No. 2 in uninsured health care, No. 4 in hunger, in the top 10 in poverty and among the highest rates of adult and youth mental health needs.
Most telling, Oklahoma is No. 1 in the number of children with an ACEs score of 4 or higher, according to the National Survey of Children’s Health. Nearly half of the state’s children have a score of 3 or more.
Those children grow up to become parents, caregivers and professionals.
“If we want to prevent ACEs, that means it’s generational. If we don’t help the people who are bringing up the children, then it’s going to perpetuate,” Coon says.
The next move from the team was to
act upon the findings.
“We quickly realized that training of medical residents needed to be implemented because the rates of ACEs among adults were so high. There is nothing that existed, so we created it,” says Julie Miller-Cribbs, director of OU’s Anne and Henry Zarrow School of Social Work and the Oklahoma Medicaid Endowed Professor in Mental Health.
“It keeps getting better and better. We are doing the training and simulation more, learning more, coming up with good scenarios and finding better ways to do it.”
The campus training started with residents in family and community medicine and internal medicine, along with social work students. It has since expanded to nursing and allied health (occupational and physical therapy) students, faculty members and clinic care managers. Emergency medicine and obstetrics/gynecology residents are also interested in adopting the training.
Training requests are coming from outside the university and have included staff at St. John Medical Center in Tulsa and health-care providers at the Muscogee (Creek) Nation.
“What distinguishes us is that we are focusing on working with adult patients,” says Frances Wen, director of behavioral health and the Founders and Associates Research Chair in Family Medicine.
“A lot of work in ACEs focuses on early childhood. So, we are unique in that we are helping health care professionals work with adults who have been affected by ACEs, whether that is about their health outcomes or parenting or other areas.”
The ACEs score wasn’t meant to be a medical diagnostic screen but can be used as a starting point. That is where OU-Tulsa’s simulation center becomes critical. It provides a safe place for students to practice discussing issues around ACEs.
“It’s about the conversation, and it’s also about the approach,” Wen says. “The conversation with adults needs to shift from ‘What’s wrong with you?’ to ‘What’s happened to you?’ And, it’s thinking about working with people over the long term and not ‘I’ve got 15 minutes and have to solve this.’ ”
The ACEs training is consistent with trauma-informed care, says Miller-Cribbs.
“We train students so they understand ACEs completely and how it will affect the health of people and how to bring up the conversation,” Miller-Cribbs says. “These are hard conversations to have. It’s a complex, biological phenomenon. So how do you explain that to a patient? We’re in a state with high, high levels of trauma.”
Just because a person has a high ACEs score doesn’t mean impending doom or even a referral for mental health therapy. But, understanding a patient’s behavior can help steer a person into change.
Much of that can be done within a doctor-patient relationship, researchers say.
“The good news for adults is that brains can change,” Miller-Cribbs says. “We’re talking about interventions for adults. There are things you can do, and you can re-wire a brain for a lifetime.”
Since 2014, more than 700 people have been trained how to discuss ACEs with patients. Opportunities for expanding the curriculum nationwide include writing an online Continuing Medical Education training manual for the American College of Physicians and presenting an ACEs residency training to the American Academy of Family Physicians.
Reaching out to established physicians and health-care providers has been a challenge, but one the team is determined to overcome. At an internal medicine professional conference, Jelley says only about 15 percent of practitioners had heard of ACEs.
“This is about brain health,” Jelley says. “Your brain is part of your body and learning about ACEs, childhood trauma and neurobiology really helps in that integration. We’re talking about integrating behavioral health, and we’re wanting to do even more.”
Team members have been doing the ACEs work around their other primary responsibilities in each respective department. The ultimate goal would be to create an ACEs center on campus. A director could coordinate the efforts full time and bring leaders from the various disciplines under one roof.
While a center remains a dream at this point, the possibilities are exciting to the team. ACEs is getting public policy attention, with the Oklahoma State Legislature conducting an interim study and the Oklahoma Department of Education getting ready to host an ACEs statewide conference.
“This is all so new and early in universities and clinics that there isn’t that much focus on the adult part,” Jelley says. “There is starting to be, but we really want to promote that. We have to focus on the ACEs in adults before we can truly address the primary prevention problem.”
Ginnie Graham is a reporter for the Tulsa World.
To see the ACEs questionnaire, click here.
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