Skip to content
Link copied to clipboard

Effect of childhood events often overlooked by doctors

Jeffrey Brenner, M.D., founder of the Camden Coalition of Healthcare Providers, wrote this for "The Field Clinic" on and

Jeffrey Brenner, M.D., founder of the Camden Coalition of Healthcare Providers, wrote this for "The Field Clinic" blog.

For nearly 15 years we've had the secret to delivering better care at lower cost in America. The information has sat, hidden away in the medical literature, and barely mentioned among doctors. It's a remarkable story of bias. The neglect of this information by the medical community tells you a lot about our failings as a profession and the poor training we receive. It's also a powerful commentary on the values of our society and the biases built into our society's view of health and health care.

In the 1990s, Dr. Vincent Felitti of Kaiser Permanente in California conducted a mail survey with 17,000 middle-class patients. He asked them questions about traumatic events that happened to them as children. Incredibly, more than 70 percent responded.

The survey asked questions about things like the death of a parent, physical abuse, sexual abuse, and substance abuse by a parent. Nearly half had at least one Adverse Childhood Event (ACE), and he coined the term "ACE score" for the point score created for the survey.

Incredibly, the ACE score predicted health-care use and spending, obesity, substance abuse, smoking, alcoholism, and prevalence of poorly controlled chronic disease better than anything we've ever found.

In short, the terrible things that sometimes happen to children can cause a lifetime of health impacts. This is true even for middle-class patients. And poverty raises the odds for higher ACE scores.

In my work in Camden, building interventions for high-cost complex patients, the issue of early life trauma and compounding later life trauma has become a core one. Many of our high users of the local system tell us horrible stories of their childhood, when asked. We've recently published research on these findings.

In my training as a family doctor, I was told not to pull up the lid on something you don't have the time and training to treat, like early life trauma. I am deeply embarrassed at my early career in Camden because I followed this advice too often.

Some physicians, such as Nadine Burke, a pediatrician in California, are leading the way in using ACE scores in clinical practice.

I believe ACE scores should become a vital sign, as important as height, weight, and blood pressure. There was a time when doctors were reluctant to ask about and address smoking, unsafe sexual activity, and obesity. The taboos and discomfort about discussing childhood traumas with patients need to be lifted, too.

It's interesting to ask why this information hasn't permeated medical training or health-reform efforts. The answer is simple: our society has a huge bias against discussing these issues and the medical community reflects these broader biases.

We need more trauma victims to publicly discuss how their early life experiences have affected their life and health, and we need more doctors to talk publicly about the importance of this issue. We also need research on ways to bring ACE scores into routine primary care. The stigma surrounding early life trauma needs to be lifted.