ACEs and Illness in Primary Care

A colleague asked how I would screen for Adverse Childhood Experiences (ACEs) in primary care patients with unexplained illness, chronic pain or functional syndromes such as irritable bowel or fibromyalgia.  (A blog of mine describing ACEs is here with an important web site here). Here is my answer:

Since time is limited in the primary care setting, if I want to screen for ACEs I would not go through the full ten item ACE questionnaire.  My leading question is: 1. “Were you under stress as a child?” and/or 2. “Did anything happen to you as a child that you would not want for your own children (or a child you care about.)”

There is a tendency for people to minimize the impact of their ACEs (or deny them altogether) but this tendency is reduced considerably when people are asked to imagine adversity for their own children, hence the use of the 2nd question.

If I get a positive response I will follow up with: “Can you tell me, on a scale of 1 – 10 (10 being worst) how stressful these experiences were for you?”

Next comes: “Can you tell me more about what happened that leads you to give it that number?”

If  the medical clinician’s attitude toward these questions (and the responses) is routine, patients will usually be quite willing to divulge information they may have shared with few others.  It can be therapeutic for them to do so.  It also helps to include follow-up questions (“How old were you when the abuse began?” for example.)

If the patient’s answers take more time than is available then I add: “This is very helpful information and I am glad you are willing to share it.  We don’t have time today for everything but we can discuss it further when you return.  Please make a list for me of all the stresses you have suffered in the past and currently and bring it in next time.”  The act of writing this list helps people recognize the magnitude of what they have endured and simultaneously starts the process of considering solutions.

When significant ACEs are identified, psychotherapy directed at the long-term impact of these issues usually produces significantly improved outcomes for the patient’s physical ailment(s).  This is why routine questioning about ACEs is essential in the evaluation of so many chronic conditions.

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