For half of adults who are treated for anxiety or depression and, for a quarter of those same adults who are also living with heart disease or cancer, their condition can be linked back to trauma that they experienced in their childhood.
Dr. Robert Maunder, Director of Body-Brain Integration, Medical Psychiatry Alliance, explains why health care providers need to do a better job of recognizing this when they care for patients, and why a lack of awareness can be both damaging and costly.
Maunder, who is also Professor in the Department of Psychiatry at the University of Toronto and Deputy Psychiatrist-in-Chief & Head of Research, Department of Psychiatry, Sinai Health System, spoke with MPA Senior Communcations Advisor, Sandeep Punia, about his area of research at the interface of mental and physical health, called Slouching Towards Disruption: The Impact of Childhood Adversity on Health.
This is also the subject of his upcoming lecture at various Rounds at healthcare organizations in Toronto, including Sunnybrook Health Sciences Centre (Dec. 8), Women’s College Hospital (Jan. 31) and Sinai Health System (Mar. 2).
What do we mean by childhood adversity?
Childhood adversity refers to a number of serious stressful events that can happen to children, and affects their mental and physical health later in life as an adult. The list includes three categories: abuse (physical, sexual, emotional); neglect; and household dysfunction (for example, witnessing violence in the home, or living with older members who have substance abuse or criminal issues). Overall, this list has about 10 types of adversities that can be faced by children. We tally these experiences up to come up with what we call an ACE (Adverse Childhood Experience) score.
About 40% of adults have a score of 0. However, 60% of the population has been exposed to at least one adversity as identified on the ACE list. The number of things that people have been exposed to turns out to be really important, because it’s not how bad the exposure was, but the sum total of all the experiences you’ve grown up with that affects health.
We know, and have known for a while, that these childhood adversities are crucial to long-term health.
So, how does childhood adversity impact adult health?
Exposure to the kind of adversities I’ve described is linked to a broad range of adult health problems. The nature of the relationship is that, the more adversities you have experienced, which means the higher your ACE score, the higher your risk is for health challenges later in adulthood, such as heart disease, lung disease, sexually transmitted diseases, early pregnancy, smoking, drinking, drug use, and obesity. These also contribute to early mortality.
How would this impact our healthcare system?
The ACE score is as statistically important a risk for adult health diseases as other factors (such as smoking). However, the concept of childhood adversity impacting adult health is not widely recognized by health care providers. It’s not even a part of their conversation with patients.
Sometimes doctors may say, “Well, what are we supposed to do about this now? This happened 30 years ago.” Okay. But, doctors can realize the impact of this risk factor on their patient’s health.
Experiences with trauma can shape a person’s experience of what it is like to be sick throughout life. It can interfere with the trust and clear communication that is needed to provide good care. So, ACE doesn’t just make you sick, it makes it harder to get better. Doctors should also think about the public health implications and what can be done for patients in the next generation; it’s not too late for them.
Why is the relationship between childhood adversity as a risk for adult mental and physical health, not a part of the medical conversation?
Well, there are two problems here. None of us (educators, healthcare providers) have been trained in how to ask our patients these questions sensitively. The MPA’s new education and training programs are starting this conversation and helping providers recognize these complexities.
The second problem is the stigma attached to this topic. It’s uncomfortable. Physicians don’t want to ask, or think that perhaps patients don’t want to be asked. At the end of the day, these physicians are like everyone else: a good portion of them have experienced their own stressors and traumas, which may make the conversation harder.
In your role as MPA Director of Body-Brain Integration, how is your work aiming to improve this stigma, and impact positive change across our healthcare system?
To be honest, it’s a big knowledge translation challenge. We don’t need any more evidence about what the problem is, but we need to change this.
We’re trying to address different audiences in different ways. For the general public, we’re letting them know that this is an important topic to raise with your health care provider and team. It’s okay to talk about it. For health care providers, we’re showing them the evidence that this is a substantial risk factor for healthcare. For example, patients with a history of sexual abuse in their childhood might not want an invasive procedure such as a pelvic or breast exam. So to the health care provider, the unspoken and the invisible will look like resistance, and they cannot help them meet their health care needs
We’re giving people tools to approach their providers and have these conversations that need to happen, for the best health care outcomes possible.
If you could tell your fellow peers one message around this topic, what would it be?
Ask the question.
By this I mean, ask your patients if they’ve experienced stressors in their childhood. Introduce the topic. We have evidence that most patients want to be asked. They only ask that the topic is raised in a way that feels safe, that they will be believed if they talk about their own experience. Most patients are not going to bring it up on their own. So, it’s up to the health care provider.
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