12 November 2018
Suffer little children … or can we, as GPs, help?
Can GPs help reduce the impact of adverse child experiences on our patients?
In 1998, a landmark study established a correlation between adverse experience in childhood and poor outcomes in life, on almost every measure of physical, mental and social wellbeing.
The impact of adverse experiences is particularly potent in the first two thousand days of life.
Neuroscience has demonstrated plausible physiological pathways that could explain the correlation. These pathways explain how these experiences are potentially detrimental to the architecture and chemistry of the developing brain.
Consequences include unfavourable impacts on the hypothalamic pituitary axis, the immune system and the inflammatory system.
Further, epigenetic changes induced by the environment alter the expression of a child’s genes, an alteration that is then transmissible across generations.
Research has shown that adverse childhood experiences not only increase the risk of poor social and psychological outcomes such as life dissatisfaction, separation/divorce, heavy drinking and anxiety, but also poor physical outcomes in terms of higher rates of cardiovascular disease and cancer.
But managing these patients and changing the natural course of this scenario can be tricky.
Adults (and children) with a history of adverse experiences may be difficult. Their behaviour may unwittingly elicit ongoing traumatising responses from those who are charged with their care.
The first rule in managing patients who have had adverse childhood experiences is don’t add to the established harm.
In trying to gauge the patient’s degree of risk from their history, researchers sometimes refer to an ACE (Adverse Childhood Experience) score – a simple 10-point check list that gives numerical representation of the extent of potentially damaging experiences a patient may have had.
The ACE score is established by asking about childhood experience of any of the following:
? Physical neglect
? Emotional neglect
? Exposure to domestic violence
? Household substance abuse
? Household mental illness
? Incarcerated household member
A yes or no question about each of these experiences produces an individual’s ACE score that will be between 0 and 10
As GPs, we cannot change a patient’s past, but just knowing that a patient has had a significant adverse experience as a child can increase our awareness of possible sequelae – social, psychological and physical – and perhaps trigger an early intervention.
General practice defines itself as the medical discipline that offers whole person care. We can be the constant that provides safety and support in the context of promoting the best health outcomes possible for that patient.
Because of our often long-term and ongoing relationship with our patients we may also be in a position to prevent the impact of these adverse childhood experiences being felt through the generations.
If children of parents affected by adverse experiences in childhood are to experience sustained, safe and nurturing relationships, then the parents themselves need sustained, safe and nurturing relationships.
GPs are in the business of providing sustained, safe and nurturing relationships, and as such we can certainly make a difference.
Awareness of adverse childhood experiences may be enough to trigger a preventive, if unexpected, intervention. Consider the following case study:
A four-year-old patient skipped into the room with her dad. Nothing lifts the spirits quite like the sight of a skipping child. The family were long-time patients of the practice.
A number of years ago, during a one-on-one conversation, the dad (who hadn’t been a dad at the time) had talked about growing up with a violent, alcoholic father.
The father had long since died and there hadn’t seemed any obvious consequences for my patient except perhaps that he didn’t drink at all. However, I never forgot that conversation.
This visit was a follow up. Lilli (Not her real name) had been in with her mother a week before.
The family was stressed. Lilli who had been perfectly dry day and night since about the age of two and a half was, for some months, now frequently wet both day and night.
She was happy and healthy. Her two years of continence made a structural lesion unlikely, and a specimen of urine was collected.
Now, Lilli was back, this time with dad. The urine specimen had been essentially normal.
I explained that we had all but ruled out an organic cause for the wetting. There was also no obvious source of psychological distress unless it was the arrival of her now 18-month-old brother.
Dad reported that he and his wife and instituted a star chart and that Lilli’s was interested in gaining stars.
I congratulated dad on his parenting skill, not only for introducing the star chart but also in the way they had Lilli engaged in the process.
I went on to observe that while there was no recipe to guide the way forward, there were principles to guide what not to do. Chief among these is the need to avoid shaming Lilli as a technique to induce behaviour change – a very tempting technique, especially when parents become understandably frustrated.
“Of course, doctor, of course”, dad said.
Then after a few moments reflection he went on: “You know I think I might have done that sometimes … I am going to work on that.”
I realised then, that for this dad, anger, and possibly violence, as a response to frustration would have been his learned response from childhood.
Being with this dad as he developed this insight – an insight likely to be of profound consequence for Lilli, and Lilli’s children – generated at least as much joy in this doctor, as did the sight of Lilli skipping towards him.
We can make a difference.
Dr Michael Fasher is Adjunct Associate Professor at University of Sydney and Conjoint Associate Professor at Western Sydney University