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Upterrlainarluta: Always Getting Ready

Upterrlainarluta describes the story of people subsisting on the frozen tundra of western Alaska.  The translation of this impressively long, Yup’ik Eskimo word is always getting ready. To live in this land of extremes and acclimate to all the changes that have come to the Arctic, there is a tradition of always getting ready for the next season and whatever lies ahead.   The survival of Yup’ik people and their culture depend on always being ready.

Public health and health care systems must always be getting ready too.  We need to be poised to face the next epidemic, address emerging challenges, identify opportunities for early intervention and, ideally, move towards primary prevention.  Adverse Childhood Experiences (ACEs) is an increasingly high profile issue on our horizon.  There is growing interest and emphasis in routine screening for ACEs in many sectors.   As a national dialogue unfolds about the feasibility and value of asking about ACEs, it makes me think of the importance of always getting ready to prepare for some of the inevitable challenges and needs that will emerge with ACEs assessment.

Asking about ACEs is not totally new terrain.  Questions about ACEs have been part of the self-administered patient’s health history questionnaire at Kaiser Permanente (KP) since the mid-1990’s when the Centers for Disease Control (CDC) and KP began collecting baseline data for the ACE Study (http://www.cdc.gov/ace/questionnaires.htm).  Questions have been asked in a piecemeal fashion about some past adverse childhood experiences in a variety of settings, but the ACE questionnaire uses a more comprehensive approach that covers ten different childhood adversities from which a summary ACE score can be derived.  It is being used in a growing number of public health and social service agencies across the nation.  However integration of ACEs assessment into mainstream medicine has moved more slowly.  

Many practical questions have been raised, such as how will this information integrate into electronic medical records and the reality of time constraints? There are so many things that clinicians are expected to ask about in such a short amount of time during an office visit.   With more and more emphasis on evidence-based practices, there is also the very practical issue of empirical evidence demonstrating that asking about ACEs leads to better outcomes.  This is a very important point in terms of always getting ready because it takes time to build a body of evidence.  If we really want to advance ACEs assessment as a routine clinical practice, we need to systematically evaluate what we already know and what we need to know to build a strong case.  

More than two decades of debate and resistance to routine screening for domestic violence in the health care setting illustrates how challenging it can be to change clinical policies and practices.  Similar to the body of research demonstrating the long-term health effects of ACEs, there’s no shortage of studies demonstrating the link between domestic violence victimization and poor health outcomes for adult victims and their children.  The U.S. Preventive Services Task Force’s (USPSTF) recent decision to recommend screening women of childbearing age for domestic violence is a monumental step forward that is supported by a limited but growing number of rigorous studies showing that there are effective screening tools for domestic violence and that screening can make a difference.  It has been a long journey from the Task Force’s initial “I” rating indicating that, in their opinion, there was insufficient evidence to assess the balance of benefits and harms of screening for domestic violence to the current “B” recommendation supporting routine assessment for domestic violence.   It is a crucial victory for people working in the field of domestic violence because the USPSTF’s recommendation carries a lot of weight within the medical community and influences decisions regarding reimbursement and clinical practices.   This didn’t just happen—there has been years of strategizing, planning and collaboration to obtain the USPSTF’s stamp of approval.  If the goal for ACEs is routine universal screening, then we need to be getting ready now by identifying where the gaps in the evidence to support screening for ACEs.

And there’s more to this domestic violence analogy.  With the implementation of screening for domestic violence, there have been some critical lessons learned.  We need to be ready before we start asking about sensitive, trauma-related issues.  Any setting asking about ACEs needs to have trauma-informed practices in place.  Being trauma-informed is essential to doing no harm and  for maximizing the potential to help ACE survivors.   It’s hard work because it is not only about creating a safe space for patients so that these questions can be asked, but also training and supporting staff so that they are comfortable in talking with patients about ACEs.   It is also about the reality that many health care providers are ACE survivors themselves.  We have to be able to practice self-care and take care of ourselves first in order to be able to help others.  We need to understand how vicarious trauma can sneak up on us when we really start opening the door to talk about ACEs, and begin to take steps to make care settings more cognizant and supportive environments for this work to take place, both for providers and the people they serve.

In other words, we need to be always getting ready as we determine where we are going with routine assessment for ACEs.   Before screening for ACEs is implemented, the first assessment in any setting should be about trauma-informed practices and staff.   On the national level, experts need to discuss what’s working, what’s not working, and what we need to know to safely and effectively ask about and address ACEs in the health care setting.

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