Childhood trauma is tied to health risks, but Michigan doctors don’t ask

Physicians trained in asking patients about childhood trauma are better able to recognize underlying symptoms or problems that can affect their physical and mental health.

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By now, the medical evidence is clear: Childhood trauma can have profound effects on physical and mental health.

Even so, Michigan physicians like Timothy Kval remain all too rare. Working out of a Muskegon clinic, Kval evaluates more than a patient’s symptoms, blood pressure readings and cholesterol scores.

He also screens adult patients for past traumatic events like physical abuse, neglect, domestic violence in the home or the loss of a parent through divorce or death. He is looking for links between what researchers call Adverse Childhood Experiences (ACEs) and higher rates of everything from obesity to heart disease to heavy drinking and depression.

RELATED: Michiganders: Take this test for childhood trauma

“What this gives the patient is self-awareness,” Kval said of the questions he asks. “It can be a very useful tool. It just correlates with a lot of health issues.”

He cited the example of a patient who is dangerously overweight.

“You might ask why aren’t they losing weight. Why are they slightly depressed? And low and behold, their ACEs score is high.”

In many cases, he said, doctors armed with this information are better able to refer these patients to social workers or counselors based at the clinic. They refer some for outside treatment.

“This can help you to talk to them. It’s a conversation starter. It helps us get at the root cause of things we glossed over in the past.”

Indeed, a 2016 Michigan survey found that adults who endured four or more traumatic events as children were nearly four times more likely to be diagnosed with depression than those with none. They were more than twice as likely to have asthma as those with no traumatic events.

Childhood trauma by the numbers 

A 2016 survey of Michigan adults revealed widespread reporting of childhood trauma. Based on those surveyed, a projected: 

  • 1.3 million Michigan residents experienced 4 or more traumatic childhood events
  • 1.4 million lived in households where adults were physically violent to each other
  • 1.1 million were sexually abused as children
  • 1.9 million lived in a household where the parents were divorced or separated
  • 2.1 million lived in a household with an adult with a substance abuse issue
  • 1.4 million lived with someone with mental illness
  • 600,000 lived with an adult who was incarcerated

Sources: U.S. Centers for Disease Control and Prevention, Michigan State University, Michigan Department of Health and Human Services

Thirty percent of those with four or more traumatic events in childhood also said they were in poor or fair health — compared to 13 percent of those with none, according to the study, conducted by the U.S. Centers for Disease Control and Prevention, Michigan State University and the Michigan Department of Health and Human Services .

Nearly a fifth of those surveyed — projecting to 1.3 million residents statewide — had four or more of these traumatic events in childhood.

Despite that staggering number, Kval and the Muskegon clinic appear to be an outlier among Michigan health providers. 

Asked by Bridge to estimate the share of Michigan doctors who assess patients for childhood trauma, Teresa Holtrop, past president of the Michigan Chapter of the American Academy of Pediatrics, offered a bleak appraisal.

“I would say it’s no more than 1 percent.” 

“There’s an understanding that ACEs play a huge role in the lives of our patients. But there’s a lot of fear of what do I do if I get a positive assessment.”

Teresa Holtrop, past president of the Michigan Chapter of the American Academy of Pediatrics, said there’s “a lot of fear” among physicians about to do with patients with multiple childhood traumas. (Courtesy photo)

Why doctors don’t ask 

While experts agree on the link between childhood traumas and poor health outcomes, Holtrop said many physicians balk at adopting trauma assessment. Some resist, she said, because they’re concerned about additional paperwork.

But others are unsure what behavioral health or other resources are available to help patients with high trauma scores. Holtrop cited the example of a parent with multiple traumas, which could be an indication their child was at risk as well.

“Say for example I screen the parent of a 4-year-old and found out that the parent had a huge ACEs score and I don’t have the knowledge of what might be out there in the community to help that child move forward. It’s going to be real challenging for me to be helpful.”

In Muskegon County, urologist Brian Stork – an advocate for greater trauma assessment by physicians – helped conduct a 2018 survey of county physicians to calculate how many knew of the ACEs questionnaire and how many used it. The finding was better than Holtrop’s grim estimate, but not by much.

Muskegon County urologist Brian Stork conducted a survey that found just 4 percent of county physicians uses childhood trauma assessment, a result he called “abysmal.” (Courtesy photo)

Of 226 physicians who responded, 4 percent said they used trauma assessment in their practice. Only a fifth were even aware such a questionnaire existed.

“That’s just abysmal,” Stork said.

Perhaps in recognition of this gap, the Michigan State Medical Society, which represents 15,000 physicians, approved a resolution this year encouraging annual screening for trauma by pediatricians.

Jared Burkhart, executive director of the Michigan Chapter of the American Academy of Pediatrics, concedes there’s “plenty of room for growth” among physicians for trauma screening.

He said pediatricians are among more than 100 individuals certified as master trainers on ACEs for the Michigan ACE initiative, a two-year statewide project to train educators, public health experts, nurses, doctors, police officers and others in how to identify children facing a high trauma score and properly intervene.

Jared Burkhart, executive director of the Michigan Chapter of the American Academy of Pediatrics, said there remains “a lot of work still to be done” in advancing physician trauma assessment. (Courtesy photo)

He added: “I would say there’s a lot of work still to be done.”

A research consensus 

Focus on childhood trauma has been building nationally for a couple decades, following a landmark 1998 study conducted in conjunction with the CDC.

It found that adults with at least four traumatic risk factors as children were four times more likely to be depressed, six times more likely to be alcoholics and 11 times more likely to have injected drugs than someone with no childhood trauma. It also found they were also more likely to have heart disease, high blood pressure and severe obesity.

A follow-up CDC survey of 25 states — including the one involving Michigan — released in November, confirmed those findings.

In the national survey, adults who experienced four or more traumatic events as children were 1.8 times more likely as those with none to have heart disease, twice as likely to have experienced a stroke, five times more likely to be depressed and nearly twice as likely to be a heavy drinker.

In the meantime, researchers also found links between trauma and abnormal brain development — and subsequent health and behavioral problems.

In 2011, the American Academy of Pediatrics cited mounting evidence that the “toxic stress” of  childhood trauma impairs normal brain development in infants and young children — with long-lasting emotional and physical effects. It pointed to studies that found trauma can actually cause physical changes to the brain’s architecture “that create a weak foundation for later learning, behavior and health.”

What doctors do with this information  

So, the question remains: What are Michigan doctors to do with these findings?

Perhaps they could learn from the Center for Youth Wellness in San Francisco, a clinic in a low-income neighborhood that transformed its practice around the recognition of the role traumatic experiences play in childhood development.

California surgeon general Nadine Burke Harris has been a pioneer in advocacy of universal screening for ACEs. (California Surgeon General’s Office)

Founder Nadine Burke Harris — a pediatrician and now California’s first surgeon general — has said she was puzzled that so many children in her practice were suffering from chronic abdominal pain, headaches, asthma or behavior disorders.

After learning of the original ACEs study results, the clinic began to screen every child for trauma and evaluate family history as well as health history. By finding connections to past trauma, doctors could connect children and families to mental health and social workers for further treatment.

Prompted by Harris, California legislators approved a budget in June that will move California toward universal ACEs screening. The state set aside about $45 million to reimburse Medicaid providers in the state for trauma screenings of adults and children and $50 million to train primary care providers in how to administer the screenings.

Praise for universal screening is not universal. Aside from the cost, there are questions about proper screening techniques and whether identification of past trauma can help remediate future health risks.  

“We have treatments for effects of abuse, like depression, but not for the experience itself. Not everyone who was abused will necessarily have problems or need treatment,” wrote David Finkelhor, a professor of sociology at the University of New Hampshire. “Moreover, just sending a child to a counselor doesn’t mean the counselor has something effective to offer.” 

Aside from the Michigan State Medical Society’s encouragement of pediatric ACEs screening, Michigan is nowhere near California in moving toward universal screening.

But in October, several southeast Michigan hospitals and the Detroit Wayne County Health Authority began an initiative to train pediatric medical residents in the use of ACEs assessment and how to “take therapeutically appropriate next steps” with children or their parents. It’s funded by a $78,000 grant from the Michigan Health Endowment Fund, created when the Michigan Legislature authorized Blue Cross Blue Shield of Michigan’s conversion to a mutual insurance company.

Jasmine Gray, a third year pediatric resident at Children’s Hospital of Michigan in Detroit, has already immersed herself in research linking multiple trauma with adverse physical and mental health outcomes.

Detroit pediatric resident physician Jasmine Gray said she believes childhood trauma has a “crucial role” in patient outcomes. Jasminegray.jpg (Courtesy photo)

“I kind of did my own research,” she said. “I think trauma-informed practice is very important. I don’t think it’s something we’ve ignored, but it’s something that we haven’t incorporated into practice as much could be.”

Gray said she intends to carry trauma assessment into her future practice, likely at a health center for the underserved in the Detroit area.

“It definitely has a crucial role in the prognosis and course of treatment of a patient,” she said.

At Muskegon Family Care, physicians adopted trauma screening following the 2016 community survey of adult county residents that found that nearly a third had experienced four or more childhood traumatic events — far higher than the state average of 18 percent.

Nearly 23 percent of respondents said they had experienced sexual abuse. More than a fifth said they had been physically abused as children.

For Muskegon County behavioral health service providers, those findings could be a roadmap to ways to end abuse and provide treatment.

Lauren Meldrum, community relations manager for HealthWest, the county’s community mental health agency, said the community’s already building on what it learned from the 2016 survey.

A $4 million federal grant awarded in 2018 to Muskegon HealthWest is aimed at comprehensive treatment services including crisis assessment, outpatient mental health and substance abuse treatment services and care coordination including partnerships with emergency rooms, law enforcement, and veterans groups.

Meldrum said that a separate $4 million, 4-year 2016 federal community grant paved the way for adding seven mental health professionals in county schools. Another dozen mental health professionals were placed in schools through Hackley Community Care, a federally qualified health clinic.

From his experience, Kval, the Muskegon physician, said apprehensions about onerous paperwork tied to trauma assessment are largely unfounded. For adult patients, he said, physicians at Muskegon Family Care use the questionnaire just once. He said nearly all patients agree to complete the form.

“The beauty of it is it’s just one and done. It provides not only the practitioner a glimpse into the patient’s deeper universe. It can really show the patient how you can benefit from this therapy or treatment.”

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Fri, 12/13/2019 - 5:36pm

Normally don’t post anonymously, this exception is to protect a child. Not only do pedestrians and others not ask about prior and / or current childhood trauma they are dismissive when its brought to their attention. Major health institution affiliated with a big ten college in Michigan, not only unequipped to deal with a traumatized adolescent but unwilling to treat beyond medication due to insurance issues. County mental health, understaffed, inexperienced and indifferent. Child protective services, only will refer the worst cases for action. I was personally told by a privileged Michigan school system that unless the abuse and neglect was noticeable & extreme they wouldn’t call CPS, CPS came in based on a different complaint and couldn’t close the case file fast enough. For three years I’ve worked the system looking for help for a traumatized child and it’s response has been inadequate at best. This article doesn’t tell the half of it, try finding a mental health professional that takes state insurance and is experienced with childhood trauma and sexual assault treatment. Good luck with that, well off enough to pay cash then perhaps you’ll find the right therapist, perhaps. If I seem a little angry its because I am. Angry because a bright and loving child has been damaged by the adults around her/him and no one cares. Sad eh

Mary Taylor
Mon, 12/16/2019 - 1:19pm

So true! Finding help is hard, finding quality help is almost impossible. And it is costing us as taxpayers more and more every year.

Nancy Phillips
Sat, 12/14/2019 - 2:26pm

There is DEFINITELY a connection between childhood trauma and mental health issues, substance abuse issues, higher rates of suicide attempts, etc. How do I know? Because I am one of them. I never really knew how "sick" that I was until 2010 when I attempted suicide. I knew that I was depressed and in 2006, I admitted, out loud, that I was an alcoholic. I have multiple dx's as it relates to my mental health. I have become a Certified Peer Specialist. I have maintained my sobriety for almost a year, this time. I am in therapy and have been since 2010 and I probably will always be and that's OK. If you would like to talk to me, I would welcome the opportunity because what I went through as a child and what I am living with today is important and my story needs to be heard. I am an open book and I will answer any questions you might have. Thank you.

Allan Blackburn
Wed, 12/18/2019 - 10:22am

Haven't commented here for some time but this one is a doozy. Trauma was a huge part of my formative years. From being beaten for having potty accidents as a small child, shamed & humiliated for being male, stabbed in the arm with a hotdog fork for getting answers wrong on multiplication tables, having dog feces smeared on my face for missing it in the yard, pushed backwards out the door and down a couple of steps to take out the trash and cracking my head on the patio, hands tied behind my back before I went to sleep so I wouldn't suck my thumbs, beaten with electrical cords, belts, boards, etc., trauma was my childhood. I was terrified of my mother. What occurred at home followed me to school where I was also bullied for not liking sports, being small, not being a fighter, etc. The best time in my life was when I learned to ride a bicycle and escaped the house as often as I could. I also began earning my own money at a young age and began to get high with marijuana. Independence was important to me and getting out of a house which was not a good environment to be around. When my dad finally had enough he and I left. My older sister joined us and my younger sister remained with my mother. My younger sister got pregnant at age 15 and my older sister did at age 17. I joined the military at age 17 and never returned to live except for 6 months after discharge. Even though I stopped drinking & using drugs when I was 20 years old early childhood trauma has affected my entire life. Both of my sisters were sexually abused and I was sexually abused through sadistic beatings. Both have been married and divorced multiple times. I was sexually promiscuous until my latter 20's but I met a good woman and I have been married ever since. We have been together for 34 years presently. The things I am most proud of is being well educated, having decent morals and values, having many stable friendships now that have lasted over 40 years, I have a stable life, had a successful career, live a spiritual life with little strife & conflict and I am able to forgive as not doing so eats me up rather than people I am mad at. Trauma is so important, words matter, how you treat your children is very important, how you treat each other is highly relevant. My biggest regret is that I never gave myself a chance to be a parent. I was too afraid of passing my childhood on to another human being. Today I have many nieces & nephews that I love immensely. No matter what happened in my early childhood, which I had no control of, I am grateful for the life I have lived and the life that I have had. I have had my share of medical issues which I attribute to the trauma experienced which couldn't help but predetermine health. In all, be kind! It matters.

Tue, 01/07/2020 - 9:49am

So glad you were able to overcome such a traumatic childhood. I hope you share your story in schools/classrooms to let other children know they are not alone and that there is a light at the end of the tunnel. As a child who also suffered trauma I can remember feeling like an outcast at school. I was withdrawn, bulimic, got low grades, hung out with ALL the wrong people and was promiscuous as I just wanted someone to love me. I am extremely fortunate to also be happily married to a wonderful man for the past 30 years, but it is all still with me. You never forget, but you can rise above. It took me a long time. Four of my older siblings still carry the weight. We're all over 50 years old. Maybe with the ACES assessment people can move past their trauma quicker than I did and lead healthier lives. Thanks for your story.

Tue, 12/31/2019 - 8:41am

Interesting as psychotherapists have known and validated this for decades, the Mind Body interactions, Diathesis Stress Model.. Also, Other health professionals may do well to include the ACE in their assessment IF they actually use it to help their patients/get help for their patients. I recently found a dentist in Mishawaka IN that uses the ACE in such a manner.

Tue, 12/31/2019 - 9:07am

WE have known this for decades. It has been validated.
However, even when using the ACE as a screening instrument, I remain cautious in recommending it as a GENERAL screening instrument by health care professionals.
To Remember:
NOT ALL who have experienced trauma, victimization in childhood require psychotherapy.
Not ALL how have experienced trauma, victimization in childhood will have physical symptoms as a result.
DO NOT minimize the symptomatology or their illness, treat the physical illness even if you have ascertained that your patient has experienced abuse as a child.
Never force your patient/client to get psychotherapy /counseling.

Make certain that the patient/client gets APPROPRIATE TREATMENT for their past experiences and what effects it has on their present lives.
Not all who are listed as counselors, therapists, etc. are versed in dealing with victimization, trauma , and its effects.
Please ensure that the person/group you refer them to has the credentials, the experience, the specialization in victimization, abuse, and it's treatment!!

Hiram Fitzgerald
Fri, 01/03/2020 - 8:47am

Excellent article drawing attention adverse childhood experiences, now generally referred to as ACES. But, adverse childhood experiences have been part of the human experience for far longer than the ACES study of 1999. State and national assessments of the prevalence of ACES occurs annually and professionals in all health related fields should be evaluating ACES from the prenatal period on and making cross referrals when warranted.

Canequia Moulder
Tue, 01/07/2020 - 10:59am

I am definitely glad that there is more attention focused on how PCPs, Pediatricians, Behavioral Health specialist's etc. can impact individual health outcomes if they take the time to acknowledge that what they are treating a patient for symptomatically may be the result of a much greater and hidden issue related to ACEs. In the Pontiac community, we have been working tirelessly to expose the community at large on the impact of trauma. There are those who would ignore this topics where others are working to expose the community to a term that gives credence to what they have experienced in childhood and it is impacting their adult behaviors socially, emotionally, and physically. I would love to see trauma informed care across the board however there requires funding for adding the ACE assessment and training for providers who may have never heard of the study or research. The common complaint will be "Dr.'s already only have 20 mins to see there patients for one issue, now they want us to assess them for ACEs." I hear it now; we will continue in Oakland County to push for trauma informed care in clinics, hospitals, and private practice; because to keep ignoring it is leading to serious SDHs that people are not overcoming especially young people. Great article, now push more funding into cities who are doing the ground work, like Pontiac we need so much help.

Sun, 01/26/2020 - 1:04pm

Your test fails to account for female aggression and abuse. I grew up in a family with a mother who routinely hit, punched kicked and scratched my father thus delivering a traumatic childhood to my brother and myself.