Mrs. W, 37, has been my patient for five years. During her annual exam, we always discuss her weight, high BP, smoking, depression, and failure to take her medications consistently. This year I tried a new approach: “Sometimes when my patients are struggling with issues like these, it’s because they’re still troubled by things that happened to them when they were younger,” I told her. “Do you think that could be a factor for you?” Mrs. W burst into tears and disclosed for the first time that she had been molested by her grandfather when she was a child. As she recounted her story, I knew that although my schedule would be thrown offfor the rest of the day, I had opened a door that might lead to healing and positive change.
Because of the way we are trained, health professionals tend to approach patients’ problems by offering medications and procedures. When our interventions are unsuccessful, we wonder why.
Frequently, we fail to see what lies beneath our patients’ symptoms. Family violence is epidemic in the United States. More than one in four families is affected, with children often both witnesses and victims. By the time they reach 18, at least one in five girls and one in 10 boys will suffer some kind of sexual abuse. Experts have found important links between child maltreatment and poor physical and emotional health in adulthood. The Adverse Childhood Experiences (ACE) Study collaboration between the CDC and Kaiser Permanente in San Diego is a landmark piece of research. This study involved more than 17,000 HMO members who answered questions about adverse childhood experiences, including physical, emotional, and sexual abuse; substance abuse; mental illness in the home; parental separation; and incarceration of a household member. As the number of adverse experiences increased, so did the number of ailments, including chronic obstructive pulmonary disease, depression, ischemic heart disease, liver disease, and obesity.
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The conclusion: Adverse experiences during childhood are major risk factors for all leading causes of death and disability. Yet it is a risk factor about which we rarely ask. What we perceive as poor lifestyle choices may actually be coping strategies. Our patients may be treating their anxiety, depression, and post-traumatic stress disorder with nicotine, alcohol, illicit drugs, and food. According to Vincent Felitti, MD, one of the lead investigators for the ACE Studies, “…much of what is recognized as common in adult medicine is the result of what is not recognized in childhood.”
We must get better at recognizing child maltreatment and family dysfunction and at familiarizing ourselves with resources for intervention. Your local Child Advocacy Center can help; check for local facilities at www.nca-online.org.
For adult patients, we need to rethink our approach to addressing chronic disease and lifestyle choices. We must ask about childhood experiences just as we ask about smoking, alcohol intake, and exercise. And we must be prepared to help patients get the treatment and support they need. Check with local mental-health facilities, or contact the Darkness to Light organization at www.darkness2light.org.
As for Mrs. W, she is seeing a skilled therapist and now realizes that her lifestyle choices were a response to early trauma, not a character flaw. With that understanding, she has been empowered to make better choices, and we both have renewed hope for the future of her health.
