Week 8 Initial Discussion Post

One Thing that Stands out to me the most in Adverse Childhood Experiences (ACE) Research

The ACEs study was back in the mid-’90s; ACEs stands for Adverse Childhood Experiences. Dr. Vincent Felitti and Dr. Robert Anda had good ideas in their experiences as physicians that adverse experiences in childhood had very direct correlations to very specific health outcomes. So, they did a study of over 17,000 participants and made the distinct correlations between specific and common health outcomes that they and others were seeing. These outcomes were and are very prevalent, they were able to directly connect prevalent outcomes to adverse situations in childhood, such as abuse and neglect. Defying conventional belief, this study famously revealed a powerful relationship between our emotional experiences as children and our physical and mental health as adults. In fact, the ACE study shows that humans convert childhood traumatic emotional experiences into organic disease later in life. Revolutionary at its inception, Felitti’s groundbreaking research remains extremely relevant to today’s healthcare models. One thing that stands out to me the most in ACEs research is that women, American Indian/Alaskan Natives, and African Americans/Blacks were more likely to experience four or more ACEs (CDC, 2019). If this is the case, then why, how, and what is the correlation between these groups and ACEs study?.

The Importance of ACEs Assessment Instrument/Tool in Psychiatric Mental Health Care

The Adverse Childhood Experience (ACE) Questionnaire is a 10-item self-report measure developed for the ACE study to identify childhood experiences of abuse and neglect. The study posits that childhood trauma and stress early in life, apart from potentially impairing social, emotional, and cognitive development indicates a higher risk of developing health problems in adulthood. The instrument/questionnaire helps researchers and mental health professionals identify childhood abuse and neglect and family dysfunction such as domestic violence, incarceration, and alcohol and drug issues.The survey consists of ten questions. Each affirmative answer is assigned one point. At the end of the questionnaire, the points are totaled for a score out of ten, which is known as the ACE score. 

The questionnaire has many applications and may be administered by clinicians to better understand the trauma history of people who are experiencing domestic violence, drug and alcohol issues, incarceration, mental health conditions and suicidal thoughts, and chronic health conditions. Since the ACEs study suggests that there is a significant link between adverse childhood experiences and chronic disease in adulthood, including heart disease, lung cancer, diabetes, and autoimmune diseases, the questionnaire may be able to help those who have a high ACE score become more informed about their increased risk factor for health issues. It could also encourage them to seek treatment or therapy if they have not already done so.  Additionally, the study highlights how these childhood experiences influence the possible development of mental health issues in adulthood and may serve to assist mental health professionals in better understanding certain mental health concerns.The connection between adverse childhood experiences, social issues, and adult mental and physical health might also be used to help inform programs and health policies that support the prevention of these issues and recovery from them (Cattane et al., 2017).

Barriers to Responding to the ACEs Research

Barriers to assessing ACEs in practice have been reported to include provider discomfort with the topic, including their own history of adversity, and lack of training or clarity on resources and appropriate response to the assessment of results. Worries that asking about ACEs will trigger severe traumatic reactions are of concern. However, research documenting the the role, value, and methods for assessing and addressing ACEs in child and family clinical contexts are beginning to emerge. Thus, many questions and controversies exist, including whether and how to directly inquire about ACEs with children and youth in addition to ACEs of parents, if ensuring assessment promotes trust and empowers families and children, other information to collect simultaneously, data protection and confidentiality, and feasibility and practice redesign implications. Since assessing ACEs in clinical or community public health contexts are not yet well studied, researchers approached the study with neutrality as to the value, efficacy, and feasibility of ACEs assessment in practice (Cattane et al., 2017).

Best Options for Treatment of Borderline Personality and Rationale

Patients diagnosed with borderline personality are often extremely difficult to work with, as they have a peculiar ability to “get under the skin” of clinicians by inducing transference. According to DSM-5 diagnostic guidelines, five or more criteria must be present in a variety of contexts for the diagnosis of borderline personality disorder. These patients normally present with a pattern of mood instability, intense interpersonal relationships, impulsivity, identity disturbance, recurrent suicidal acts and/or self-mutilating behaviors, intense anger and rage. They are afraid of abandonment, idealizes and devalues people, sees the world in black and white (no gray areas), have recurrent suicidal behavior and self-mutilating behavior, chronic feelings of emptiness, and stress-related paranoid ideation or severe dissociative symptoms. Research shows that childhood sexual abuse (which is an adverse childhood experience)is the most significant correlation with severity. Thus, psychoanalytic theories focus on poor parental/caretaker attachment and the individual’s resulting difficulty with separation (Klamen, 2021). 

Considering the above background information on borderline personality and recommendation of experts, best options for treatment include completing the history and physical examination with consideration of previous neurological trauma, psychiatric evaluation with a focus on personal and social history, including the history of abuse, thyroid function studies, complete metabolic panel, liver enzymes, complete blood count with differentials, and careful assessment of cuts, bruises, and scars where a patient could have caused self-harm through cutting, burning, or self-injury.

The best option for treatment should include both pharmacological and psychotherapy interventions. The clinician should first of all:

·      Establish a trusting interpersonal professional relationship 

·      Stabilize symptoms that are the most distressing to the client (mood instability, psychosis, suicidal thoughts, and actions)

·      Pharmacological therapy: Olanzapine (Zyprexa) has recently shown promise in stabilizing labile moods, controlling the characteristically brief psychotic episodes, and impulsive behavior. Consider selective serotonin reuptake inhibitor (SSRI) for depression.

·      Psychotherapy: Studies have shown that long-term psychodynamic psychotherapy is the most useful if not the most successful long-term form of treatment. 

·      Dialectical behavioral therapy (DBT): This therapy attempts to help clients explore their own behavior, thoughts, and feelings in the present without delving into the client’s childhood, which tends to be regressive in these clients, resulting in increased suicidal behavior and acting out.

·      Give patients clear, non-technical answers.

·      Do not encourage patient to idealize you or other members of the treatment team.

·      Strike a balance that is not too close, but not avoidant or punitive.

·      Set limits early and often on what behavior is acceptable.

·      Crisis intervention is frequently the most common acute treatment along with brief hospitalizations for threats to suicidal ideation, plan, and intent (Rhoads & Murphy, 2016).

ACEs experiences can include things like physical and emotional abuse, neglect, caregiver mental illness, and household violence. The more ACEs a child experiences, the more likely he or she is to suffer from things like heart disease, diabetes, poor academic achievement, and substance abuse later in life. An ACE study with adults has found that compared to people with no ACEs, those with 4 or more ACEs are more likely to have been in prison, develop heart disease, develop type 2 diabetes, have committed violence in the last 12 months, and have health-harming behaviors (high-risk drinking, smoking, drug use). When children are exposed to adverse and stressful experiences, it can have a long-lasting impact on their ability to think, interact with others, and on their learning. Research also found that a relationship with one trusted adult during childhood can mitigate the impacts of ACEs on mental and physical wellbeing (CDC, 2019).

 The Adverse Childhood Experiences survey also found that as the number of ACEs increased in the population studied, so did the risk of experiencing a range of health conditions in adulthood. A first-ever CDC analysis provides comprehensive estimates of the potential to improve Americans’ health by preventing Adverse Childhood Experiences (ACEs). ACEs can include experiencing abuse, witnessing violence or substance misuse in the home, and having a parent in jail. Exposure to ACEs can result in extreme or repetitive toxic stress responses that can cause both immediate and long-term physical and emotional harm. At least five of the top 10 leading causes of death are associated with ACEs. Preventing ACEs could potentially reduce chronic diseases, risky health behaviors, and socioeconomic challenges later in life. These findings appear in CDC’s latest Vital Signs report, which examines the associations between ACEs and 14 negative outcomes. CDC analyzed data from 25 states that included ACE questions in the Behavior Risk Factor Surveillance System (BRFSS) from 2015 through 2017. State survey data were used to estimate long-term health and social outcomes in adults that contribute to leading causes of illness and death and reduced access to life opportunities. CDC scientists analyzed data from more than 144,000 adults and found that ACEs are linked to chronic health problems, mental health, substance misuse, and reduced educational and occupational achievement. Preventing ACEs has the potential to reduce leading causes of death such as heart disease, cancer, respiratory disease, diabetes, and suicide. ACEs prevention can also have a positive impact on education and employment levels (CDC, 2019).

In summary, CDC findings include the following:

·      Adults reporting the highest level of ACEs exposure had increased odds of having chronic health conditions, depression, current smoking, heavy drinking, and socioeconomic challenges like current unemployment, compared to those reporting no ACEs.

·      Women, American Indian/Alaskan Natives, and African Americans/Blacks were more likely to experience four or more ACEs.

·      Preventing ACEs could have reduced the number of adults who had heart disease by as much as 13% up to 1.9 million avoided cases, using 2017 national estimates.

·      Preventing ACEs could have reduced the number of adults who were overweight/obese by as much as 2% up to 2.5 million avoided cases of overweight/obesity, using 2017 national estimates.

·      Preventing ACEs could have reduced the number of adults with depression by as much as 44% up to 21 million avoided cases of depression, using 2019 national estimates.

CDC Efforts to Reduce ACEs include:

·      Educating states and communities about effective social and economic supports that address financial hardship and other conditions that put families at risk for ACEs.

·      Encouraging employers to adopt and support family-friendly policies such as paid family leave and flexible work schedules. 

·      Increasing access to programs that enhance parents’ and youths’ skills to handle stress, resolve conflicts and reduce violence. 

·      Improving school environments to lessen the impact of ACEs and prevent further trauma.   

·      Educating healthcare providers to recognize current risk in children and ACEs history in adults, and to refer patients to effective family services and support. 

CDC encourages communities to take advantage of the best available evidence and join CDC in efforts to prevent ACEs. Everyone can help: Parents, teachers and school counselors, religious leaders, business leaders, health care professionals, and charitable organizations (CDC, 2019).

References

Cattane, N., Rossi, R., Lanfredi, M., & Cattaneo, A. (2017). Borderline personality disorder and childhood trauma: Exploring the affected biological systems and mechanisms. BMC Psychiatry, 17(1), 221–223.

Klamen, T. (2021). Case files psychiatry (6th ed.). McGraw Hill Lange.

Center for Disease Control and Prevention. (2019). Preventing adverse childhood experiences (ACES) to improve U.S. health.

            Retrieved from https://www.cdc.gov/media/releases/2019/p1105-prevent-aces.html

Rhoads, J., & Murphy, P. (2016). Clinical Consult to Psychiatric Nursing for Advanced Practice (1st ed.). Springer Publishing Company.