A Focus on Adverse Childhood Experiences: Interview With Dr. Julie Miller-Cribbs
As an emergency room social worker, Dr. Julie Miller-Cribbs saw the effects of adverse childhood experiences on a regular basis. At least she thinks now that she did. It was the 90's, though, when she went to work at Barnes Hospital in St. Louis, and she didn't yet make a conscious connection between adverse childhood experiences – or ACEs, as they are now called -- and adult health. At that time, few did. The landmark Kaiser-Permanente Adverse Childhood Experiences study hadn't been published yet, though the groundwork had been laid.
At the inception of that study there had been a doctor intent on learning why his weight-loss program wasn't working, specifically why people kept dropping out and relapsing when they had been seeing healthy weight loss. When the doctor talked with his "drop-outs", issues of childhood abuse unexpectedly emerged. Asked how much she had weighed when she became sexually active, one woman gave the shocking answer, “40 pounds”. It turned out that this woman wasn't alone. And it turned out that for some, the connection to adult weight went deeper than the common practice of using food to feel better. Extra pounds offered protection or invisibility; losing them served to increase anxiety. This doctor met up with another doctor, an epidemiologist who had studied the correlation between depression and heart disease – and who had observed that the compounding mental states didn’t occur randomly in the population.
Tackling Adult Health Issues
Adverse childhood experience is not synonymous with abuse. Early adversity encompasses many things, Miller-Cribbs notes, from parental dysfunction to witnessed violence. So much change can occur, she says, when a doctor flips the question from “What’s the matter with you?” to "What happened to you?" Often the connections are not immediately apparent. Patients don't see a connection between the heart disease they’re battling now and the traumas that took place decades earlier -- though there may well be a connection. Addressing these traumas helps manage health even at a later stage in life when serious issues have manifested.
On a patient level, recommendations can include mindfulness training and Cognitive Behavioral Therapy. Physician training can go a long way toward setting healing forces in motion. Miller-Cribb’s research group at the University of Oklahoma is working to train medical residents to open healing dialogues. The goal is that these future physicians will ask their patients key questions and either continue the dialogue or help their trauma-affected patients access support elsewhere. The dialogue is in itself a challenge. The ACE paradigm is based on the neurobiological. Medical residents are experts in biological systems. They need to practice their skills, though, in order to bring the neurobiological down to the level a patient can understand, and to dialogue about it effectively in simple language.
Whole buildings need to become trauma-informed, Miller-Cribbs asserts: everyone from the clinical staff to the receptionist. Miller-Cribbs is a fan of integrated care as an alternative to old school referral. In this system, a doctor can say “Here, let me walk you to our social worker,” or “Here, let me walk you to psychiatry”.
Working Toward Systemic Change
Trauma awareness is also necessary at the systemic level. Healthcare access is another of Miller-Cribbs's interests. It is well-known in the world of ACEs that there is a stairstep effect where a higher "ACE score" – more trauma categories -- results in worsened emotional and physical health as well as worse health behaviors. Miller-Cribbs has found there is also a connection between ACE score and healthcare access. People with higher levels of early trauma are more likely to go for periods of time without insurance. They are more likely to carry medical debt.
Miller-Cribbs notes that people know about ‘failure to thrive’. They know about the most severe effects of the most severe forms of trauma. They don't necessarily know about the effects of intermittent trauma. When asked how the physiological basis of the ACE/ health connection can be used as a talking point for policy change, she notes there is a lot of research out there. One of her most recommended sites is Harvard University’s Center for the Developing Child. Among her most recommended resources is the short video “Serve & Return” which summarizes how neural architecture forms in response to adult interaction (http://developingchild.harvard.edu/resources/three-core-concepts-in-early-development/). The video series also highlights the negative effects of flooding the developing neural system with stress hormones.
The best outcomes occur when children's development is supported in the early stages. Experts in the field of human development now know that different aspects of development are tightly interconnected: the cognitive, the social. A baby may be learning, “Sometimes when I cry, someone helps. Sometimes when I cry, no one helps.” Unfortunately, this is happening to an active, agile brain where neurons are learning to adapt. There is a good chance it will affect health behaviors and outcomes down the line. However, interaction with supportive adults fosters resiliency.
Practitioners are working with their own patients and within their own systems. Also needed are community-wide initiatives. Some states are writing adverse childhood experiences into their health plans.
What about those that aren't? What about those communities that are too daunted by the costs of supporting early childhood development to work to affect change? This is something Miller-Cribbs can answer in very simple language, "We pay now or we pay later."