Engaging the disengaged: could exploring adverse childhood experiences be one of the solutions?

I’ve always been fascinated by what makes people tick. That’s why I became a psychiatrist. Increasingly, my curiosity has become more focussed on the factors influencing adult behaviour, in particular in self-care for long term conditions. That curiosity has brought me to think about the effects of adverse childhood experiences (ACEs) on the choices that adults make on a day to day basis. Given that 40% of adults have experienced at least one ACE and 10% have experienced four or more, the potential for greater understanding around this is huge.

Why is there a cohort of people that we serve, to whom we repeatedly tell horror stories about all the awful things that might happen to them if they don’t improve their diet or exercise, or diabetes control……and yet they carry on with the same health harming behaviours? And how do we support them better? Here are my thoughts. 

Imagine this. You are in your house when someone breaks in. Your threat system triggers all the sympathetic physiological responses you need to manage this threat. You are in fight, flight, freeze or appease mode. Everything in your body and brain is focussed on surviving this situation.  And then someone starts to discuss your high HbA1c with you and ask why you are still eating an unhealthy diet. You will either, get annoyed with them, not engage with them, or say anything to make them shut up and go away. You don’t have the mental capacity to concentrate on what they are talking about because your survival is at stake.

Now of course that is a ridiculous example. But the problem is that because of our new homo sapien brains, our evolutionarily useful physiological response to threats doesn’t differentiate much between real in-the-moment threats and the reliving or ruminating over past threats. For some people who have experienced childhood adversity this is almost a permanent state of being. And so, the intruder scenario is not that different to the internal world experience of someone in your clinic room who has a significant history of ACEs. 

There is a dose-response curve between the number of ACEs experienced and the risk of developing mental health problems and health harming behaviours and therefore it is not so surprising that people with four or more ACEs are likely to die 15-20 years younger than their peers.

But it isn’t all doom and gloom. Large scale studies about routinely enquiring about these experiences in the healthcare setting consistently show:

  • People generally welcome being asked
  • It doesn’t lead to increased referrals for therapy, 
  • It doesn’t lead to acute crises,
  • It is manageable within routine primary care 
  • It improves healthcare utilisation 
  • It improves the therapeutic relationship with the clinician.

“What happened to you?” is much more powerful as an intervention, than “what is wrong with you?”. It conveys so much more compassion just in the slightest tweak of the wording. And the evidence above indicates that, with the right training, it needn’t be scary. Done well, with curiosity and compassion it opens up areas of discussion that allow us to find out more about what is going on for the person now. It allows them to feel that we are interested in more than just their biological parameters. 

The definition of insanity is to keep doing the same thing over and again and expect a different result. Could adversity in childhood be a factor that is worth keeping in mind the next time we are face to face with people we struggle to engage?



5 Replies to “Engaging the disengaged: could exploring adverse childhood experiences be one of the solutions?”

  1. This is an interesting blog and I am wondering if I can share what a young boy with T1DM said to me when I asked why he found his recommended diet so difficult. He told me that it wasn’t anything to do with his diet but he noticed that doctors and nurses were much more interested in those who ate all the ‘wrong’ things and became ill and that when he stuck to his recommended diet the doctors and nurses barely talked to him and he felt that he didn’t matter to them like those who did all the ‘wrong’ things. I took from this that everyone wants and needs genuine attention and interest in their lives with praise and admiration for their achievements.

  2. Thank you. Very helpful.
    In my experience of working as a therapist, before I retired, I found that “limited reparenting” techniques could sometimes be useful in repairing the damage caused by ACEs.

  3. A pilot evaluation of asking about ACEs in general practice in Wales “found considerable support for the acceptability of ACE enquiry in general practice to patients and practitioners, both of whom understand its relevance and added value in supporting individuals’ health and wellbeing. Thus ACE enquiry in this setting offers a welcomed opportunity for patients to disclose ACEs within the context of a supportive relationship with a health professional. Whilst ACEs are clearly associated with poor mental health outcomes, and findings provide tentative support to the notion of a therapeutic universal benefit derived from ACE enquiry, how practitioners may use an understanding of ACEs to inform the treatment and support provided to patients remains unclear”. It is an interesting study – the full report is at http://www.wales.nhs.uk/sitesplus/documents/888/Asking about ACEs in General Practice.pdf

    1. thank you Steve. Yes this is great work and our local GPs have found similar responses from Warren Larkin’s REACh work @warren_larkin

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