Social Determinants of Health (SDOH) screenings have become more common in practices and hospitals as a way to identify the needs of patients so that providers can begin addressing their underlying needs and improve their health. Many times, providers screen for anxiety, depression, food insecurity, housing issues, substance abuse, family and community support, and connections. They may not realize, though, that some of these factors are also the causes and results of Adverse Childhood Experiences (ACEs). While providers may be asking the right questions, acting on patient responses to these questions is essential to fully address a patient’s needs.
AFMC’s Chief Medical Officer, Dr. Chad Rodgers, recently went on AFMC TV to discuss the connection between ACEs and SDOH. He says social determinants are “factors that impact your health which are not related to medications or diagnosis but might be more relative to where you live, work, and play.” Health care researchers have often said that an individual’s zip code is more influential on their health than their genetic code. In fact, health care providers often say that around 80% of health care is determined outside the clinical setting. “If you live in a poor neighborhood, or you don’t have reliable access to food or transportation, you are surrounded by factors that negatively impact your health,” Dr. Rodgers says.
A patient's zip code is more influential on their health than their genetic code. Nearly 80% of health care is determined outside the clinical setting.
ACEs are, unfortunately, common experiences that occur early in infancy and early childhood, which are crucial developmental periods of the brain and the body. These experiences cause unneeded and sometimes avoidable "toxic" stress, resulting in a survival response that triggers the release of stress hormones that prepare the body and mind to fight or flee from real or perceived danger. Not being able to remove themselves from this stress results in a prolonged, detrimental, and often repeated response.
Most screening tools look for things patients can actively change (cholesterol, blood pressure, and heart rate). Some screening tools, however, also screen for SDOH. “You should only screen the patient for things you have a solution for,” Dr. Rodgers says. “Your screening tools are going to be tailored to your local communities. If you screen for food insecurity, you should know local food pantries in your area to which you can refer your patient.”
Only screen for things you have a solution for. Your screening tools should be tailored the resources and solutions available in your local communities.
Screening for SDOH allows providers to understand the overall needs of a patient instead of just their medical needs. “If your basic needs are not met,” Dr. Rodgers adds, “You are not going to have an even harder time meeting your medical needs.” If a provider has a patient who has diabetes, instead of simply telling the patient they need to eat better, results of SDOH screenings can allow the provider to find local resources that help the patient eat nutritious foods and put them on the path to healthier eating.
Many of the things that providers screen for are connected with ACEs. Many times, when providers screen for SDOH, their causes link back to ACEs. If, for example, a provider screens a patient for chronic depression, that depression could be linked to a traumatic experience from the patient’s childhood.
10 ACEs Factors
Using ACEs screening tools, providers can elicit 10 possible experiences that are known to have detrimental effects on long-term health:
- Physical abuse
- Emotional abuse
- Sexual abuse
- Emotional neglect
- Physical neglect
- Household dysfunction
- A caregiver with a mental illness
- A caregiver with a substance abuse problem
- Seeing a caregiver treated violently
- Parental separation due to divorce or incarceration
If a child has experienced one of these experiences, they are more likely to have also experienced others. These 10 ACEs do not include all traumas a child could potentially experience, but research has shown that the more of these a child experiences, the poorer their mental and physical health. They often also experience an overall reduction in quality of life and early death. An individual with an ACEs score of seven or more is more likely to have a mental illness, use illicit substances and abuse alcohol, and have chronic health conditions such as asthma, diabetes, irritable bowel syndrome, and cancer. Individuals with more than seven or more ACEs also have an increased risk of suicide. “The score doesn’t tell you everything, though,” Dr. Rodgers says. “The score allows you to see the amount of trauma, but it doesn’t tell you how well a patient is coping.” While patients may have high ACEs scores, a strong support system who can teach them resilience leads to healthier coping mechanisms.
Teaching Patients to Build Resilience
The most important thing to tell someone experiencing trauma is that “all hope is not lost.” An individual’s ACEs score does not commit them to a life of suffering. Trauma and stress are part of being human. However, to prevent and heal the impact of ACEs, providers and other health care professionals who interact with children must promote protective factors and build a community where all people feel they belong — a culture of safety, connectedness, and support where everyone can work, live, play, and improve for the good of one another. Protective factors, such as having consistent and nurturing caregivers who provide support and model and build resilience, can offset traumatic experiences. The more positive experiences children have, the more they can learn to be empowered and rise above their trauma. Knowing that a patient has one or more ACEs enhances and improves the patient’s experience and outcomes, too.
An individual's ACEs score does not commit them to a life of suffering.
So, when providers screen for SDOH, they also assess a patient for ACEs. By treating patients like EJ, a 45-year-old accountant, with an awareness of the connection between SDOH and ACEs, providers can provide more whole-person care. EJ is being treated for high blood pressure, cholesterol, and depression/anxiety. He lives alone after a divorce and admits to drinking heavily. His provider knows from EJ’s social and family history and screening that EJ’s uncle adopted him after his father was incarcerated for drugs (parental separation due to incarceration). His mother committed suicide after a long struggle with depression (mother with mental illness). Growing up in poverty, EJ moved from house to house and sometimes wasn’t sure where and when he would have his next meal (physical neglect). He wore tattered clothes to school, where he was made fun of by others and never felt like he belonged. His uncle did the best he could but often called him "stupid" and EJ always felt like he was a burden to his uncle (emotional neglect and abuse).
Fortunately, EJ had a grandmother who, despite poor health, often picked him up from school and kept him on the weekends. She provided a safe and loving place and reminded him of his mother. A schoolteacher saw that EJ was very intelligent and encouraged him to attend college (positive experiences – resilience factors). He got scholarships and found work during college to complete his degree. EJ has an ACEs score of five or more. But he had two positive factors in his life — his grandmother and a teacher — who helped build Positive Childhood Experiences for him and change the trajectory of his health for the better.
Through positive connections and influences in his life, the trajectory of EJ's life and his overall health improved.
Just by knowing EJ has a high ACEs score, his provider can screen for factors that contribute to his mental and physical health. Instead of wondering, “What is wrong with EJ?” providers can ask themselves, "What happened to EJ?" and build a therapeutic and empathetic relationship with him. Research supports that knowing and acknowledging his trauma can improve his health outcomes. Looking at underlying causes, providers can address the impact his traumas have on his social issues. Providers can address his substance abuse while also addressing his anxiety and depression. Increasing social support for him with his family and community through appropriate referrals will improve his ability to make decisions and make changes that will improve his blood pressure, control his cholesterol, and improve his quality of life.
Improving your knowledge of ACEs improves health care. AFMC’s Adverse Childhood Experiences landing page provides fact sheets, additional information on ACEs and toxic stress, and a sign-up sheet to join our ACEs coalition: a group that works together to prevent and heal the damage caused by ACEs and help make our community a great place for children to grow up. Additionally, AFMC recognized that much of a person’s health care is determined by what goes on outside the clinical setting. To drive outreach and education on ACEs, AFMC hosted an ACEs Summit. Our seventh annual ACEs and Resilience Summit — The Power of Belonging — is on Thursday, August 3, at Pulaski Technical College in North Little Rock. We encourage all providers, health care professionals, teachers, administrators, or anyone else responsible for the care and well-being of children to register for the summit and become a sponsor. This year’s conference will be held in person so that the community can come together to form strong connections with one another and learn to care for one another while also looking out for our children.
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*This blog is based on a recent article Dr. Rodgers submitted to the Arkansas Hospital Association on the connection between ACEs and SDOH.