I asked my patient, “As a child did you ever experience any trauma?”
He said, “Do you mean like when an older brother hits you?”
“Well, not really the usual roughhousing between siblings, but more like any trauma that might have been physical or sexual or emotional in nature,” I replied.
My patient at the time was 55 years old, and he had never disclosed what had happened to him, not even to his significant other. As we talked about the secret he had kept for nearly 50 years, a picture of the consequences of childhood trauma began to emerge.
He had been hospitalized in his teens for a “stomach ailment” and had surgery, but he was not sure why. He detailed a string of failed relationships, substance abuse leading to Hepatitis C, and poorly controlled insulin-dependent diabetes. At times he was afraid to leave his house, paralyzed by anxiety and depression, and was often not able to make his doctor’s appointments. He ended up in my clinic for people who had been admitted multiple times to the hospital in a short period of time.
Unfortunately, his story is all too common. A study by Kaiser Permanente of 17,000 of its patients found that nearly two-thirds experienced at least one adverse childhood experience — ACE — and about 15% experience four or more. We have known for at least 20 years that ACEs, such as childhood sexual abuse, are associated with increased risk of chronic disease in adulthood. In fact, individuals who have experienced more than four ACEs are at significantly higher risk for seven of the top 10 leading causes of death including heart disease, diabetes, emphysema and suicide. Individuals with six or more ACEs have a life expectancy about 20 years less than average.
The common nature of ACEs helps us understand how individual trauma can impact the overall health of our community and the health care system as a whole. A recent study in the American Journal of Preventive Medicine linked greater exposure to ACEs to higher out-of-pocket medical expenses and financial burden in adulthood. Other studies tell us that patients who have experienced ACEs will use more, and higher-cost, medical services than patients with the same diseases who did not experience ACEs.
Clearly, there is something inherent in the history of trauma itself that causes financial burden even when you compare people with the same severity of disease without ACEs in their past.
Not only do ACEs increase the chance you will have a chronic medical and/or behavioral health problem, they also increase the financial burden on individuals to treat those problems. This financial insecurity ends up being one of the biggest challenges to health care engagement. When the decision is between medications and copays or rent and food, people tend to choose the latter.
What can be done to mitigate both the financial and medical issues caused by ACEs? Obviously, prevention of trauma can go far in decreasing associated future health care costs.
For those with trauma in their history, it is important to share that with your care provider, as difficult as that might be. With that information, he or she can devise a care plan specific to trauma that can place medical and behavioral symptoms in a context that helps to guide better care. There are therapies available for those with a history of trauma that can help in recovery and enhance the quality and effectiveness of your care.
As the story of my patient points out, ACEs are associated with many detrimental issues in the lives of people growing into adulthood. Trauma can lead to chronic disease and poor engagement with the health care system, and this can increase costs and produce poorer health care outcomes.
A history of trauma, however, does not have to invariably lead to only negative consequences. Talking to others about what happened to you — while it cannot undue the past trauma — can help your care team plan care for you in a more holistic way. It can allow the care team to tap into areas of resiliency and provide more effective and better quality care.
Jeffrey R. Martin, M.D., is chair of Penn Medicine Lancaster General Health’s Department of Family and Community Medicine and chair of the Partnership for Public Health.