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Q&A: NPR’s Laura Starecheski reports on childhood adversity (Part 1)

Q&A: NPR’s Laura Starecheski reports on childhood adversity (Part 1)

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[Read Part Two here.]

In March, National Public Radio presented “What Shapes Health,” a series that delved into the social and environmental factors that influence health. At the heart of the coverage were four deeply reported stories from NPR health reporter Laura Starecheski, exploring how adversity, trauma and neglect endured in childhood may shape health much later in life. Starecheski delved into the original research on childhood adversity, spotlighted programs seeking to combat its effects, and helped explain why the ACE study hasn’t yet taken over the medical establishment. For those interested in children’s health, it’s a must-listen series.

Reporting on Health recently spoke to Laura about her reporting. The following has been edited for clarity and length.

Q: What prompted you to tackle this series looking at childhood adversity now?

A: I had read the Paul Tough article in the New Yorker when it came out and that made an impression on me. This series was an assignment I got from Anne Gudenkauf, who runs the science desk at NPR, to look into the ACE study. She’s known about the study since it came out in 1998, but it didn’t get much press attention initially. Gudenkauf suggested that now, about 15 years later, was a good time to revisit this. If the findings are as notable as Dr. Vincent Felitti and Dr. Robert Anda say, why don’t more people know about the study? And why hasn’t it been integrated more into medicine?

I started digging around and after a couple of meetings, we realized this wasn’t just one story. From there it grew into a larger series. I could’ve obviously done a lot more — the study’s findings involve the entire life course from birth to death, so there are a lot of angles you could look at it from.

Q. How did you come to understand the potential health impacts of childhood adversity and the science behind it?

A: In the beginning, I was coming at it from a lay perspective. The numbers sound really significant: A score of 4 or more potentially doubles your risk of heart disease, for example. That sounds like a big deal. But is an ACE score predictive? Does it tell individual people what’s going to happen with their health? It doesn’t. But it takes some shift of your understanding — at least it did for me — to really learn how to communicate that to people.

What really helped me understand the study’s findings better was to talk to outside epidemiologists, who had no connection to the ACE study. I asked them to read through some of the study papers with me, and talk me through the findings.

It was really interesting to me to hear how these epidemiologists considered the study. Was it convincing to them? I learned that if you can find the scientist that’s skeptical, and hard to convince, and always wants to consider other possible explanations for a finding, then I think you’ve found someone who is really good to bounce stuff like this off of.

Q: Were the epidemiologists you spoke to skeptical?

A: I went over the lung cancer paper, for example, with an epidemiologist named Sarah Floud at Oxford University in England. She’s been working on a study of a million-plus women in the UK, looking at things like the relationship between being married or not, and having heart disease.

When I went over some of the research with Floud, I asked her: If someone is otherwise healthy, not a smoker or a drinker, not obese, does the ACE study show that adverse childhood experiences alone could cause a physical disease like lung cancer?

Floud told me she was convinced by the findings that high ACE scores raise someone’s risk of addiction, depression and behaviors like smoking and drinking, and that in turn raises risks of physical disease — but she wasn’t convinced that a high ACE score alone could make someone more likely to get cancer. One of her issues with the study was the size. The 17,000-some participants in the ACE study sounds like a lot, but in a study of, say, a million people, Floud told me researchers could more effectively rule out other possible explanations for the higher incidence of lung cancer among people with high ACE scores.

That just underscored for me the importance of trying to strike a balance between the way that scientists think and consider data, findings and facts, and the way that regular people might understand this kind of stuff. The epidemiologists I spoke with weren’t saying that the findings were wrong. They were just saying that like all studies, the ACE study isn’t perfect, and that’s why it’d be helpful to see it replicated with larger numbers. Until that’s done, the original study on its own can’t prove a direct causal link between having an adverse childhood experience itself, and physical disease.

I still worry that if people hear the theories or hear coverage of the ACE study, their takeaway will be, “Well, if I have ‘x’ number of ACEs, then this is what’s going to happen to me, and I’m going to have all these bad health outcomes.” And that’s not what the study says, but if you’re not a scientist, it’s really hard to understand that. A population study can’t predict what will happen to one individual person. It doesn’t work that way.

Q: What did you find are the biggest obstacles to this approach gaining wider more traction in medical practice today? Skepticism about the research or obstacles in getting doctors to incorporate the findings into their practice?

I think it’s the obstacles to getting doctors to incorporate the findings into their practice. As I talked to doctors about the idea of using ACE scores, they said things like, “There are new screening tools thrown at us every week. The idea that one of them is going to be so good that we’re going to demand it, our patients are going to want it, and we’re going to take the time to create billing code and bill for it and incorporate it into practice — it just doesn’t happen very often.”

Richard Young, a family doctor I talked to, said he would have to really believe, and see it proven in a randomized control trial, that collecting ACE scores from patients would change their outcomes for the better, and he hadn’t seen that. That information isn’t out there.

Q: In one of your stories, you quote Dr. Jeffrey Brenner, famous for his “hot-spot” work. He told you: “I can't imagine, 10, 15 years from now, a health care system that doesn't routinely use the ACE scores. I just can't imagine that." Is he being overly optimistic?

A: If we do want to see doctors using ACE scores in 10 years, it’s got to become part of medical school curricula now. And so I started poking around, asking, ‘Are people teaching this?’ I’ve since heard of a few medical schools that teach about the ACE study during sections on psychiatry.

Dr. Nancy Hardt told me she’d managed to get in one hour on the ACE study into the medical school curriculum at the University of Florida. And what I learned from talking to Dr. Hardt and others is that one hour in the medical school curriculum is a lot of time. There are so many things medical school faculty could teach, and there are so many new technologies, and there’s constant competition for what’s going to take up time in the curriculum.

That said, I do feel like there’s sort of a tipping point right now, where there’s a lot more interest around the ACE study in health care communities. I know that the Robert Wood Johnson Foundation has been funding efforts to increase awareness around ACEs, by supporting groups like the Philadelphia ACE Task Force, for example. There’s a fervor about it — once people learn about the research, it’s like, “Oh my god, I must spread the word, I must push for this as the next big thing.”

I think there’s potential for the research to catch on in a more mainstream way in medicine, but I have no idea whether that will actually happen or not. I don’t know about you, but my experience as a patient is that you change jobs, you change insurance, you move — you don’t have a doctor who knows you over a long period of your life.

That to me is another significant challenge to integrating this information: The way regular people encounter the health care system is not very coherent. It seems like ACE scores would be most useful if you had a doctor who would know you for decades, and who could track how things from your childhood affected you once you grew up. Most people use the health care system in an inconsistent or patchwork way. Dr. Felitti knows that’s a huge barrier.

Next: How Starecheski went about highlighting the people and programs working to lessen the effects of childhood adversity.

Photo by Guian Bolisay via Flickr.



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