October was domestic violence awareness month, and perhaps no other correlation between domestic violence and an issue of tantamount importance to healthcare providers is more clearly defined than the one between domestic violence and adverse childhood experiences (ACEs). Domestic violence is largely defined as a “pattern of behaviors used by one partner to maintain power and control over another partner in an intimate relationship” (NDVH). This translates to abuse of any kind, be it physical, mental, emotional, or otherwise. The children who witness these abuses and who are also thereby much more likely to be themselves a victim are at a drastically increased risk of premature death, as well as to be in poor health as an adult across the spectrum. We have known this since the original 1998 study on ACEs that revealed these correlations. Yet this knowledge remains mostly in academia and has not translated to action where it will be most effective: the way in which it informs healthcare practices. It’s time to move this knowledge out of academia and into practice in order to affect real change on a clinical level.
In the original Kaiser Permanente study on ACEs, the questionnaire used to collect this data included 17 questions. Of these 17 questions, 12 of them are direct questions about having been either a victim of or a witness to various forms of domestic violence in the home. Of the other 5 questions, only one is not at least tangentially related to domestic violence. ACEs and domestic violence are tragically and inextricably linked.
The original Felitti et al. 1998 study demonstrated that not only is there a correlation between the number of categories of childhood exposure to ACEs and adult health risk behaviors and diseases, but there is also a graded relationship between them; i.e. the greater number of the events, the greater the risk of disease. The study found that people who had experienced four or more of these separate categories of ACEs as compared to those who experienced none had a 4 to 12-fold increased risk for alcoholism, drug abuse, depression, and suicide attempts; to 2 to 4-fold increased risk of smoking and poor self-rated health, and almost twice the risk of physical inactivity and obesity. A graded relationship was observed for the number of categories of ACEs experienced and presence of adult health diseases such as ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease (Felitti et al. 1998).
According to the National Coalition Against Domestic Violence, 1 in 4 women and 1 in 7 men will be victims of severe physical violence by a partner in their lifetime. All too often the immediate focus of both the general public and healthcare practitioners is on the direct and immediate consequences of violence. But a plethora of data exists that demonstrates if a victim survives their abuse, the indirect and long term consequences are widespread, they are incredibly serious, and they directly impact mortality rates. Domestic violence is so incredibly pervasive, and given what we know about what sort of lifelong effects can be expected for the children who witness this abuse and are themselves victims, it is staggering to think of how many health problems we as healthcare providers treat that are fundamentally rooted in an adult patient having experienced childhood trauma. From this perspective, the importance of trauma informed care cannot and should not be understated.