Impact of early adversity on clinical assessment and outcomes in later life

Adverse childhood experiences can lead to poorer clinical outcomes due to an inability to articulate a coherent narrative

For health practitioners, it is critical to get clear, accurate information from “the patient”. Sometimes, people are poor storytellers, and it is up to the health practitioner to tease out the key issues.

We must remember that for many patients, even getting to a GP practice is a huge deal, let alone talking about personal issues, which can be very hard and scary.

Steph, who works as a supermarket checkout operator, presents by saying, “I’m buggered, and I don’t know what to do. I can’t sleep and have butterflies all the time, and the kids are acting up as they know something’s not right. I’m having dizzy spells, and that’s scary.

“I am scared all the time – what about our future? It’s just not right that the pandemic has caused people to go silly. I really don’t know what to do with Paul – he’s hopeless.” Then Steph starts sobbing.

For a GP new to Steph, they might go straight to anxiety and prescribe medication and counselling, or perhaps sleep hygiene practices. However, I have known Steph for many years, and she occasionally uses me as a sounding board for personal problems.

Growing up in Kawerau, Steph and her whānau experienced extreme poverty. We know that financial strain can mean a child will lack basic necessities, such as food, clothing and schoolbooks. Experiencing severe financial strain in childhood can also lead to uncontrollable, chronic stress, which can hinder healthy development and effective learning later on.¹

Further, Steph has a background of adverse childhood experiences (ACEs), among which were violence and abuse from extended whānau (for more on ACEs, see “How to treat”, New Zealand Doctor, 17 March 2021). Research has shown ACEs can lead to poorer clinical outcomes due to an inability to articulate a coherent narrative.²

Research shows that people who can talk about their problems well get better healthcare, whereas those who get confused and chaotic often do not fare as well in the health system.³ So, coaxing out the full story from Steph is required.

As outlined by Maunder and Hunter in 2021, the qualities of a good narrative were described by the philosopher Paul Grice as:²

• having evidence for what you say (quality)
• being succinct, yet complete (quantity)
• being relevant to the topic at hand (relation)
• being clear and orderly (manner).

Psychologist Mary Main and colleagues used Grice’s four maxims to describe how a person’s state of mind regarding important relationships in their life can be affected by unresolved childhood trauma and loss. During emotionally taxing interviews about those relationships, they found people with unresolved trauma could be identified by failures in the quality, quantity, relation and manner of the stories they told.⁴

It is a short leap from that research to the high-stakes communications in an emergency department or GP’s office where someone such as Steph struggles to make their condition clear and, therefore, get the help they need.

There are two styles of narrative incoherence. Steph’s style is preoccupied. She is too overwhelmed by fear and anxiety to organise her thoughts, so a lot of jumbled and incomplete information is presented at once.²

The second style is dismissive, whereby the person provides conclusions without evidence, and generalisations without examples. The listener feels unwelcome to ask more.²

For example, when asked, “How does that feel?” they may answer, “Same as always.” Or, when asked, “How long has this been going on?” the answer might be, “A while.”

The conversation is brief, and at its end, the healthcare provider still knows nothing. Does this sound familiar?

Steph wears her anxiety on her sleeve and, after specific questioning, I learn that husband Paul has left his job as a truck driver as he didn’t want to get vaccinated (Steph and the children are fully vaccinated). However, Paul does not really know why he has taken this stance – all his mates have, so that’s good enough for Paul.

Steph says, “The kids keep asking about the virus, but I can’t explain stuff to them – they’re so young.

“I don’t know how I’m going to pay the rent and get food for the kids. I can’t go on for much longer being the only parent in the house when Paul is always off to anti-vax demonstrations and meetings.”

A very topical problem in our communities in Aotearoa New Zealand (and indeed the world) is the vaccinate versus anti-vax stance.

Steph and I identify the issues for her: money, her relationship with Paul, getting information about the pandemic for her children, and her anxiety about talking to a health (or other) professional.

Together, we make a plan:

1. I refer her to Aroha at the local budgeting agency. Aroha is a great community resource, and we are lucky to have her.
2. The relationship between Steph and Paul is a bit tricky as I know how persuasive some of Paul’s mates can be, but there is an elder at the marae who is great with such situations. I suggest him to Steph, and she lights up when she realises Paul will listen to Charlie.
3. I give Steph a children’s book called Putiputi & Puddy learn about the coronavirus, written in 2020 (shameless promotion of our book; tinyurl.com/PutiputiPuddy).
4. I explain to Steph that when I feel anxious about a meeting, I do one of two things (and indeed sometimes both):

• Write down a few notes to take to the meeting about the things that are important.
• Take a friend with me who helps me stay calm and focused. Steph’s anxiety visibly decreases as she realises help is at hand, and I tell her I’d like to check in about how she’s getting on in a month.

This case study is fictional, based on a colleague’s experience

Janet Peters, MNZM, is a registered psychologist who works to bring ACEs learning into everyday knowledge of mental health and wellbeing