Brave New Approach

In disability claims management, we are continuously seeking to better understand the physical, psychological and social barriers that contribute to claimants' disabilities and prevent them from returning to work.

We also want to ensure that we are using resources appropriately and providing services that will result in positive claim outcomes. While predictive modeling has helped us gain efficiencies in determining which claims are likely to benefit most from our case management efforts, models alone cannot account for all the variables that may be driving claim duration.

Overlooked factors?

While attending an industry conference last year, I learned of the Adverse Childhood Experiences Study (ACE Study). The ACE Study is an ongoing collaboration between Kaiser Permanente and the Centers for Disease Control and Prevention (CDC) with the primary intention of investigating the connection between the incidence of childhood abuse and neglect and general health later in life. The original ACE Study was conducted from 1995 to 1997 with more than 17,000 Kaiser Permanente members. The CDC continues to follow the original ACE Study participants and updates morbidity and mortality data accordingly.

For this study, adverse childhood experiences (ACEs) that occurred in the first 18 years of life are categorized into three groups:

• abuse (emotional, physical or sexual);
• neglect (emotional or physical); and
• family/household challenges (substance abuse, mental illness, separation or divorce, violence and incarceration).

The ACE score is the total sum of the different categories of ACEs reported by participants. This score is used to assess cumulative childhood stress. The study found that as the number of ACEs increases (with scores ranging from 0 to 10), so does the risk for drug and alcohol abuse, mental health conditions, COPD, ischemic heart disease, liver disease, obesity, and a host of other behavioral, social and economic problems. Those with ACE scores of 4 or higher are most at risk for developing such problems.

Childhood trauma was very common

Findings of the ACE Study showed that childhood trauma was - sadly - very common. In fact, almost two-thirds of the study participants reported at least one ACE. Further, 87% had more than one, and more than 20% reported three or more ACEs. The 17,000 study participants were mostly Caucasian, middle and upper-middle class, college-educated, and all had jobs with healthcare benefits (as members of Kaiser Permanente).

Effects of "toxic stress"

At the same time the ACE Study was underway, scientific research on children's brains found that toxic stress physiologically damages the developing brain by altering brain structure, function and network architecture. Such changes negatively impact the circuits involved in threat detection, emotional regulation and reward anticipation. The scientific research further suggests that, to a considerable degree, the magnitude of the effect depends on the type and timing of the abuse, as different areas of juvenile brains develop at different times.

Children with toxic stress live much of their lives in fight, flight or fright (freeze) response mode. They respond to the world as a place of constant danger. With their brains overloaded with stress hormones such as adrenaline and cortisol, they find it difficult to function appropriately and to focus on learning or to build trusting relationships with peers and adults. With despair, guilt and frustration pecking away at their psyches, they often find solace in food, alcohol, tobacco and risky behaviors. They don't regard these behaviors as 'bad' because these coping mechanisms are, instead, used to escape from depression, anxiety, anger, fear and shame.

Reception by the medical community

So why hasn't the medical community embraced these profound research findings and incorporated the ACE questionnaire into a regular protocol? A number of states, including Washington, have adopted the ACE Study concepts and incorporated them into their parent education curriculum. The American Academy of Pediatrics has also added a screening for symptoms of "toxic stress" into its guidelines.

Perhaps the selective acceptance of the ACE Study findings is due to the reality that our society has tended to treat the abuse, violence and chaotic experiences that children endure as rare rather than commonplace, as the ACE Study revealed. It is difficult to address the prevalence of ACEs if we do not understand the true scope of the problem, and if gaps in medical care allow the long-term clinical effects of abuse to continue.

So what does any of this have to do with managing disability claims?

Seasoned LTD case managers are incredibly skilled at detecting unrecognized barriers or undiagnosed co-morbid conditions (often psychological in nature) that contribute to or even drive claim durations. Even with the most elite case managers completing thorough claimant telephone interviews, our industry still grapples with those claimants that lack the resiliency to sufficiently improve and return to work. Have we reached a plateau in developing case management strategies?

I believe that increasing our awareness of ACEs can help us better understand the dynamics behind the many vague and seemingly unrelated obstacles that impede a claimant's progress in returning to a full life. As our mind and body are interactive and integrated, a multidisciplinary approach is necessary to achieve the best health and claim outcomes.

In today's healthcare environment, it seems unlikely that disability insurers could succeed in an effort to ask claimants to complete the ACE questionnaire. Questions relating to relevancy, along with legal implications and public relations concerns, are daunting.

Such challenges notwithstanding, could ACE study questions be thoughtfully incorporated into claimant telephone interviews? Once rapport between the case manager and claimant has been firmly established, could some of these childhood issues be explored? Obtaining such information could lead to the discovery of previously unknown history that, if addressed, could move the claimant forward and aid in achieving positive claim outcomes. For example, a case manager may be able to find out that a claimant with a physical condition also has some ACEs that have created possible mental health issues. The case manager could then suggest that the claimant discuss this with his or her attending physician and ask for a referral to a mental health specialist for evaluation.

Human beings are complex and utterly confusing creatures -which is very apparent when managing our most complicated disability claims. I would wager that increasing our awareness of the presence of ACEs would produce a more comprehensive and clear picture of each claimant's challenges and result in better management and outcomes for LTD claims. I recognize that this may require brave new approaches - but who better to take them on than LTD case managers! While discussions surrounding childhood abuse and neglect are extremely difficult to undertake, we need to start addressing these topics for the benefit of our industry and the health of our citizens.