Trauma-Informed Primary Care - Understanding the Impact of Trauma and Attachment on Health Outcomes

 We have an abundance of highly sound research that demonstrates the long-lasting effects of adverse childhood experiences measured by the Adverse Childhood Experiences scale. The Adverse Childhood Experiences Study examined the impacts of early childhood trauma on adult health and functioning on 17,000 people (Felitti & Anda, 2009). The results were shocking clearly indicating that adverse childhood experiences (ACES) are common.

This study correlated ACE scores against health outcomes and the results of this study, as well as many longitudinal studies, have demonstrated a direct relationship between our early adverse experiences and later life health outcomes in many domains as indicated by a multitude of sources (Burke Harris, 2014; Felitti & Anda, 2009; Centre for Disease and Control, 2014): 

• ACE studies calculate that for each adverse childhood experience risk for early initiation of substances increased 3-4 times; 
• ACEs account for 1/2 to 2/3 of serious substance use; 
• ACES increased the likelihood of sex before 15 for girls and the risk for impregnating a teenager for males; 
•  There is an increased prevalence of Mood Disorders, Anxiety Disorders, Substance Use Disorders, Post Traumatic Stress Disorder (PTSD), Suicidality, and Impulse Control Disorders; 
• ACES increase the likelihood for being both the victim of or perpetrator of intimate partner violence; 
• ACES are also attributed to an increased risk for Ischemic Heart Disease, Stroke, Chronic Obstructive Pulmonary Disease (COPD), Diabetes, and Sexually Transmitted Diseases; 
• ACES are also attributed to impaired worker performance inclusive of absenteeism, job performance, and financial problems.

Burke-Harris (2014) indicates that ACES have a dose-response relationship between ACES and health outcomes. The higher your ACES score the worse your health outcome largely due to the neurological and physiological implications that these early adverse experiences have on the developing brain. Repeated HPA activation (such as in the case of childhood physical or sexual abuse, domestic violence exposure etc) causes our stress activation response system to shift from being adaptive / life saving to maladaptive/health damaging. Children are exceptionally sensitive to repeated stress exposure and activation because their brains and bodies are just developing. High doses of adversity impact the developing immune system, the developing brain, the developing hormonal system, and the way our DNA is read and transcribed. 

Burke-Harris (2014) quotes Dr. Robert Block, former president of the American Academy of Paediatrics “Adverse childhood experiences are the single greatest unaddressed public health threat facing our nation today.” 

Putnam, Harris, Lieberman, et. al., (2015) indicate that relationships of this magnitude are rare in epidemiology demonstrating that we need to recognize this as the public health crisis that it is and as one that is treatable. We therefore need to implement services for education, early intervention, and prevention and certainly trauma-informed.

What is exciting is that this has created a shift in the US - and in Canada as well. The American Academy of Paediatrics is promoting trauma-informed care and treatment as are many community and health based organizations. 

Additionally, Dr. Feletti Co-Principal Investigator, Adverse Childhood Experiences (ACE) Study found that if you ask people about their past, if their past is effecting them, and how so - essentially allowing them to form meaning, actually decreased medical and ER visits.  An excerpt from the book  The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease edited by Dr. Ruth Lanius is included below:  

We have made a limited but instructive attempt to integrate the ACE Study findings into clinical practice. At Kaiser Permanente‘s high-volume Department of Preventive Medicine in San Diego, we have used what we learned to expand radically the nature of our Review of Systems (ROS) and Past History questionnaire. We have now asked routinely of over 440,000 adult individuals undergoing comprehensive medical evaluation a number of questions of newly discovered relevance...Surprisingly, a 35% reduction in doctor office visits (DOVs) was found in the year subsequent to evaluation, compared to the year before. Additionally, analysis showed an 11% reduction in Emergency Department (ED) visits and a 3% reduction in hospitalizations. This change was dramatically and unexpectedly different from a much smaller, 700-patient evaluation carried out 20 years earlier when we worked in the more usual biomedical mode. That earlier approach provided a net 11% reduction in DOVs compared to the antecedent year, in spite of a 14% referral rate. No evaluation was made then of ED visits or hospitalization. Finally, we found that the unexpectedly notable reductions in DOVs and ED visits totally disappeared in the second year after comprehensive evaluation, when there was a reversion to prior baseline. This resource discusses questions primary care physicians can as and responses found to be most helpful. 

Excerpt from article: 7 ways childhood adversity changes a child's brain (Nakazawa, 2017)

The number of adverse childhood experiences an individual had predicted the amount of medical care she’d require as an adult with surprising accuracy:

• Individuals who had faced 4 or more categories of ACEs were twice as likely to be diagnosed with cancer as individuals who hadn’t experienced childhood adversity.
• For each ACE score a woman had, her risk of being hospitalized with an autoimmune disease rose by 20 percent.
• Someone with an ACE score of 4 was 460 percent more likely to suffer from depression than someone with an ACE score of 0.
• An ACE score greater than or equal to 6 shortened an individual’s lifespan by almost 20 years.

 The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease 

Adverse Childhood Experiences Study: https://www.cdc.gov/violenceprevention/acestudy/

Link to Trauma Toolkit for Primary Care American Academy for Pediatrics: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-foster-care-america/Pages/Trauma-Guide.aspx *Note - although geared towards foster children this all generalizes to children, youth and really adults as well as it looks at the early impacts which are then compounded upon as brain growth and development continues or is inhibited. 

Link between emotional stressors and cardiovascular disease: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31714-7/abstract

Childhood Adversity Narratives: http://www.canarratives.org ​
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