By Karen Stephen, Ph.D., PHC Mental Health Clinical Director
Part I: Implementing Trauma-Informed Care in Pediatric and Adult Primary Care Settings (Nadine Burke-Harris MD Center for Youth Wellness and Edward Machtinger MD, Women’s HIV Program UCSF)
Link to audio of entire webinar session: https://www.youtube.com/watch?v=VbqwJ1h1Qy8&feature=youtu.be
Definition of trauma: Event or series of events, or set of circumstances that are experienced by the individual as physically or emotionally harmful or life threatening that can have lasting effects on the individual’s mental, physical, social, emotional, or spiritual well-being.
Types of Adverse Childhood Experiences (ACEs)
- Abuse: Physical, emotional, and sexual
- Neglect: Physical, emotional
- Household Dysfunction: Mental illness, mother treated violently, divorce, incarcerated relative, substance abuse
Increasing number of ACEs experienced increases impact on all aspects of physical and mental health, behavioral outcomes (e.g., smoking, addiction, alcoholism), and life potential (school and work success).
SAMSA data on ACE outcomes. The landmark Kaiser study on ACEs.
| Leading Causes of Death in US, 2013 | Odds with 4 or more ACEs | |
| 1 | Heart Disease | 2.1 |
| 2 | Cancer | 2.3 |
| 3 | Chronic Lower Respiratory Diseases | 3.0 |
| 4 | Accidents | |
| 5 | Stroke | 2.4 |
| 6 | Alzheimer’s | 11.2 |
| 7 | Diabetes | 1.5 |
| 8 | Influenza and Pneumonia | |
| 9 | Kidney Disease | |
| 10 | Suicide | 30.1 |
The biology of adversity:
- Neurologic:
- Dysregulation of HPA and SAM Axes
- Activation of the amygdala
- Inhibition of the prefrontal cortex
- Hippocampal neurotoxicity
- VTA and reward center dysregulation
- Immunologic:
- Increased inflammatory mediators and markers of inflammation such as interleukins, TNG alpha, IFN-y
- Inhibition of anti-inflammatory pathways
- Impaired cell-mediated acquired immunity
- Endocine:
- Long term endocrine changes in ACTH, cortisol, adrenaline and other hormones
- Inhibition of thyroid function
- Alterations in Growth Hormone and pubertal hormones
- Cardiovascular:
- Increased plasma endothelin 1, total peripheral resistance, DBP and pulse wave velocity
- Epigenetic:
- Altered epigenetic regulation leads to differential gene expression
- Changes in way DNA is read and expressed lead to changes in the way brain and organ systems respond to stress
- Telomere erosion leads to premature cell death and altered cell replication
What is trauma-informed care in a nutshell?
- Take the person’s experience into account
- Don’t ask “What’s wrong with you? Ask, “What happened to you?”
- Needs to be addressed at clinical and organizational level.
Core principles of trauma-informed care:
- Empower patients—use their strengths to develop treatment plans
- Provide options, let patients choose
- Maximize collaboration—patients, family members, staff
- Ensure physical and emotional safety
- Create trust through clear expectations regarding who, what, and how’s of treatment
Tools to screen for ACEs:
ACE score 0-3 without symptoms = Provide Anticipatory guidance
ACE score 1-3 with symptoms or 4 or more ACEs = Counsel and refer
Basics to Institute Trauma-Informed Primary Care:
Foundation: Train ALL staff, use clinic champions, support providers, ongoing evaluation
Screen: Inquire about current and lifelong abuse, PTSD, depression, substance use
Create Environment: Calm, safe, empowering for patients AND staff
Respond: Use onsite and community based programs that promote safety and healing
What can you do tomorrow!
Realize that a lot of who we are and what we do is because of what happened to us.
Embrace trauma-informed values.
Distribute literature about impact of trauma on health
Get training for staff
Assemble a team to support the process