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What if we had a set of interventions that could reduce rates of depression, chronic obstructive pulmonary disease, heavy drinking and unemployment?¹ They might already exist. Many clinical researchers argue that these tools are already being developed and used, and that some answers to these conditions lie in the prevention and treatment of trauma in our patients, workplaces and communities.

Ever since the publication of the first adverse childhood experiences (ACEs) study in 1998,² research has consistently shown that poorer health and social outcomes are linked directly to "toxic stress" and high scores on tests measuring a person's adverse childhood experiences. We understand more each year about how traumatic events "get under our skin" on a physical level, dramatically skewing health outcomes for the worse.

In attempts to care for the whole person, we as health care providers ignore our patients' traumas at their peril. There are evidence-based guidelines designed to help those who suffer from trauma's effects and to help prevent some transmission to the next generation. How can we best use this emerging knowledge to create resources that help heal our patients and communities? Before examining possible solutions, it might be helpful to know how the first study on adverse childhood experiences started.

STUDYING ADVERSE CHILDHOOD EXPERIENCES
In 1985, Dr. Vincent Felitti was stumped. As the Chief of Kaiser Permanente's Department of Preventive Medicine in San Diego, he had been trying to figure out why the dropout rate for obesity clinic patients receiving his care was more than 50%, all of whom were successfully losing weight. While researching more than 200 members of this group, he inadvertently discovered that one of his patients had been sexually abused as a child. After he started asking more of these patients about their weight history throughout different stages in their lives, he found that most had been sexually abused as children. Many had also been bullied, physically abused or sexually assaulted as adults. He was astounded.³

In his chart review, Felitti found that the group members had been born a normal weight and instead of gaining weight gradually over time, they had gained it suddenly. When asked about their trauma, many of these patients admitted to using obesity as protection against further abuse. Obesity was not a problem for them, but a solution. As they lost weight, their anxiety about being vulnerable to further physical or sexual assaults became intolerable. Interventions that did not address these underlying issues proved unsuccessful.

When he presented this astounding information at an obesity conference in 1990, he caught the ear of an epidemiologist from the Centers for Disease Control and Prevention (CDC). The collaboration that commenced, between the CDC and Kaiser Permanente, resulted in the first adverse childhood experiences study from 1995 through 1997. The team created a survey meant to elicit answers to various kinds of child abuse and household dysfunction, then collected the responses from more than 9,000 of Kaiser's HMO patients.⁴

A few things that became apparent immediately from the study were 1) that the risk adverse childhood experiences posed to health and social outcomes was cumulative, with the risks being particularly high for people who had experienced four or more categories of these occurrences; 2) how prevalent abuse and household dysfunction are across the socioeconomic spectrum; and 3) that the risks for chronic health problems from childhood trauma reach well into adulthood — sometimes shortening lives by decades.⁵ The original categories for adverse childhood experiences were psychological abuse, physical abuse, sexual abuse, substance abuse in the household, mental illness in the household, domestic violence against the mother, and household members who were incarcerated.⁶

The CDC's most recent study on adverse childhood experiences had a sample population of roughly 144,000 people in 25 states between 2015 and 2017. The data were consistent with the original study. Overall, a little more than 60% of adults had at least one type of adverse childhood experience, and 1 in 6 people had experienced four or more types of these experiences.⁷

What is toxic stress?
Researchers believe that traumatic events lead to illness by a mechanism called "toxic stress." Toxic stress has developmental, cellular and immunological effects. Harvard's Center for the Developing Child compares the chronically activated state of toxic stress to revving a car for days or weeks at a time. It is most likely to occur when children are exposed to adverse childhood experiences with no supportive adult available.⁸ The stress response gets activated, stays activated and is easily reactivated.

Toxic stress leads to dysregulation of the limbic-hypothalamic-pituitary-adrenal axis, which elevates the release of hormones responsible for the body's "fight or flight" response. This surge of adrenal catecholamine hormones, like adrenaline, and other hormones, like cortisol and proinflammatory cytokines, leads to cascading effects on the nervous, endocrine and immune systems. In addition to these physiological effects, toxic stress can also lead to impairment of executive functioning, diminish the ability to pay attention and dysregulate a person's response to stress throughout the lifespan.⁹

The American Academy of Pediatrics states that the antidote to toxic stress is relational health.¹⁰

What is relational health?
The American Academy of Pediatrics sees relational health as key to preventing adverse childhood experiences and healing those who already have trauma. Their policy statement on preventing childhood toxic stress encourages a paradigm shift toward relational health. Relational health focuses on the development of safe, stable and nurturing relationships to build resilience and help protect against adversity. At least one of these relationships, they argue, is a "universal, biological imperative for children." Given that these relationships are more likely to form in safe and stable communities, the American Academy of Pediatrics recommends the shift toward relational health not just for pediatric practices, but also for the institutions within the communities that they serve.

The American Academy of Pediatrics' policy statement advocates following three general principles when crafting interventions to combat toxic stress, starting in the pediatric office. These include 1) supporting nurturing relationships by identifying any barriers and opportunities to strengthen or repair them; 2) reducing external sources of stress on families — such as poverty, food insecurity, racism and social isolation — and advocating for policies that support safe, stable and nurturing families and communities; and 3) strengthening core life skills, including emotional regulation and executive functioning. It also recommends the Bright Futures guideline as a starting point but acknowledges that other families may need more intensive coaching, such as is found in such initiatives as the Video Interaction Project, HealthySteps and Reach Out and Read.

For families with young children, referral of overwhelmed families to home visitation programs, like Healthy Families America and Nurse Family Partnership, has been shown to lower rates of abuse.¹¹

What else can we do to prevent and treat trauma?
In addition to promoting safe, stable and nurturing relationships, we can familiarize ourselves with issues surrounding childhood trauma and adverse childhood experiences, and then screen for them. The CDC recommends anticipating and recognizing the risk for adverse childhood experiences in children and the history of these in adults. On a societal level, they also recommend family-friendly policies like improving access to high-quality child care, paid family leave and addressing financial and other hardships that put families at risk for these experiences.¹²

The American Medical Association, the American Academy of Pediatrics and the American Academy of Family Physicians recommend that screening for adverse childhood experiences occur in the primary care setting, particularly in pediatrics.^13-15 Patients with high scores for these experiences may have toxic stress and emotional dysregulation, compromising their health and social functioning. If the patients with high scores are parents, they might need extra support to prevent passing these experiences to the next generation.

Even if a practice context doesn't yet have the capability to address adverse childhood experiences directly, practitioners can screen for household vulnerabilities — like overwhelmed parents and food insecurity — using a tool like Safe Environment for Every Kid.¹⁶ Screening directly for these occurrences or other trauma is potentially irresponsible if no resources or follow-ups are available.¹⁷

What does it mean to be 'trauma-informed'?
The Substance Abuse and Mental Health Services Administration's "Practical Guide for Implementing a Trauma-Informed Approach" also highlights the need to assess readiness and capacity before implementing a trauma-informed approach.¹⁸ Multiple tools are available for individuals and organizations to help create clinical and community environments that are welcoming and avoid retraumatization.

A common element of trauma-informed approaches is the realization that trauma is prevalent and that many actions that look like "difficult" and "noncompliant" behaviors may be trauma responses to be recognized and treated, not punished. The Substance Abuse and Mental Health Services Administration's guide encourages all sectors to be trauma-informed, including law enforcement, criminal and juvenile justice, child welfare, victim services, education, physical health care, veterans' affairs, services for housing insecurity and the military.

BEING PROACTIVE TO ADDRESS TRAUMA
As health care providers, when caring for the whole person, we need to understand how traumatic events in our patients' histories may have led to significant impacts on both their physical and mental health.

Like with Felitti, we must ask difficult questions and listen to what patients tell us. We need to be able to screen for trauma in our patients and then have culturally appropriate resources available as referrals. These should include parenting classes, trauma therapists, trauma-informed schools and social institutions that are geared toward creating safe, stable and nurturing relationships at the clinical, family and community levels. It will cost time, money and staff, but evidence shows that addressing and preventing trauma not only reduces human suffering, but may well be among the most powerful public health tools we have.

ERIN ARCHER is a freelance health writer and nurse in Tucson, Arizona. She has written for Medscape News, Microbes and Infection, Everyday Health and AuntMinnie.com.

NOTES

1. This CDC webpage says reducing early trauma has the potential to reduce negative outcomes in adulthood, including up to a 44% reduction in depression, 27% reduction in chronic obstructive pulmonary disease, 24% reduction in heavy drinking, and 15% reduction in unemployment. "Adverse Childhood Experiences (ACEs): Preventing Early Trauma to Improve Adult Health," CDC, November 5, 2019, https://www.cdc.gov/vitalsigns/aces/index.html.
2. Dr. Vincent J. Felitti et al., "Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. The Adverse Childhood Experiences (ACE) Study," American Journal of Preventive Medicine 14, no. 4 (May 1998): 245-258, https://doi.org/10.1016/S0749-3797(98)00017-8.
3. Jane E. Stevens, "The Adverse Childhood Experiences Study — the Largest, Most Important Study You Never Heard Of — Began in an Obesity Clinic," ACESTooHigh, October 3, 2012, https://acestoohigh.com/2012/10/03/the-adverse-childhood-experiences-study-the-largest-most-important-public-health-study-you-never-heard-of-began-in-an-obesity-clinic/.
4. Felitti et al., "Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults."
5. Nadine Burke Harris, "How Childhood Trauma Affects Health Across a Lifetime," TEDMED, September 2014, https://www.ted.com/talks/nadine_burke_harris_how_childhood_trauma_affects_health_across_a_lifetime?language=en.
6. Felitti et al., "Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults."
7. Melissa T. Merrick et al., "Vital Signs: Estimated Proportion of Adult Health Problems Attributable to Adverse Childhood Experiences and Implications for Prevention — 25 States, 2015-2017," MMWR Morbidity and Mortality Weekly Report 68, no. 44 (November 8, 2019): 999-1005, http://dx.doi.org/10.15585/mmwr.mm6844e1.
8. "ACEs and Toxic Stress: Frequently Asked Questions," Center on the Developing Child, Harvard University, https://developingchild.harvard.edu/resources/aces-and-toxic-stress-frequently-asked-questions/.
9. Christopher M. Jones, Melissa T. Merrick, and Dr. Debra E. Houry,"Identifying and Preventing Adverse Childhood Experiences: Implications for Clinical Practice," JAMA 323, no. 1 (January 7, 2020): 25-26, https://doi.org/10.1001/jama.2019.18499.
10. Dr. Andrew Garner and Dr. Michael Yogman, "Preventing Childhood Toxic Stress: Partnering with Families and Communities to Promote Relational Health," Pediatrics 148, no. 2 (August 2021): https://doi.org/10.1542/peds.2021-052582.
11. Jones, Merrick, and Houry, "Identifying and Preventing Adverse Childhood Experiences."
12. CDC," Preventing Early Trauma to Improve Adult Health."
13. "Adverse Childhood Experiences and Trauma-Informed Care H-515.952," American Medical Association, 2023, https://policysearch.ama-assn.org/policyfinder/detail/Adverse%20Childhood%20Experiences%20and%20Trauma-Informed%20Care%C2%A0%20H-515.952?uri=%2FAMADoc%2FHOD.xml-H-515.952.xml.
14. Garner and Yogman, "Preventing Childhood Toxic Stress."
15. "Adverse Childhood Experiences," American Association of Family Physicians, October 2023, https://www.aafp.org/about/policies/all/adverse-childhood-experiences.html.
16. Jones, Merrick, and Houry, "Identifying and Preventing Adverse Childhood Experiences."
17. "Screening for Adverse Childhood Experiences (ACEs) and Referral Pathways: Position Statement of the American Heart Association," American Heart Association, November 2019, https://www.heart.org/-/media/Files/About-Us/Policy-Research/Policy-Positions/Social-Determinants-of-Health/ACES--Screening-and-Referral-Pathways.pdf.
18. "Practical Guide for Implementing a Trauma-Informed Approach," Substance Abuse and Mental Health Services Administration, June 2023, https://store.samhsa.gov/sites/default/files/pep23-06-05-005.pdf.