Childhood Trauma Is an Overlooked Social Determinants of Health Factor
Research demonstrates strong connections between exposure to adverse childhood experiences (ACEs), chronic stress, and poor health, including frailty in older adults.1-4
The Centers for Disease Control and Prevention (CDC) estimates three in five adults have experienced at least one type of ACE and about one in six have experienced four or more types.5
“Exposure to ACE and chronic stress can result in an increase in inflammatory processes, including increases in cancer, lung disease, obesity, diabetes, heart disease, substance use disorders, suicidal ideation, and suicide attempts as well as increased depression, anxiety, and post-traumatic stress disorder,” says Laura E. Gultekin, PhD, FNP-BC, RN, clinical assistant professor at the University of Michigan School of Nursing. “In healthcare, we’re so reactive to things, and we’re not great about being preventive.”
For example, health systems could make it a priority for providers and case managers to identify ACEs among adult populations and ask for better integrated services and models of care to serve this group.
“We could think about how physical health and mental health [fit] together,” Gultekin says. “We don’t have good models in this country for how that can look, and those integrative models are important to tie together.”
ACEs and Frailty
One example of how ACEs can affect physical health involves frailty in older adults. A new study of Canadians, ages 45 to 85 years, revealed people exposed to ACEs showed elevated levels of the frailty index (FI) than those who were not exposed to childhood trauma.1
The biggest difference observed was for neglect. The study’s findings suggest screening for ACEs may be useful in identifying people at risk of frailty.
“We need models where mental health professionals are ready to partner with physical health providers so there’s an easy warm handoff between services and solid communication between systems,” Gultekin says. “We do see this in some models, like adolescent medicine, where they’ve done a good job of connecting physical health to behavioral health. But it’s not standard in most adult models.”
Barriers to this integrated model are challenges in terms of payment models and the tremendous shortage of mental health providers. “We don’t have a good system for payment for the intervention,” Gultekin says.
People with physical health and mental health problems connected to ACEs could be engaged in mental health services and receive medication for depression. But they often do not receive therapy in an integrated model.
“Talk therapy, group therapy, cognitive behavioral intervention tend to be poorly funded in our standard insurance,” Gultekin says. “Not having enough providers or reimbursement means most people don’t have access to high-level, trauma-informed mental health services.”
From a case management perspective, the first step is to screen patients for ACEs. For example, the CDC provides online information about ACEs as well as a behavioral risk factor surveillance system.5
“The next step is after someone screens positive for ACEs,” Gultekin says. “We need to recognize their reactivity and try not to mislabel it so we can respond to it appropriately.”
Stress Response and De-escalation
People with ACEs are more reactive to stress. “They misperceive situations and think they are threatening more so than someone who doesn’t have ACEs or traumatic stress,” Gultekin explains. “Cortisone and adrenaline are released and increase their blood pressure as part of the flight or fight response.”
For instance, when someone with an ACE hears a healthcare professional discuss their weight, eating behaviors, or drinking behavior, they are more likely to feel that discussion is a threat against them. They tend to become more reactive and self-protective than would patients who have not experienced an ACE.
“This makes them louder, angrier,” Gultekin explains. “We see that with COVID when people are separated from their loved ones and can’t see someone in the hospital, or when they’re being told they have to manage this illness alone.”
This is a situation in which a patient might experience a high-intensity stress response. “Someone who doesn’t have high-intensity trauma might say, ‘This is bad, but I can talk to people on the phone,’” she says. “But those who have trauma may be more reactive and sometimes be aggressive, physically or verbally, to staff.”
Healthcare providers can interpret that behavior as an aggressive response when it is just a patient’s attempt to keep himself or herself safe. “When someone is in an escalating moment, they don’t always recognize they’re in an escalating moment and are [reacting] to the fight or flight response,” Gultekin says.
When this happens, the provider must ensure his or her own safety. They need to make sure they are not in a situation in which they are confronting a patient who is angry and aggressive on their own, and in a manner in which they could be hurt by the patient.
“Leave the door open and have other people with you,” Gultekin advises. “When the patient responds in a negative manner, rather than escalating the situation, try to de-escalate by talking more quietly and trying to soothe the situation rather than make it more stressful.”
A de-escalating response could be to tell the patient: “I can’t bring you a family member right now or get you to that location, but I can connect you with another family member or talk to your provider,” Gultekin explains. “Help them recognize that you’re working with them and not against them.”
When people are in the middle of the fight-or-flight response, they are not going to respond rationally to what is happening. The right words can help them calm down.
For instance, a case manager could say, “You seem really upset. This is an important topic, so I’m going to give you some time and come back to talk with you,” Gultekin says. “This is a way to create safety for you and the patient.”
“Acknowledge what you’re seeing and feeling, saying, ‘I’m seeing that you are upset, that this is a different topic for you,’” she adds. “‘This is a tough situation. I need some space for myself to think, and I would like to offer you some space to think. Do you want five minutes, and I’ll come back? Or, do you want me to return tomorrow?’”
Offering patients some balancing of power by letting them make choices can help. It is the same tactic parents offer young children.
Case managers also should remember people who have experienced trauma need transparency.
“Say, ‘I know you have this type of insurance and you want to go to this facility. But the last time we worked with someone with your insurance, they didn’t accept someone with your insurance at this facility. What else could we do if this doesn’t work out?’” Gultekin explains. “Planning ahead and being transparent is important. You can help them set expectations and let them be a part of decision-making.”
REFERENCES
- Miam O, Anderson LN, Belsky DW, et al. Associations of adverse childhood experiences with frailty in older adults: A cross-sectional analysis of data from the Canadian Longitudinal Study on Aging. Gerontology 2021;Dec 7:1-10. doi: 10.1159/000520327. [Online ahead of print].
- Borini CH, Carlos DM, Ávila LA, et al. Suffered life, hard life: Adverse experiences in childhood of people with chronic musculoskeletal pain. Rev Gaucha Enferm 2021;42:e20200385.
- Daily SM, Dyer AM, Lilly CL, et al. Using adverse childhood experiences to explore the usefulness of community health needs assessments to monitor complex determinants of health at the local level. Eval Program Plann 2021;91:102044.
- Xie H, Huffman N, Shih CH, et al. Adverse childhood experiences associate with early post-trauma thalamus and thalamic nuclei volumes and PTSD development in adulthood. Psychiatry Res Neuroimaging 2021;319:111421. doi: 10.1016/j.pscychresns.2021.111421. [Online ahead of print].
- Centers for Disease Control and Prevention. Adverse Childhood Experiences (ACEs). Updated April 2, 2021.
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