Addressing adults with adverse childhood experiences requires a team approach

Introduction

Adverse childhood experiences (ACEs) have hazardous, quantifiable, and substantial impacts on health outcomes. An ACE score is a sum of “yes” responses to experiences of different types of abuse, neglect, and other hardships of childhood. ¹ Patients with high ACE scores often exhibit identifiable behaviors that health care teams can address by incorporating appropriate resources into patient care. ¹

Stress is an essential part of human development, which manifests in both positive and negative ways. ² “Positive” stress builds individual resilience (e.g. a child’s failure on a test can spur motivation for improvement and personal growth). “Tolerable” stressors, such as the loss of a loved one or a natural disaster, represent the potential to cause significant harm but are adequately buffered by existing support systems. ³ Severe or persistent stressors with inadequate buffering or support can produce a state known as “toxic stress.” Long-term toxic stress can disrupt neural development and cause permanent neurological injury and organ systems damage. ⁴

ACEs, including physical, emotional, or sexual abuse or family instability during childhood, are known to result in this state of toxic stress. Exposure to ACEs and toxic stress result in a quantifiable risk to health outcomes.^5,6 The higher the ACE score, the higher the risk for heart disease,^7,8 obesity,^9,10 addiction,^10,11 sexually transmitted disease (STDs), ⁷ and smoking.^7,10 The proposed correlation mechanism between toxic stress and these health outcomes is explained by inappropriate hyperactivation of the sympathetic nervous system during development. ⁴ The resulting physiologic state leads to difficulty with stress regulation and coping with otherwise harmless interactions. In other words, when development occurs in environments of toxic stress, fight-or-flight responses become easily activated and innocuous triggers such as a medical visit can be perceived as dangerous. Trauma-informed health care systems reduce the likelihood of triggering patients with high ACE scores.^1,12 This study aims to explore patients’ perspectives of what constitutes trauma-informed primary care.

Methods

This study took place at a residency-affiliated community health center with fully integrated behavioral health services in primary care. A qualitative research approach was used to conduct semi-structured interviews (see Figure 1 for interview guide) with a purposive sample of patients recommended by integrated behavioral health clinicians (IBHCs) or primary care providers (PCPs) as people that would be interested in sharing information about their experience. The two interviewers (authors AV and EC) are doctoral-level behavioral health clinicians who were previously unknown to the patients and not involved in their care. They obtained informed consent, emphasizing the optional and voluntary nature of participation. All six patients referred to the study agreed to participate. Interviews were audio-recorded and transcribed verbatim. Researchers had sole access to these transcripts, which were stored electronically and password-protected. No compensation was provided. Institutional Review Board (IRB) approval was obtained.

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Figure 1.

Interview guide.

Participants ranged in age from 36 to 61 years, 50% were female, and a variety of insurance statuses were represented, including Medicare, Medicaid, private insurance, or none. All participants carried diagnoses of depression, anxiety, substance use, and/or Post-Traumatic Stress Disorder (PTSD); all were comorbid with other diagnoses, like type 2 diabetes, arthritis, chronic heart failure, or Chronic Obstructive Pulmonary disease (COPD).

Qualitative data analysis entailed an iterative process. ¹³ Participants’ experiences with integrated behavioral health in primary care were elicited through in-depth interviews, using “open, direct, verbal questions that elicit stories.” ¹⁴ Three authors (EC, EH, and AV) first independently coded the data using Strauss & Corbin’s open coding method. ¹⁵ Open coding involves giving text excerpts descriptive labels. These labels were combined into categories, forming a number of themes. To ensure data fidelity, triangulation was employed, in which the preliminary themes were examined by the entire research team, who further refined them. The data were then reexamined, looking for confirming and disconfirming evidence for the identified themes.

Results

Discussion

A trauma-informed health system requires a paradigm shift. The traditional medical model and dyadic doctor–patient relationships work well when there are symptoms, tests are run, an answer is discovered, diagnoses are made, pills are prescribed, and the patient is cured. However, when the traditional medical model is applied to complex situations in which symptoms overlap and are confounded with social determinants of health, potential exists for re-traumatizing patients and frustrating care teams. Trauma-informed health care requires moving beyond traditional, medical, and curative models and embracing team-based, multi-disciplinary, supportive approaches (see Figure 2). It is imperative that primary care clinicians recognize the impact of ACEs and understand the need for trauma-informed care. Although the sample size is small, and results may not be generalizable to all adult survivors of ACEs, this pilot qualitative study sets the stage for larger investigation into tenets of trauma-informed care. Providing adequate, trauma-informed care necessitates that the individual patient, context, support system, coping skills, and resources all be considered to benefit patients and providers.

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Figure 2.

Tenets of a trauma informed approach.