Department of Family and Community Medicine, Office of Community Engagement and Neighborhood Health Partnerships, University of Illinois Hospital and Health Sciences System, Chicago, Ill; Center for the Collaborative Study of Trauma, Health Equity, and Neurobiology, an educational program of the Hektoen Institute of Medicine, Chicago, Ill. ajstille@uic.edu
The author reported no potential conflict of interest relevant to this article.
Trauma-informed care is a model intended to promote healing and reduce the risk for re-traumatization of patients by staff—significant concerns in clinical settings, where the dynamics of loss of power, control, and safety that are inherent in traumatic experience can be replicated.46 To operationalize trauma-informed care more formally, the Center for Health Care Strategies, Inc., and the National Council for Behavioral Health are developing recommendations for 1) standardized screening and assessment tools, evidence-based clinical interventions, implementation processes, and relevant and replicable outcome measures, and 2) policy changes to improve patient and staff engagement, enhance health outcomes, and reduce avoidable care and excess costs.47,48
Asking patients whether growing up was “mostly okay or pretty difficult” accurately confirmed childhood adversity in patients with complex chronic illness.
Lessons from neuroscienceguide effective treatment.16 Treatment begins with bottom-up strategies that are focused on decreasing suboptimal excitatory input from the survival brainstem to create safety, connect patients to resources to meet basic needs, teach self-regulation skills, and improve relational health in and outside of the office. Later-stage top-down methods, such as education and other cognitive activities, focus on strengthening the regulatory capacity of the thinking cortex.16 In many ways, treatment mirrors prevention: It emphasizes first helping patients feel safe and loved.
In a follow-up to the ACE Study, 100,000 patients had a primary care visit in which their practitioner reviewed the ACE questionnaire with them; said “I see that you have________. Tell me how that has affected you later in your life” for every “Yes” response; and listened to the answers without passing judgment. This simple intervention profoundly decreased health resource utilization by these patients during the following year: a reduction of 35% in office visits, 11% in emergency room visits, and 3% in hospitalizations.1
The neurosequential model of therapeutics assesses neurodevelopment in the context of childhood adversity and relational health to evaluate consequences of childhood adversity and direct treatment. Adopted domestically and internationally, this model has had statistically significant success facilitating improvement in patients’ physical, emotional, and social health status.16,49
Successful strategies for childhood adversity emphasize parenting education programs, trauma-informed organizational practices, and neuromodulatory treatments.
Trauma-specific treatment modalitiessuch as trauma-focused cognitive behavioral therapy and eye-movement desensitization and reprocessing (EMDR),50 a trauma-specific treatment effective in resolving painful childhood memories, are evidence-based treatments that reduce trauma-related symptoms; evidence is also emerging about the efficacy of yoga51 and neurofeedback.52 These therapies have been best studied as treatment for posttraumatic stress disorder and other mental health disorders and also hold promise for addressing physical and social consequences of adversity. They present a low risk for harm, appear to be cost-effective, and improve outcomes.
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