Childhood adversity &amp; lifelong health: From research to action

,

Applied Evidence

Childhood adversity & lifelong health: From research to action

J Fam Pract. 2018 November;67(11):690-699

By

Audrey Stillerman, MD, ABFM, ABIHM, ABOIM

Childhood adversity is a significant root cause of chronic illness and early death. Prevention, mitigation, and Tx of toxic stressors must be part of our paradigm of care.

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PRACTICE RECOMMENDATIONS

› Refer eligible patients to an evidence-based perinatal home-visiting program and all parents to an evidence-based parenting program to prevent childhood adversity. A

› Consider screening adult patients and parents for their own history (and their children’s history) of childhood adversity. B

› Recommend trauma-focused cognitive behavioral therapy and eye-movement desensitization and reprocessing as first-line treatments for adversity and trauma. A

› Consider prescribing yoga, neurofeedback, and other neuromodulatory modalities to treat the consequences of childhood adversity and trauma. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

References

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23. Miller TR. Projected outcomes of nurse-family partnership home visitation during 1996-2013, United States. Prev Sci. 2015;16:765-777.

24. Prinz RJ, Sanders MR, Shapiro CJ, et al. Population-based prevention of child maltreatment: the U.S. Triple P system population trial. Prev Sci. 2009;10:1-12.

25. Kraft C. Building capacity & support for two generation primary care. 2015 Midwest Regional Summit on Adverse Childhood Experiences. March 13, 2015. www.hmprg.org/assets/root/PDFs/2015/Summit%20Notes%20for%20Day%20Two.pdf. Accessed September 20, 2018.

26. Smith MV, Gotman N, Yonkers KA. Early childhood adversity and pregnancy outcomes. Matern Child Health J. 2016;20:790-798.

27. Leitch L. Action steps using ACEs and trauma-informed care: a resilience model. Health & Justice. 2017;5:1-10.

28. Bethell CD, Carle A, Hudziak J, et al. Methods to assess adverse childhood experiences of children and families: toward approaches to promote child well-being in policy and practice. Acad Pediatr. 2017;17:S51-S69.

29. Wade R Jr, Becker BD, Bevans KB, et al. Development and evaluation of a short adverse childhood experiences measure. Am J Prev Med. 2017;52:163-172.

30. Rush P. How learning about emotional trauma led me to a new understanding of chronic illness and health disparity. Becoming trauma-informed: Perspectives from public health, faith communities, education and medicine. Presented at 2016 Advocate Symposium, “Becoming a Trauma-Informed Children’s Hospital and Community: Building Foundations of Care, Collaboration and Practice.” Oaklawn, IL: Advocate Children’s Hospital; November 16, 2016.

31. Diderich HM, Fekkes M, Verkerk PH, et al. A new protocol for screening adults presenting with their own medical problems at the Emergency Department to identify children at high risk for maltreatment. Child Abuse Negl. 2013;37:1122-1131.

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33. Adversity. In: Merriam-Webster Online Dictionary. Springfield, MA: Merriam-Webster, Inc. www.merriam-webster.com/dictionary/adversity. Accessed September 21, 2018.

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36. EMDRIA’s definition of EMDR (eye movement desensitization and reprocessing). Austin, TX: EMDRIA: EMDR International Association. http://c.ymcdn.com/sites/www.emdria.org/resource/resmgr/imported/EMDRIA%20Definition%20of%20EMDR.pdf. Revised February 25 2012. Accessed September 21, 2018.

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46. Huang LN, Sharp CS, Gunther T. It’s just good medicine: trauma-informed primary care. (SAMHSA-HRSA Center for Integrated Health Solutions webinar); August 6, 2013. www.integration.samhsa.gov/about-us/CIHS_TIC_Webinar_PDF.pdf. Accessed September 20, 2018.

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53. Bryan M. A hospital offers frequent ER patients an out—free housing. “All Things Considered.” National Public Radio. June 29, 2016. www.npr.org/sections/health-shots/2016/06/29/482994000/a-hospital-offers-frequent-er-patients-an-out-free-housing. Acces-sed September 20, 2018.

The rising prevalence of obesity, widespread community violence, and the opioid epidemic are urgent health crises that we have, so far, failed to solve. Physicians must therefore ask: Are we employing the right framework to effectively understand and address these complex problems?

Careful review of the literature reveals that these problems and many others begin with, and are profoundly affected by, childhood adversity. Compounding this, studies over the past 20 years that have focused on abuse and neglect without including community, structural, and historical adversity demonstrate that our definitions of adversity and trauma have been too narrow. The prevalence and diversity of factors affecting development and health is much greater than our medical model anticipates.^1,2

CASE

Eileen W, a 55-year-old married, self-employed woman with a 20-year history of autoimmune thyroiditis, longstanding insomnia, and anxiety presents with intense episodes of terror related to public speaking, which are compromising her work performance. Her history is significant for tobacco and alcohol use beginning in early adolescence and continuing into young adulthood, as well as 2 unplanned pregnancies in her 20s. Additional adversities included the murder of her maternal aunt while Ms. W was in utero, resulting in her parents having fostered 2 young cousins; bullying; and the premature death of a special-needs sibling.

What treatment strategies might have been undertaken to manage consequences of the adversities of Ms. W’s childhood—both on her own initiative and as interventions by her health care providers?

^{IMAGE: © ALICIA BUELOW}

Our medical model must be updated to be effective

Because at least 60% of Americans have had 1 or more experiences of childhood adversity, family physicians care for affected patients every day—a reality incompletely addressed by our conventional theories and practices.^1,3 Consequently, updating our medical model to incorporate research that confirms the critical and widespread impact of childhood experience on health and illness is an essential task for family medicine.

Core values of family medicine integrate biological, clinical, and behavioral sciences. They include comprehensive and compassionate care that is provided within the context of family and community across the lifespan.^4,5 Family medicine is therefore the ideal specialty to lead a movement that will translate scientific evidence of the effects of childhood adversity on health into training, delivery of care, and research—transforming clinical practice and patient health across the lifespan.

Because at least 60% of Americans have had 1 or more experiences of childhood adversity, family physicians care for affected patients every day.

This article describes the dramatic impact of childhood adversity on health and well-being and calls on family physicians to play a crucial role in preventing, mitigating, and treating the consequences of childhood adversity, an important root cause of disease.

Continue to: Childhood adversity makes us sick