Tuesday, June 21, 2022

Adverse childhood experiences, toxic stress, and trauma-informed neurology

Ortiz R, Gilgoff R, Burke Harris N. Adverse Childhood Experiences, Toxic Stress, and Trauma-Informed Neurology. JAMA Neurol. 2022;79(6):539–540. doi:10.1001/jamaneurol.2022.0769 

The COVID-19 pandemic has substantially increased stress globally. It has and is expected to continue to increase rates of stress-related disease and cognitive impairment without appropriate interventions. Much of what we know about how stress changes our biology comes from the body of work related to the Adverse Childhood Experiences (ACE) study published by the US Centers for Disease Control and Prevention and Kaiser Permanente.1 ACEs include child abuse (emotional, physical, or sexual), neglect (physical or emotional), and household challenges (household incarceration, mental illness, substance use, intimate partner violence, or parental separation or divorce) experienced by 18 years of age.1 ACEs are associated in a dose-dependent way with over 60 mental and physical health outcomes and premature death,2 including many of the leading causes of death in the US, such as heart disease, cancer, unintentional injuries, stroke, chronic lower respiratory disease, diabetes, kidney disease, and suicide.1-3 ACEs are also associated with common neurological and neuropsychiatric conditions, including dementia and memory impairment, epilepsy or seizure disorder, attention-deficit/hyperactivity disorder (ADHD), and headaches, in addition to sleep disturbances, developmental delay, learning or behavioral problems, autism spectrum disorders, mood disorders and posttraumatic stress disorder, and chronic pain. It is inevitable that clinicians and investigators across the discipline of neurology will regularly encounter individuals with ACEs and their health outcomes. In one assessment, an estimated two-thirds of US individuals have experienced at least 1 ACE, and 1 in 4 have experienced 2 or more... 

The emerging evidence for an underlying toxic stress response as a treatable physiologic association between ACEs and common neurological presentations should serve as a call to action. While potential causal mechanisms between toxic stress and neurological (and nonneurological) symptoms or conditions are still being investigated, the discipline of neurology is strategically placed to advance the clinical applications of ACEs and emerging toxic stress science to more accurately assess and treat the root neurobehavioral causes for these health conditions. A trauma-informed, toxic stress–responsive approach is one in which the clinician recognizes how early adversity or trauma may physiologically contribute to a health condition and respond with supportive, evidence-based care that avoids retraumatization.9 Understanding how to recognize and best respond to stress-related clinical impacts in neurological practice may inform treatment for conditions spanning from ADHD to COVID-19–related spikes in stress-related disease, including stroke and dementia. 

Medication management for ADHD exemplifies how accounting for the biology of toxic stress is important in clinical decision-making and highlights the need for ongoing research. ACEs and other childhood adversities are associated with greater odds of ADHD, and patients with ADHD who also have a history of ACEs often exhibit a poorer response to stimulant treatment. In classic ADHD, stimulants counteract deficits in circuits involving the neurotransmitters norepinephrine and dopamine, effectively improving attention, working memory, and executive function. However, excessive catecholamine activity is also associated with executive functioning deficits. For individuals with ACEs who may be experiencing prolonged activation of the stress response, α2-adrenergic agonists, like guanfacine, are increasingly being used in pediatric centers to help regulate catecholamine signaling, thereby improving prefrontal processes like executive function and attention. Treatment for ADHD in the setting of toxic stress should also include behavioral therapy to reduce environmental risk factors and address underlying toxic stress physiology by using stress-buffering strategies... 

Trauma-informed neurology can center patient experiences, more effectively treat toxic stress-associated health impacts, and inform future research (Figure). Neurologists stand poised to help patients understand the role that toxic stress physiology may play in the clinical presentation or severity of neurological condition(s)—and in effective treatment thereof. Such an approach can aid clinicians in more specifically managing clinical conditions associated with ACEs when toxic stress is suspected by incorporating interventions targeted at regulating stress physiology, and help reduce blame, shame, and stigmatization patients often feel in connection with early adversity and/or toxic stress symptomatology. Interventions to regulate and counter stress physiology include routine physical activity, antiinflammatory diets, supportive relationships, experiencing nature, quality sleep, mindfulness practices, and mental health treatment. 

Adys Mendizabal, Cody L. Nathan, Pouya Khankhanian, Marissa Anto, Cynthia Clyburn, Alexandra Acaba-Berrocal, Louise Breen, Nabila Dahodwala. Adverse Childhood Experiences in Patients With Neurologic Disease. Neurol Clin Pract Feb 2022, 12 (1) 60-67; DOI: 10.1212/CPJ.0000000000001134 


Background and Objectives To describe the prevalence of high adverse childhood experiences (ACEs) among neurology outpatients and determine their association with health care utilization rates and comorbid medical and psychiatric disease. 

Methods This was a cross-sectional study of adults seen for outpatient neurology follow-up at the University of Pennsylvania. Participants completed the ACE questionnaire and depression/anxiety screenings. Health care utilization metrics (emergency department [ED] visits, hospitalizations, and outpatient calls) were obtained for all participants. High ACE scores were defined as a score of ≥4. The prevalence of high ACE scores in our cohort was compared with US historical controls. Statistical associations were adjusted for age, sex, and race/ethnicity. 

Results One hundred ninety-eight patients were enrolled in the study. Neurology patients were more likely to have elevated ACE scores compared with US population estimates (23.7% vs 12.6%, p < 0.01). High ACE scores were associated with increased ED utilization (odds ratio [OR] = 21, 95% CI [5.8–76.0], p < 0.01), hospitalizations (OR = 5.2, 95% CI [1.7–15.0], p < 0.01), and telephone encounters (OR 3, 95% CI [1.1–8.2], p < 0.05). High ACEs were also associated with medical and psychiatric comorbidities (OR 5.8, 95% CI [2.0–17.0], p < 0.01 and OR 4.5, 95% CI [2.1–9.6], p < 0.01) and high depression and anxiety scores (OR = 6.9, 95% CI [2.8–17.0], p < 0.01, and OR = 4.3, [95% CI 1.7–11.0], p < 0.01). 

Discussion Patients with neurologic conditions are more likely to have high ACEs than the US population, which was associated with higher rates of health care utilization, increased number of medical and psychiatric comorbidities, and higher anxiety and depression scores. Addressing ACEs may be a way to improve the health outcomes of patients with neurologic conditions. _________________________________________________________________________


Trauma-informed care can be distilled to four main principles—the “Four Rs” defined by the Substance Abuse and Mental Health Services Administration, Dr. Ortiz explained. 

“The first R is realizing that trauma and toxic stress exists, and is pervasive, and that many people have experienced it across all socioeconomic characterizations, races and ethnicities,” she said. “The next is recognizing that trauma may manifest in some of the signs and symptoms or diagnoses a neurologist may see, like changes in behavior or attention. The third R is responding with care and compassion at the patient level, in collaboration with other specialists. And the final R is resist retraumatization. Offer an inclusive and responsive environment in which, for example, the provider asks permission of the patient before conducting a physical exam or taking a certain approach to the encounter.” 

Next, consider this in your differential diagnosis. “If you have a patient who is not responding to treatment the way that you would expect or is utilizing health care more often than the typical patient—with lots of ED visits, hospitalizations, phone calls—that should trigger a question as to whether this patient could have a history of childhood trauma or toxic stress,” said Dr. Mendizabal. 

But one should be cautious in approaching these questions, as a well-meaning clinician who asks about a patient's ACEs history without a plan as to what to do when the patient answers yes to those questions may cause more harm than good. 

“If you have a clinic with social workers and/or a mental health provider who works closely with you so that you can quickly and safely refer the patient for services, then ideally you should be asking all patients questions about ACEs and trauma,” Dr. Mendizabal said. “But in reality, there are so many barriers to mental health services access, and so many neurology practices don't have a social worker or anyone trained to address this. The concern is retraumatizing someone if you don't have the appropriate resources to help. You need to have a good referral system.” 

Trauma-informed care does not necessarily mean the clinician needs to know the details of someone's trauma experience, Dr. Ortiz noted. “Our approach emphasizes a ‘universal precautions’ methodology. We know that as many as 70 percent of the population may have had ACEs as traditionally defined, and many more have experienced other forms of adversity associated with a toxic stress response, such as racism. All practicing providers should consider taking a trauma-informed care approach with all patients, whether or not something is specifically identified. This can only serve to create a more inclusive, safe, and trustworthy environment.” 

A useful tool to begin education in trauma-informed medicine is a June 2021 report from the California Surgeon General, The Science of ACEs and Toxic Stress. It notes that toxic stress is amenable to treatment, citing studies that have found new opportunities to more precisely interrupt the toxic stress response, break the intergenerational cycle of ACEs and toxic stress, and promote an intergenerational cycle of health. It also posits that early intervention can improve brain, immune, hormonal, and genetic regulatory control of development; and that treatment of toxic stress in adults may prevent transmission of neuro-endocrine-immune-metabolic and genetic regulatory disruptions in offspring.




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