The Journal of the Arkansas Medical Society Med Journal Jan 2020 | Page 8

Cover Story
by Casey L. Penn
Are You Trauma-Informed?
The Importance of Understanding Trauma and Its Effects on Patient Care
I
“
ntuitively, physicians have known that
[traumatic] experiences that happen out-
side of the exam room – in the home, at
school, at work – have a bigger influence
on a person’s health than what occurs in the
exam room,” said Pediatrician and Arkansas
Foundation for Medical Care Physician Chad
Rodgers, MD. “Now, we have the science to
back that and the words to talk about it.”
To understand this phenomenon, Dr. Rod-
gers used an example that people understand
to some degree, post-traumatic stress disorder.
“With PTSD, people have gone to fight a battle.
They see these traumatic things, and then they
come back into a normal environment,” he be-
gan. “On the other hand, imagine a child who
has, for a prolonged period, been in an envi-
ronment of trauma, oftentimes during devel-
opmental periods of life. When these experi-
ences are ongoing, they will influence health.”
Noting how the effects of traumatic ex-
periences can follow children into adulthood,
he continued, “We’re built to survive. Being
anxious, for example, is a survival instinct that
prepares us to run away from danger or fight
back. We’ve all been there. You feel your heart
rate pick up, you start to sweat, your stomach
doesn’t feel good – you’re not worried about
digesting food, you’re worried about ‘fighting
the bear,’ as it were. When kids stay in this hy-
per-aroused, fight-or-flight state, it influences
their blood pressure, heart, liver, endocrine,
and inflammatory systems. I think we would all
acknowledge the mental health ramifications
for children whose bodies stay in that anxious
state. We’re beginning to understand the phys-
ical ramifications, too.”
Bringing all this home to present-
day Arkansas, AFMC reports
that our state has the highest
percentage of children with at least
one ACE, nearly 56% compared to a
46% average of children nationally.
156 • The Journal of the Arkansas Medical Society
Adverse Childhood Experiences
Past traumatic events are called Adverse
Childhood Experiences (ACEs). The term dates
to a foundational Kaiser Permanente study
involving more than 17,000 participants. The
study, conducted in the mid-1980s by Vincent
Felitti, MD,* and researchers from the Centers
for Disease Control and Prevention, ques-
tioned participants about their exposure to
traumatic events such as child abuse, sexual
abuse, and neglect; emotional trauma; poverty
and homelessness; household dysfunction due
to parental separation or incarceration; mental
illness in a caregiver; and violence in the home.
Dr. Felitti’s study revealed not only the
commonality of ACEs across the large patient
base but also the association between ACEs
and chronic illness. According to the study, the
more ACEs a person has, the more likely they
are to develop difficult-to-manage chronic
health conditions.
In addition to the original ACEs study,
which focused on mostly Caucasian individ-
uals with some college education, the Phila-
delphia Urban ACE Study looked at racially di-
verse adults with only a high-school education.
Together, these studies showed that a large
portion of the population – regardless of race
or socioeconomic status – had experienced at
least one ACE. Further, a smaller portion of the
population had experienced four or more ACEs.
In response to studies like Dr. Felitti’s,
movements to understand ACEs and provide
trauma-informed care (TIC) have gained ground
nationwide. They have led to initiatives like Ad-
vancing Trauma-Informed Care, led by the Cen-
ter for Health Care Strategies (made possible by
the Robert Wood Johnson Foundation).
The initiative included a video series re-
laying feedback from clinicians who were im-
plementing TIC in their practices. A featured
physician in the series was Edward Machting-
er, MD, professor of medicine and director of
Women’s HIV Program for the University of Cal-
ifornia San Francisco. “The majority of illnesses
that people are treating in primary care settings
are trauma-related,” he noted, “especially the
real hard issues that physicians and clinicians are
struggling with – substance abuse, chronic pain,
opioids – things that providers are struggling so
hard to change and help with and are failing and
feeling really frustrated with.”
Upon implementing TIC, Dr. Machtinger re-
ported, “This is working … the effectual side for
providers is dramatic. Our experience as a provid-
er has changed from being overwhelmed, from
having a chaotic clinic, from telling each other
the worst war stories possible as a way of cop-
ing – which is actually just retraumatizing – to an
experience where we are feeling like we’re doing
the absolute best job possible.”
TIC Efforts in Arkansas
Bringing all this home to present-day Arkan-
sas, AFMC reports that our state has the highest
percentage of children with at least one ACE,
nearly 56% compared to a 46% average of chil-
dren nationally. Further, as many as one in seven
children in the state have experienced three or
more ACEs.
Following in the steps of national initiatives
and organizations, AFMC and the Arkansas De-
partment of Health came together in 2017 to co-
found the Arkansas ACEs/Resilience Work Group.
The cross-sector collaborative of public and pri-
vate stakeholders is addressing childhood adver-
sity and working to build community resilience
through awareness and policy change. So far, the
organization has held three ACEs Summits that
have analyzed and addressed various aspects of
TIC in Arkansas.
“By reframing our tendency to ask ‘What’s
wrong with you?’ to ask the better question, ‘What
happened to you?’, physicians and their staff will
be better equipped to understand and connect
with patients, [engaging] their patients to foster
greater ownership of their health futures,” ex-
plained Catherine Bain, AFMC chief administra-
www.ArkMed.org