How to treat patients with bad childhood experiences

We’re increasingly aware of the lifelong effects of trauma in early life, and these experts give tips on how to spot and manage such patients.

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The importance of social determinants of health, the non-medical factors which influence health outcomes, are well recognised⁽¹⁾. However, the impacts of adverse childhood experiences and the mechanisms of their effect across the lifespan are perhaps less well known.

We advocate for the use of a trauma-informed approach in the primary care setting for both the identification of adverse childhood experiences and resilience factors, as well as for the development of mitigation strategies to minimise potential negative health outcomes. 

What are adverse childhood experiences?

The term adverse childhood experiences is used to describe extremely stressful events or experiences a child might be exposed to.

The landmark CDC–Kaiser Permanente Adverse Childhood Experience (ACE) study, published in 1998, was the first study to establish a strong, dose-dependent association between the number of adverse childhood experiences and chronic illness in adulthood ⁽²⁾. Key such chronic diseases include ischaemic heart disease, cancer, chronic lung disease, fractures and liver disease^(2,3).

The “ACE score” is a term commonly used in research and refers to the total number of adverse childhood experiences a person has had.

This concept of adverse childhood experiences has evolved to include community level adversity exposures in addition to those identified in the initial ACE Study^{(2, 4)}:

• Abuse: direct psychological, physical, or sexual
• Neglect: physical, psychological and medical
• Measures of household dysfunction: including parental alcohol or substance misuse; parental mental ill health or witnessing domestic violence; household criminal behaviour
• Parental loss: separation or divorce, living in foster care
• Community-level adversity exposures such as poverty and community violence
• Historical oppression of communities and cultures (such as racism)  
• Experience of other specific trauma (such as being a refugee)

Why do adverse childhood experiences matter?

Multiple studies have found that adverse childhood experiences are common and affect all groups within society^(2,5).  

Large, representative datasets suggest that up to 61% of adults have experienced at least one adverse childhood experience before age 16 and 10-15% have experienced four or more adverse childhood experiences^(2,7). Given that the experience of abuse, neglect and significant household dysfunction is often associated with a sense of shame and secrecy, it is unsurprising that adverse childhood experiences are not generally discussed or disclosed directly with healthcare providers^{(8, 9)}.

There is also a dose-dependent relationship between the number of adverse childhood experiences and poor health outcomes. Higher ACE scores are associated with poorer outcomes, with scores ?4 especially associated with poorer outcomes^(2,7). The experience of stressors such as poverty, historical oppression, and intergenerational trauma adds further complexity. There is often a higher prevalence of adverse childhood experiences within these groups⁽⁵⁾, reflecting the additive impacts of community level adversity exposures to those experienced at an intrapersonal level or within the family.

How are adverse childhood experiences linked with long-term impacts?

There are multiple postulated mechanisms responsible for how adverse childhood experiences are linked with poor health outcomes later in life. These include the result of health risk-taking behaviours repeated over time, the “toxic stress theory”, epigenetic processes and intergenerational impacts of trauma. Over the past 20 years, there has been increasing understanding of the medium and long-term impact of these exposures on poor health outcomes in adulthood^{(4, 5)}. 

Risk-taking behaviours

It has been suggested that adverse childhood experiences potentially result in behavioural changes as coping mechanisms.

Such behaviours may start early after such exposures in childhood. For example, teenagers with high ACE scores (?4) have been associated with increased odds of risk-taking behaviours such as substance use, alcohol abuse, smoking and high-risk sexual exposures⁽¹⁰⁾. Early onset chronic disease states in adulthood onset may ensue, with the repetition of these behaviours over time⁽¹¹⁾.

Toxic stress theory

A complex maladaptive biological response to persistent, severe stress, or “toxic stress”, in early childhood has been postulated to be part of this pathway toward illness in adulthood⁽¹²⁾.

Experience of toxic stress in early life may result in epigenetic changes, that is, the expression of genes involved in the stress response impacts how adults subsequently respond to stress in later life⁽¹²⁾. Toxic stress has been found to have significant impacts on three, inter-related systems: the neurological, endocrine, and immune systems. 

Neurological: Persistent excessive stress leads to a heightened “flight or fight” response, which in turn is linked with maladaptive neural development. Hypervigilance, impulsivity, and fear conditioning are frequently observed post-trauma exposures, and have been associated with impairments in longer-term emotional regulation, memory, and executive function⁽¹²⁾.

Endocrinological: Elevated levels of cortisol and stress hormones can predispose to insulin resistance and development of metabolic syndrome⁽⁷⁾. Additionally, children experiencing adversity have higher odds of developing obesity and hypertension in later life⁽¹²⁾.

Immunological: High adverse childhood experiences have been associated with recurrent infections and higher rates of developing chronic autoimmune conditions⁽¹²⁾.

Intergenerational impact

The impact of the trauma experienced through adverse exposure in childhood is not simply contained to an individual’s lifespan but can have a cascading effect through generations ⁽¹³⁾. For instance, people with elevated trauma exposures (many of which are also adverse childhood exposures) are vulnerable to multiple associated negative medical, mental health, economic and social consequences. This makes people who have experienced trauma, particularly childhood trauma, vulnerable to deficits in attachment and parenting to their own children, which then contribute to adverse childhood experiences of their children. In this cyclical manner, disadvantage and trauma can become entrenched in some families and social groups^(13,14).

 What can be done? And what about resilience?

The general practitioner, as the provider of family medicine, is uniquely positioned within the healthcare system to both bear witness to the impacts of intergenerational trauma on families as well as having the potential to intervene and support family members across multiple generations.

There is a danger of fatalism and thinking it is futile to attempt to mitigate the potential health impacts of trauma over the lifespan. However, the published research on adverse childhood experiences describes population level risks^(2,6).

Adverse childhood experiences are not prescriptive or deterministic for any given individual or family ⁽¹⁴⁾. While some children will go on to experience health risk-taking behaviours and adult disease states, many individuals will recover following trauma and demonstrate resilience in the face of their experience of adversity^(14)­.

Resilience factors must be considered concurrently when looking at adverse childhood experiences. Acknowledging resilience is key, as we are not passive recipients, but autonomous beings who actively shape and participate in our lives. A multisystemic approach to resilience considers the intrapersonal, interpersonal, and environmental factors that might contribute to an individual being able to cope with adversity⁽¹³⁾. Adopting this lens shifts away from fatalism and can allow health professionals to review strengths in patients, their families, and communities, and to consider how we might be able to enhance these structures to further promote positive outcomes.

The following provides suggestions that can be implemented in clinical practice. 

A trauma-informed approach

Utilising a trauma-informed approach seeks to reduce both the stigma associated with exposure to adverse childhood experiences and that which is associated with seeking help and support. This approach re-frames health and support seeking as a strength which can further promote resilience and reduce the likelihood of re-traumatisation.

A trauma-informed approach begins with awareness and recognition of both the potential negative impacts of adverse childhood experiences and the potential protective factors that promote resilience. It is an approach that demonstrates compassion by asking questions about adversity with a starting point of: “What’s happened to you?” and not, “What’s wrong with you?”⁽¹⁵⁾

Trauma-informed care can be woven into any interaction, however short or long. It includes elements of:^{(15, 16)}

• Listening to and validating a patient’s experiences
• Providing psychoeducation around the potential impacts of trauma on physical, emotional and social health
• Identifying strengths and using these to empower ongoing positive momentum
• Providing positive reinforcement around a patient seeking support
• Working collaboratively and considering multidisciplinary allied health support including psychological support or trauma-specific services.

All the above combine into an approach that fosters a person’s dignity and promotes safety, which in turn further supports the development of trusting relationships within healthcare. 

Early intervention: the first 2000 days

Early intervention is another key facet of responding to disclosures of adverse childhood experiences in children.  Interventions in the first 2000 days can make a significant difference to a child’s health, growth and development^(17,18).

General practitioners are the vital link in the provision of: regular child health and development check-ups, immunisation, oral health care, access to parenting programs and attending high-quality early childhood education⁽¹⁹⁾. For children who have experienced trauma and adversity, these interventions are an active way of promoting resilience.

Additionally, understanding a patient’s background and context can assist in assessment, early identification and intervention of developmental and behavioural problems. For example, children with multiple adverse childhood experiences are more likely to have learning difficulties⁽²⁰⁾. Trauma can masquerade and present with features of other behavioural and developmental conditions such as attention deficit hyperactivity disorder (ADHD)^{(11, 20)}.

Prompt identification allows for timely linkages to community paediatric services, allied health care and initiation of early intervention programs.

Family Support Services 

General practitioners can offer support to children beyond the first 2000 days and to additional family members across generations⁽⁹⁾. To support families within their communities, each state in Australia has a dedicated family support service, which is funded by each state child protection service and delivered by a state-contracted NGO service.

Family support services function as a central point to which health professionals can refer, or families can self-refer. Families receive time-limited case management to promote the wellbeing and safety of children and young people by connecting families to support services and community resources. 

Conclusion

Many patients have been exposed to adverse childhood experiences; however, these are rarely discussed in medical encounters.

There are significant improvements to healthcare outcomes with the recognition and acknowledgment of adverse childhood experiences and their impacts on individuals and their family.

Using strengths-based and trauma-informed approaches are essential strategies in addressing the negative impacts of experiencing childhood adversity and abuse. GPs are able to work in partnership with families across generations by advocating for and linking patients with local community resources, and prioritising early intervention in children with high burdens of adverse childhood experiences.

All these strategies combined work to mitigate the negative impacts of childhood adversity and to promote safety and resilience.

Links to state and territory family support services: 

ACT 
OneLink

NSW 
Family Connect and Support 

NORTHERN TERRITORY 
Territory FACES 

QUEENSLAND 
Family Child and Connect 

SOUTH AUSTRALIA
Family Support Services SA

TASMANIA  
Strong Families, Safe Kids Advice & Referral Line 

VICTORIA 
Child FIRST (Transitioning to The Orange Door) 

WESTERN AUSTRALIA  
Family Support Network 

Dr Neela Sitaram is a staff specialist paediatrician at Connected Care Clinic, Blacktown and Mt Druitt Hospitals, Western Sydney Local Health District, staff specialist, ambulatory, Sydney Children’s Hospital Network, NSW.

Ms Sema Mustafa is a senior social worker at Connected Care Clinic, Women’s and Children’s Stream, Western Sydney Local Health District, NSW.

Associate Professor Stephen Sze Shing Teo is a senior staff specialist paediatrician at Blacktown and Mount Druitt Hospitals, Western Sydney Local Health District, NSW and associate professor, paediatrics and child health, Western Sydney University.

Dr Glenys Griffiths is a  staff specialist paediatrician at Connected Care Clinic, Blacktown and Mt Druitt Hospitals, Western Sydney Local Health District and clinical director, Medical and Forensic – Prevention and Response to Violence Abuse and Neglect (PARVAN) Service, Northern Sydney Local Health District, NSW.

References

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17. First 2000 Days | North Carolina Early Childhood Foundation (buildthefoundation.org)
18. Moore, T, Arefadib, N, Deery, A, & West, S 2017 The First Thousand Days: An Evidence Paper. Parkville, Victoria; Centre for Community Child Health, Murdoch Children’s Research Institute
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