Childhood adversity & lifelong health: From research to action
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.
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
Single-question screener. A Chicago internist interviewed more than 500 patients using a single-question screener that asked whether growing up was “mostly okay or pretty difficult.” This tool accurately confirmed childhood adversity in patients with complex chronic illness, prevented re-traumatization by allowing patients control over disclosure, and opened the door to collaborative healing work over time.30
The Hague Protocol, now mandated in the Netherlands for health and justice professionals, focuses its efforts upstream by offering early detection of children at risk for adverse experiences. The protocol requires asking adults who present with intimate partner violence, suicidality, psychiatric disturbance, or severe substance abuse whether they care for children in any capacity. Those who are so identified are referred to a center at which support services are offered.31
Uncertainty about the utility of existing tools. Many screening tools appear to be promising in terms of identification of the risk for, or actual, childhood adversity, patient and provider satisfaction, and their “fit” in the clinical workflow. Even so, no best practice guidelines exist in primary care to steer screening efforts. Questions remain about27-29:
- broad implementation of a specific tool
- how, when, and where screening should take place
- whether to screen adults, parents, or children—or all 3
- how best to use the content and pacing of screening questions to promote self-regulation and prevent re-traumatization
- best strategies for training and supporting health care workers around screening activities
- how to optimally manage a positive screen.
How best to approach treatment
Treatment includes trauma-informed care, an organizational transformation process (described in TABLE 232; in “The lexicon of childhood adversity: Concepts and tools for care”33-45; and in the subsection, “Lessons from neuroscience”), and individual treatment strategies. The Substance Abuse and Mental Health Services Administration (SAMHSA) of the US Department of Health and Human Services is advocating for implementation of trauma-informed approaches in health systems.
Continue to: The lexicon of childhood adversity...
