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Hello!  I am a new member, I am a physician who has been working in the trauma-pain world for over 2 decades here in Arizona, and I am soon to start on an MPH with focus on epidemiology.  I am going to survey primary care practices with regard to screening for trauma in children and adults throughout the state, and I would like to know if other members are interested in this project.  I would welcome your input!   

The idea is to get solid data on how many providers are screening for trauma, and for those that do screen: what tools are used, how confident the primary care provider is that they understand trauma treatment well enough to refer the patient appropriately, and what resources they have and what  barriers they meet in  connecting their patients to appropriate trauma care resources.  This is a necessary first step, I believe, toward bringing Arizona online with some of the things that are happening in California and elsewhere with regard to funding for provider education, for primary care level trauma screening, and for adequate trauma treatment.  

I am reaching out to like-minded colleagues throughout the country as well, for example the Center on Trauma and Adversity and Case Western Reserve University.   There seems to be a lot going on… Finally.

To shed light on my thinking in relation to the trauma-pain connection, here is a webinar I recently did on the topic, for behavioral health and medical professionals :

https://www.youtube.com/watch?v=-z42dPeqIMs&t=4s.

Warm Regards to All!!!

-Bennet Davis, M.D.

Original Post

How do you suppose that asking the ACE questions of a family would actually lead to anything positive?

I think most of us know that most families have a high trauma burden.

I personally think that it would be damaging to families, especially the children and dangerous to get a score on a kid and send that, his medicaid number and a distinct billing code that would define that kid to any state agency.   

Last edited by Jane Stevens (ACEs Connection staff)

Great point!  For clarity, we do not advocate that we ask parents/adults in family unit about their child's ACE score.  When it comes to children, preventative interventions targeting  communities and populations are the approach being rolled out by Health Depts and DOJs. We are looking at asking adults, given the evidence that treating trauma reduces physical illness and reduces utilization of resources, and our impression that we do not screen for trauma exposure currently.  We want to know if that impression is true and if so why.  Expect similar results to what has been show in the IPV literature.  This type of survey is a necessary step toward developing trauma care reources.

Last edited by bennet davis

I think you would do better looking at neglect in infancy, figuring out ways to make sure you can find it and determining the quality of the attachment relationship at that time.  We always miss neglect in infancy and we miss emotional abuse.   No adult can retrospectively remember or even understand that she was neglected and emotionally abused as a baby. 

But emotional neglect in infancy creates the origins of dissociation, avoidance, fractured and incomplete sense of self, an inability to regulate affect, lack of empathy, violence towards self and others and personality disorders, in essence, everything we need to prevent.   

 

Last edited by Former Member

Another great point.  We are starting with a very basic baby step, starting with adults.  The question we infrequently answer in primary care is: To what degree is exposure to trauma (not necessarily developmental trauma) responsible for the current health status?  Preliminary data from a chronic pain population is 75% of the time.  Yet none of the thousands in this data set had received any trauma treatment.  The idea is to  expose the magnitude of the problem and the disconnect so that, among other things, screening for neglect becomes a higher priority.

A little more on that: I have a long history working with AHCCCS (medicaid) in AZ and other health plans as well as self insured larger businesses as the medical director for the employers health alliance of AZ.  My experience is that they do not know that most families have a high trauma burden.   More to the point, they don't know the cost of unrecognized and untreated trauma.  And they dictate resource allocation.  

Incomplete answer, to be sure:

There are 6 randomized controlled trials showing that EMDR is effective treatment of chronic pain, and one for somatic experiencing that I know of.  We have a long way to go to more clearly define which treatment suits which patient...but my anecdotal experience these past 20 years is that somatic experiencing completely changed the game for several hundred patients.  SE was our go to because SE was what was most available.    My colleagues in trauma psychiatry insist that for complex trauma (repetitive developmental trauma) SE is best.  But where is the research? 

Addressing grief and social isolation is important as well.  And getting people moving during this treatment is important,,,there is evidence that exercise improves PTSD treatment outcomes and there is some mechanistic data that support it - showing increases in transcription factors in the CNS with exercise.  In my opinion, we have a long way to go.  Yet the funding for research in this area is sparse according to my neuroscience and epidemiology colleagues.  Back to the need to demonstrate the magnitude of the problem...

Dr Hahn, to your question, I'll give an answer that I admit is anecdotal: I have been at a residential trauma treatment facility for 21/2 years now and I would say that effective trauma treatment requires: First - create a sense of safety in the therapeutic environment.  Second - connection, a peer group with similar challenges is needed, a therapeutic community.  Third- trauma and grief  specific therapy (SE, EMDR, CPT, etc).  Fourth- access to professional support on demand to assist patients with processing.  

I have seen good results with fairly resilient people in outpatient treatment that offers aspects of this, as well.  

Neurofeedback. 

Neurofeedback needs study into how to best use it but if you have a disintegrated mind because you experienced a lot of early abuse at the hands of your parents, it is really helpful.  EMDR works theoretically by integrating the hemispheres.   Neurofeedback integrates the hemispheres too. 

The biggest problem with developmental trauma is that when you grow up, you have to untangle the lies and the modifications to how you see information and see the world, Pat Crittenden and her Dynamic Maturational Model is really good in understanding this.  We have no choice but to modify how we see the world in  a very warped way starting in infancy to keep dangerous parents from murdering us.   We leave childhood with false ideas like like I am worthless, I am garbage, I should have never been born.  

These "messages" and beliefs and ideas need to be straightened out.  That isn't easy to do when most of the so called helpers out there don't get how this is all messed up in the mind.

It's kind of hard to straighten all that out  in a world where the adults and the TV people and your school and everyone and everything is participating in a massive psychological operation though.    Propagandizing Americans on US soil sucks.   I know a kid who committed suicide  a couple months back because of this. 

Anyway - Good luck with your work. 

Last edited by Former Member

From my work history as an emergency room RN case manager we seen a lot of chronic pain recidivism visits that truly became mental health evaluation however, would it have served the patient to have done an ACE/trauma screening instead? I actually understanding what you are attempting as Bessel van der Kolk addresses both PTSD and developmental trauma and the physical injury that both create within the body.  Personally, speaking as a parent with a neurodiverse child, trauma comes from outside a family environment such as public school, where aversion intervention is applied to address disability-related behaviors which very much becomes developmental trauma.  Applying what I am know learning about toxic stress and trauma, I look back at the care we gave ER patients and realized we missed the opportunity to screen for a trauma history- how trauma impacts their perception of pain, pain tolerance and other  capacities regarding pain. A visit to the ER for help actually ends up re-traumatizing them. I  transfer this knowledge onto chemical use, mental health (anxiety) and adaptive traits such as dietary, exercising and smoking. Health care exists too much on parentalism which re-traumatizes individuals. Physicians cannot simply screen though, they must know what to do with the results. SAMHSA has a great education series on trauma informed care  which should be done in conjunction with trauma screens; no matter the diagnostic tool.  I believe that all well child visits, like California, should screen for ACEs but we shouldn't stop there and screen adults too. There is a lot of good research why we should screen adults especially if they have children themselves. Research projects that tend to give the greatest savings (quality of life, higher achievements, cost savings) typically are the programs where a relationship exists between the professional and individual. Usually a nurse case manager or social worker that creates a safe, non-judgmental mentoring relationship that has been missing from the individual's life. Just look to Public Health's Nurse-Family Partnership program-amazing and consistent results.   I can only tell you that in my state there is no such thing as a trauma screen and outside of one single ACE study specific to Native Americans, no other has been completed. That is a public health shame (in my opinion) as we have elevated mental health rates, alcohol usage/abuse and other disparities. Best of luck! 

Teresa

Hi, Bennet: Thanks for posting. I added you to the

Trauma Informed Health Care Education and Research (TIHCER) Collaborative 

for healthcare researchers who are addressing this, among other issues in ACEs science and trauma-informed care.

Also, I think an important first healing step that can be done without referring to other activities β€” whether housing, job, counseling, rehab, etc. β€” is just to talk about ACEs science with patients, to educate them about an important aspect of their health and to acknowledge their trauma, whether they want to talk about it at the time they learn about it or later.

Hi Bennet - I am one of the founders of TIHCER, that Jan mentions above.  We are a group of about 100 health care professionals who do believe that trauma affects adult health and that we have to address it and teach about it.  We certainly don't have all the answers but have found that educating ourselves and our trainees about ACEs science helps us care for our patients and can help patients understand the origins of their health problems and behaviors.  Several of us feel that understanding trauma and its effects can help with physician burnout, which is very high.  I am a general internist and I don't screen all my patients, but I do more of a case-finding approach.  I explore patients' histories when they are having problems that aren't improving.  Or early on when it appear likely there has been trauma.  We are working on a set of competencies for medical students in trauma-informed care and hope to study interventions for chronic disease patients in the future.  Let me know if you'd like to join our group.  We do monthly Zoom meetings.  

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