Article In Brief
Early life stressors can lead to and impact neurologic disorders later in life. Researchers and neurologists discuss trauma-informed neurology and why it is important to inquire and address adverse childhood events in neurologic practice.
Adverse childhood experiences (ACEs) and other forms of toxic stress have been associated with a wide range of common neurologic and neuropsychiatric conditions later in life. In a Viewpoint published April 25 in JAMA Neurology, experts in so-called trauma-informed medicine call on neurologists to become educated about how these ACEs may contribute to toxic stress and underlie associated neurologic disorders, and to incorporate that awareness into how they manage these patients.
“Trauma-informed neurology can center patient experiences, more effectively treat toxic stress-associated health impacts, and inform future research,” wrote the research team, led by Robin Ortiz, MD, MSHP, assistant professor of pediatrics and population health at the Grossman School of Medicine at New York University and a member of the ACEs Aware Initiative of the Aurrera Health Group in Sacramento, CA. “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.”
ACEs include child abuse (emotional, physical, or sexual), neglect (physical or emotional), and household challenges (incarceration, mental illness, substance use, intimate partner violence, or parental separation or divorce) experienced by 18 years of age.
These ACEs are far more common than many people think. The Centers for Disease Control and Prevention reports that about 61 percent of adults surveyed across 25 states said they had experienced at least one type of ACE before age 18, and nearly one in six reported they had experienced four or more types of ACEs. A significant body of research has found that ACEs are associated, in a dose-dependent way, with lifelong health consequences, including more than 60 mental and physical health outcomes—such as epilepsy or seizure disorder, headache, sleep disturbance, learning and behavioral problems, and chronic pain—as well as premature death.
“Early life stressors and the associated prolonged activation of the stress response system may alter brain structure, function, and connectivity (eg, altered pain and reward processing, autonomic imbalance, impaired cognition and memory, and accelerated aging), affecting behavioral and cognitive abilities and increasing biological susceptibility to adverse health outcomes into adulthood,” Dr. Ortiz and her colleagues wrote.
“We used to think that traumatic stress was purely a psychological problem, but more and more research is uncovering the structural, functional, and even epigenetic changes that occur in response to trauma,” said neurologist Jorina Elbers, MD, who was not involved with the study.
Dr. Elbers—founder of the Trauma Recovery Project at the HeartMath Institute in California and former director of the pediatric stroke program at Stanford Children's Health/Lucile Packard Children's Hospital Stanford—said: “Over time, the body's stress response system adapts, leading to dysregulation across the whole nervous system. This physiological dysregulation is the underlying cause of the symptoms we see in these patients.”
Dr. Elbers has published several papers on ACEs and nervous system dysregulation, including a 2018 case series study in Pediatric Neurology involving 80 children (aged 5 to 17) with unexplained medical symptoms lasting three months or longer affecting at least four of six neurological domains: somatization, executive function, autonomic function, digestion, sleep, and emotional regulation. She found that 94 percent of these children reported chronic or traumatic stressors; 65 percent of them had had ACEs.
Those findings were borne out in an adult population in a study published in Neurology: Clinical Practice in February, which found that patients with neurologic conditions are more likely to have had higher ACEs than the US population.
In the study, adults seen for outpatient neurology follow-up at the University of Pennsylvania completed the ACE questionnaire and screening for depression and anxiety. Neurology patients were more likely to have elevated ACE scores compared with US population estimates (23.7 percent vs 12.6 percent, p < 0.01). These higher ACE scores were also associated with increased utilization of the ED [emergency department] (p< 0.01) and hospitalizations (p < 0.01). High ACEs were also associated with medical and psychiatric comorbidities (p < 0.01) and high depression and anxiety scores (p < 0.01, and p < 0.01, respectively).
“We were inspired to pursue this research based on our own experiences as neurologists,” said Adys Mendizabal, MD, the lead author of the study in Neurology: Clinical Practice. Dr. Mendizabal, a clinical fellow in movement disorders at UCLA Health, said: “I had repeatedly noticed that a subset of patients—such as those with headaches who were repeatedly presenting to the ED or others not responding to typical treatments—often had a history of trauma when I asked them questions. I then spoke with different mentors who made me aware on how chronic stress or ACEs could lead to chronic health conditions. That led to the question: Are ACEs associated with neurological conditions in adults and is adversity, leading to differences in the utilization of health care?”
Beyond the traditionally defined ACEs, many other factors may contribute to accumulated toxic stress. “The ACE questionnaire is a great tool, but we also need to understand that this does not totally define or is the limit of trauma or chronic stress affecting our patients,” said Dr. Elbers. She cited, for example, the impact of racism or medical trauma as two other major factors that cause a chronic stress response in both children and adults, but do not appear in the ACE survey.
How to Incorporate Trauma-informed Neurology
If both ACEs and chronic stress in adulthood can be linked to a constellation of neurologic conditions, then how can neurologists practice “trauma-informed neurology” to better serve these patients?
First, it's important for neurologists (and all clinicians) to understand that toxic stress produces a physiological response with clinical implications throughout the body, including neurologic conditions. “There is a general misunderstanding and misconception around patients with multiple medically unexplained symptoms that it's all in their head. This can lead to stigmatization and even retraumatization for these patients when they're dismissed by the medical community,” Dr. Elbers said.
“The real issue is that we don't have a way to investigate the subcortical and autonomic networks, and that's where a lot of the problems lie. Talking about nervous system dysregulation as the root cause of symptoms helps to relieve the stigma, and gives us something more concrete to work with. In order for toxic stress to be a diagnosis of exclusion, it must first be a diagnosis of inclusion. We need to understand it better, recognize the symptoms, and include it in our differential diagnosis.”
Four Principles of Trauma-informed Care
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.
Training is also available at www.ACEsAware.org/training, a free, two-hour online course that offers CME credit. And Dr. Elbers is currently in the process of launching a website that will bring together literature, resources, and forums for discussion of trauma-informed care.
The sources quoted in this article report no relevant disclosures.