Megan H Bair-Merritt, MD, MSCE

Editors' Note: This article's views do not necessarily reflect those of 

, the editors, or the Editorial Advisory Board.

 article described the Adverse Childhood Experience (ACE) studies conducted by Vince Felitti and Rob Anda as “the most important public health study that you have never heard of.”

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	In brief, Felitti and Anda surveyed over 17,000 adults insured by Kaiser Permanente about adult health and ACEs (including childhood emotional, physical, or sexual abuse and neglect; violence against one’s mother; parental separation or divorce; and living with household members who were substance users, mentally ill, or suicidal, or who had been imprisoned). The studies documented that ACEs were prevalent in this largely Caucasian, educated sample, with approximately two-thirds of adults having at least 1 ACE and one-third having 2 or more. In addition, the more adversities experienced, the greater the risk for poor adult health.

 article, knowledge of the ACE studies has increased substantially, and the recognition of the impact of childhood adversity on adult health has become more commonplace among primary care providers. However, important questions remain about how best to change primary care to effectively address the needs of patients (and families) with histories of traumatic events.

	Indeed, “trauma-informed care” has become a buzzword for providers, policymakers, and researchers. The Substance Abuse and Mental Health Services Administration (SAMHSA) has a National Center for Trauma Informed Care, which delineates the following 6 key principles of trauma-informed care

	6. Cultural, historical, and gender issues.”

	These principles support the larger trauma-informed system that acknowledges the prevalence and impact of adversity on health and seeks to avoid re-traumatization. Models to change systems and to inform best practices are under development.

	However, it will likely take time for these models to be effectively disseminated to primary care practices. This delay leaves primary care providers in a quandary, specifically: What can they do 

, within the context of their current practice, to address the impact of psychosocial adversity on health? This article seeks to answer that pressing question by providing 5 “evidence-informed” recommendations for primary care providers.

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	As a word of caution, these recommendations have not been tested in a randomized, controlled trial. However, they are based on the principles of trauma-informed practice

 as outlined by SAMHSA and other leaders in the field, and they are designed to be strategies that can be implemented within everyday, busy primary care practices that often face competing demands.

	These 5 evidence- and trauma-informed practices for busy primary care physicians are:

1. Develop trauma-informed practice habits in day-to-day interactions with patients.

 Specifically, slow down, explain, and ask permission. For example, a thyroid exam may be triggering for an adolescent who has been choked by her partner. A standard Tanner stage assessment of a young child may similarly lead to significant anxiety in a mother who has been sexually abused. Explaining the exam prior to touching the patient and, as appropriate, asking permission to touch the patient can help build safety and trust, and empower the patient to have control over his or her body.

2. Keep traumatic experiences on the differential diagnosis.

 For example, consider trauma in patients or families who: frequently miss appointments; have angry interactions with staff; have pain without organic cause and/or that is unremitting; cannot seem to adequately manage a chronic health condition; and also for all behavioral health concerns. This recognizes the prevalence of traumatic experiences in our patients. Provide all patients with education about the known association between prior trauma and current health, and consider a universal screening question such as, “Since the last time I saw you, has anything particularly upsetting or scary happened to you [or your child]?”

3. Help patients and caregivers build resilience.

 Spend several minutes talking about resilience-building strategies, including ones that honor and respect patients’ culture and traditions. For example, discuss social supports and the importance of self-care, such as finding time for walks, deep breathing, or writing in a journal. For parents, encourage family routines. Proactively discuss child development and catching children “being good.”

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4. Celebrate with patients their existing strengths.

 Encourage the mindfulness adage that there is “more right than wrong with us.” Among those strengths, parents are taking a positive step for their children’s health by presenting for primary care.

 Forming strong links to community-based groups is critical, and these links can encourage peer support. A system of partnership that allows primary care providers to identify patient concerns and connect them with effective community organizations will enhance the bond between healthcare and health.

	Increasingly, individual providers, practices, and health systems are considering key elements of trauma-informed practice and making decisions about how to embed trauma-informed care into practice. While these innovative changes in care delivery are forthcoming, providers can use the above strategies to make subtle, but important, changes in their day-to-day care of patients.

Acknowledgement: Dr Bair-Merritt is a William T Grant Foundation Distinguished Fellow. She would like to express her gratitude to the Foundation, which gave her the opportunity to explore the best ways to integrate research into practice settings.

	1. Stevens JE. The Adverse Childhood Experiences Study-the largest public health study you never heard of. 

http://www.huffingtonpost.com/jane-ellen-stevens/the-adverse-childhood-exp_1_b_1943647.html

. Updated December 8, 2012. Accessed July 9, 2015.

	2. Felitti V, Anda R, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. 

	3. Substance Abuse and Mental Health Services Administration. Trauma-informed approach and trauma-specific interventions. Available at: 

http://www.samhsa.gov/nctic/trauma-interventions

. Updated July 7. 2015. Accessed July 9, 2015.

	4. Elliott DE, Bjelajac P, Fallot RD, Markoff LS, Reed BG. Trauma-informed or trauma-denied: principles and implementation of trauma-informed services for women. 

	Dr Bair-Merritt is Associate Professor of Pediatrics, Associate Division Chief, and Fellowship Director of General Pediatrics, and Medical Director of the Child Witness to Violence Program, Boston University School of Medicine/Boston Medical Center, Massachusetts. She also has consulted for Futures Without Violence, a nonprofit public benefit corporation working to end violence against women and children, and has written family violence prep questions for family physicians.

	For more information on how to screen children and their families for the hidden signs of IPV, read Dr. Bair-Merritt’s article “Screening and intervention for intimate partner violence” in the May 2013 issue of 

Articles

A 2012 Huffington Post article described the Adverse Childhood Experience (ACE) studies conducted by Vince Felitti and Rob Anda as “the most important public health study that you have never heard of.”

Author | Megan H Bair-Merritt, MD, MSCE

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Five steps to a trauma-informed practice