ACEs and ABI: A Trauma-Informed Approach · 2020. 11. 12. · Noshene Ranjbar M.D. University of Arizona. November 11, 2020. Disclosures The presenter has no financial conflicts of

ACEs and ABI: A Trauma-Informed Approach

Noshene Ranjbar M.D.University of ArizonaNovember 11, 2020

Disclosures

The presenter has no financial conflicts of interest to disclose.

Assistant Professor, University of Arizona Department of Psychiatry

Faculty, Andrew Weil Center for Integrative Medicine

Faculty, The Center for Mind-Body Medicine

Faculty, Integrative Psychiatry Institute

Board Member, American Board of Integrative Medicine

Learning Objectives

Define Developmental trauma and adverse childhood experiences (ACEs)

Understand Psychoneuroimmunology of trauma & ACEs as related to acquired brain injuries (ABI)

Gain Insight from the polyvagal theory and mind-body medicine as related to the impact and mitigation of ACES

Overview

Stress, ACEs and Trauma-Informed Care

How Does ABI fit into ACEs?

Caregiver Factors

An Integrative Approach

Case Example of ABI and ACEs: Ana

• 11-year old girl, suddenly developed seizures after a fever and GI illness

• Generalized tonic-clonic, intractable• Ambulance called, rushed to ED, hospitalized• Unable to break seizures despite multiple medication trials• Induced medical coma for 6 weeks• Diagnosed with Febrile Infection Related Epilepsy Syndrome (FIRES)• Eventually controlled seizures with high dose CBD oil as part of a

clinical trial, in addition to anti-epileptic meds

https://www.abc.net.au/news/2017-10-11/how-teenage-girls-around-the-world-want-to-create-change/9030504

Pre-ABI Medical and Developmental History• Healthy, met all developmental milestones

• No prior significant illnesses, surgeries, or injuries

• No medications

• Enjoyed dancing, cheerleading, and playing in the school band

• Social, easily made friends, got along well with parents and older brother Jose

• All A’s in school

Pre-ABI Family History

• Dad on service-connected disability with the VA due to severe PTSD from Iraq, also alcohol use disorder

• Mom with anxiety and depression, executive director of a marketing company

• Paternal grandfather with alcoholism and depression history

• Older brother, healthy

Pre-ABI Social History• Both parents Hispanic, very large extended family

• At times Dad would get drunk and yell at Mom and/or Annie and her brother

• Mom managed most of the finances and household activities while working full time

ABI Treatment Course

• Numerous hospitalizations and medication trials

• Due to specialized needs, most appointments and hospitalizations occurred 2 hours from home

• Regression of emotion & behavioral regulation, memory and cognition

• Utilized biofeedback, neurofeedback, mind-body skills training, and individual psychotherapy

• Puberty and individuation process

• Took appx 1.5 years to regain much of cognitive and executive function

Post-ABI • Mom and Dad divorced 2 years after the start of the illness

• Jose developed depression and started experimenting with alcohol at age 14, significant anger towards Ana

• Traumatic incident with Dad • Dog died suddenly due to a car

accident• Custody battle between Mom and

Dad

https://www.sgdivorcelawyer.sg/blog/getting-a-divorce-in-singapore-in-2020

Post-ABI, Cont’d

• 6 years post-ABI, age 17• Some improvement in relationship with

Jose• Final year of high school• Back to dancing and playing music• Still attends monthly individual

psychotherapy • Avoiding re-unification counseling with

Dad

Some questions to consider:

• What were some of the potential pre-disposing factors to Ana’s ABI?

• What resiliency factors helped Ana in recovery?• How has Ana’s ACE changed from pre- to post-ABI?• What impact has Ana’s ABI treatment course had on her

neurodevelopment and current prognosis?• How have her caregivers managed her ABI and what impact

has their stress and ability to manage their stress had on the outcome?

Stress, ACEs & Trauma

Stress

• Hans Selye, an endocrinologist, defined stress in 1936 as “the [physiological] response of the body to any demand for change”.

• Eustress: beneficial stress -either psychological, physical (i.e. exercise) or biochemical/hormonal. Greek for “good stress”

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We are born with our brainstem and limbic system hardwired for survival

Dr. Dan Siegel, Hand Model of the Brain: https://www.youtube.com/watch?v=gm9CIJ74Oxw

https://www.youtube.com/watch?v=gm9CIJ74Oxw

Trauma

-“injury”— to our mind, body, and spirit

“Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically and emotionally harmful or threatening and that has lasting adverse effects on the individual’s physical, social, emotional, or spiritual well-being” (SAMHSA, 2014)

Causes of TraumaWar

Torture

Natural disasters

Racism and Historical Trauma

Poverty

Child Abuse

Spousal Abuse

Rape and other violent crimes

Health crisis—life threatening illness

Health care itself

Witnessing any of these

In fact, all of us have been or will be traumatized 17

Who Does Trauma Affect?• 82% of individuals in the U.S. have experienced at

least one traumatic event in their lifetime• 8-18% of trauma-exposed individuals develop PTSD• 7-19% develop Major Depressive Disorder• “Co-morbid” conditions with PTSD have been

reported to be as high as 37%• Risk of developing PTSD after trauma exposure is

twice as high in women than in men

18Patel R, Spreng RN, Shin LM, Girard TA. Neurocircuitry models of posttraumatic stress disorder and beyond: A meta-analysis of functional neuroimaging studies. Neurosci Biobehav Rev. 2012 Oct;36(9):2130-42.

Post-Traumatic Stress Disorder

In PTSD there may be a prolonged Fight or Flight Response with agitation, hyper-arousal, etc.

Freezing is also a response to overwhelming trauma and a possible prelude to PTSD, and an ongoing response characteristic of PTSD.

• Parasympathetic system overdrive• Feeling stuck, inert, unable to feel or act• Avoidance• Possible long-term consequences – depression and

withdrawal• More research necessary

19

Post-Traumatic Stress DisorderPTSD is a kind of fixation—the characteristics that follow describe

some of its subjective and objective components. They do not adequately convey the experience.

Re-experience of the Original Trauma• Intrusive recollections• Nightmares• Flashbacks• Intense distress at reminders of the trauma

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Post-Traumatic Stress Disorder

• Sleep disturbance• Persistent increased arousal• Irritability• Concentration impairment• Hyper-vigilance• Exaggerated startle response• Heightened physiological reactivity

• Increased heart rate• Sweating

21

Forgotten or hidden trauma?

Understanding Trauma

Complexity… spectrum

Not caused by the event itself

May or may not lead to…

Any experience that overwhelms the system

May come to any or all of us

and, associated with zip code…

Not a weakness

Can transform into a strength

Trauma and the Brain

24

Trauma Physiology

Trauma may cause prolonged changes in:

• Brain structure• Systemic neurological

functioning • Cellular performance• Endocrine function• Memory processes

(c) 2017 Center for Mind-Body Medicine

Trauma Physiology, Cont’d

1. Hyperactivation of the Amygdala2. Alteration in Hippocampal

Functioning and Volume3. Hypoactivation of key prefrontal

cortex areas: hypersensitivity to potential trauma and decreased ability to mobilize judgment, make decisions, feel grounded in body and have empathy for others

26Patel R, Spreng RN, Shin LM, Girard TA. Neurocircuitry models of posttraumatic stress disorder and beyond: A meta-analysis of functional neuroimaging studies. Neuroscience & Biobehavioral Reviews. 2012 Oct; 36(9):2130-42.

Image credit: http://sage.buckinstitute.org/wp-content/uploads/2015/12/cerebro-ganglios-basales-cortex.png

Hormonal Changes• Increased levels of

Catecholamine, CRF, ACTH, cortisol, opioids

• Interruption of circadian cycles• Inhibition of conscious memory

(amnesia) and dissociation• Prolonged arousal in animals

may cause permanent change • If more aggressive, then

aggression• If defensive, then become more

inhibited• Feedback loop

27

Image credit: http://image.slidesharecdn.com/metabolicresponsetoinjury-140213142949-phpapp01/95/metabolic-response-to-injury-12-638.jpg?cb=1392301873

Bremner JD, Narayan M. The effects of stress on memory and the hippocampus throughout the life cycle: implications for childhood development and aging. Development Psychopathology. 1998; 10(4):871-885.

Hormonal Changes - Cortisol

• Short-term healthy stress response• Prolonged stress response• Physiological effects↑ Abdominal fat deposits↓ Sensitivity of fat cells↑ Cholesterol↑ Appetite ↓ Immunity ↓ Cells in hippocampusCompromise in gut function & the microbiome

28

Hypothalamus

Corticotropin Releasing Hormone (CRH)

Anterior Pituitary

Adrenocorticotropin (ACTH)

Adrenal Cortex

Cortisol

Chronic/excess Stress Influences the Onset and Course of Virtually All Illness

Coronary Heart Disease Gastrointestinal Dysfunction

Progression of HIV/AIDS Headaches

Recurrence of Herpes Premature Death

Asthma Eczema

Common Cold Anxiety and related disorder

Acute Clinical Incidents such as Cardiac arythmia, sudden Death

Cancer

Depression Sleep-related ailment

Obesity PTSD

Diabetes Alzheimer's and cognitive decline

Pain and Chronic Pain Cellular Aging

(c) 2017 Center for Mind-Body MedicineSource: Institute of Medicine

29

The Polyvagal Theory

1. “We start out trying to use our “social engagement system” to look at each other and resolve things warmly; that’s our first, myelinated vagus parasympathetic circuit.”

2. “If social engagement fails, we devolve into more primitive fight/flight animals, where our sympathetic circuits take over.”

3. “And if that fails, our ancient reptilian unmyelinated vagus circuit takes over and knocks us out into immobilization, called dissociation in humans.”

Credit: Peter Levine, PhD

(c) 2017 Center for Mind-Body Medicine 33

“Tend and Befriend” Modifies Fight/Flight/Freeze Responses

• Mediated by oxytocin (from the pituitary gland)

• Potentiated by opioids and estrogen• Reduces SNS activity and cortisol release• Is inhibited by naloxone, an opiate

antagonist

34Taylor S., et al. (2003). Biobehavioral responses to stress in females: tend and befriend, not fight or flight. Psych Rev., 107:411-429.

The Autonomic Nervous System

The Gas PedalSympathetic

Healthy: respond to demandsExcess: “Fight or Flight” Response

The BrakesParasympathetic

Healthy: Relax, Rest, & RestoreExcess: “Freeze” Response

https://optimizeme.nl/en/blog/2017/03/03/measure-resilience-heart-rate-variability-using-smartphone/?noredirect=en_US

Childhood or Developmental Trauma

36

37http://image.slidesharecdn.com/scunthorpeteacherspdfjan2015-150104153728-conversion-gate01/95/attachment-trauma-emotional-regulation-in-school-to-make-sense-of-nonsensical-behaviour-teachers-safeguarding-conference-barton-local-collaborative-trust-january-2015-4-638.jpg?cb=1420386741

Adverse Childhood Experiences Study(ACES)

• Followed 17,000 people in Southern California since 1995 (http://www.cdc.gov/violenceprevention/acestudy/)

• Felitti and others• Assessed for stressful childhood experiences, found

significant correlations to prevalence of chronic disease (examples: autoimmune, pain/headaches, heart disease), health risk behaviors (alcohol/drug use, obesity/over eating, smoking), mental health, reproductive health, etc.

• Extensive subsequent studies, now being used in primary care, schools, etc.

© Embody Your Mind, LLC

http://www.cdc.gov/violenceprevention/acestudy/

ACE – List of Stressors• Physical abuse• Sexual abuse• Emotional abuse• Physical neglect• Emotional neglect• Mother treated violently• Household substance abuse• Household mental illness• Parental separation or

divorce• Incarcerated household

member


Source: npr.org

Experiential Activity

What is your ACE score?

Experiential Activity

What is your resilience score?

ACE – Key Findings

• Childhood trauma was very common, even in employed white middle-class, college-educated people with great health insurance

• Direct link between childhood trauma & adult onset of chronic disease, depression, suicide, being violent and a victim of violence

• More types of trauma → ↑ risk of health/social/emotional problems• People usually experience >1 type of trauma – rarely is it only sexual

abuse or only verbal abuse, etc.

ACE – Key Findings

• The higher your ACE score, the higher your risk of health, social and emotional problems

• 2/3 had at least 1, 87% of those respondent had 2 or more

• Example correlations: ACE score ≥ 4 → ↑likelihood of chronic pulmonary lung disease 390%; hepatitis 240%; depression 460%; suicide, 1,220%

ACE score ≥6 associated with:

• 273% ↑ odds of reporting depression• 2436% ↑ odds of attempting suicide• 373% ↑ odds of reporting drug use• 284% ↑ odds of reporting moderate-heavy drinking after

adjusting for sociodemographic factors (Merrick 2017)

Demographics

• Original study participants -- mostly white, middle/upper-middle class, college-educated, employed, with access to quality health care

• Implications – rates are very high across society; marginalized populations often have higher rates of exposure

Image Credit: http://www.acestudy.org

See http://communityresiliencecookbook.org/by-the-numbers/ for additional learning

http://communityresiliencecookbook.org/by-the-numbers/

Expanded list of ACEs may include:• sibling and peer victimization• bullying• medical procedures, illness, surgery• property crimes • parental death when you were a child • community violence • spanking • racism• losing a parent to deportation• living in an unsafe neighborhood• involvement with the foster care system

• parent experiencing life threatening illness • being homeless• living in a war zone• being an immigrant• moving many times• witnessing a sibling being abused• witnessing a parent or other caregiver or

extended family member being abused

• involvement with the criminal justice system• attending a school that enforces a zero-

tolerance discipline policy


Mechanisms still being elucidated:

• Development of coping mechanisms – eating, smoking, promiscuity, alcohol and other self-medicating

• Related to the complex effects of unrelieved stress – impacting CNS/ANS neurodevelopmental – endocrine/HPA, inflammation, immune response (mind-body medicine, psychoneuroimmunology)

• Epigenetic mechanisms• Psychological inflexibility recently found to be a significant mediator between

ACEs and depression/anxiety states (Makriyanis et al. 2019)

Shared Neurophysiological Mechanisms

Changes in neurochemistry

Alteration to autonomic

activity

Alteration to hypothalamic-

pituitary-adrenal (HPA)

neuroendocrine axis

Breakdown of faciliatory and

inhibitory nociceptive physiology

Breakdown of inflammatory and immune

processes Whole System State: Multi-Directional Changes & Interactions

© Embody Your Mind

ACEs, Chronic Stress, and/or Trauma May Impact Autonomic Nervous System Physiology Mind-Body Skills

Training Can Assist with Improving

Regulation Capacity Chronic Over-

Activation/ Hyper-Arousal StatesExample Symptoms: High Tone, Inability

to Relax, Anxiety

Optimal Range for Eustress,

Performanceand

Homeostasis- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -Sympathetic – Activate (The “Gas Pedal”)

Parasympathetic – Settle (The “Brake Pedal”)

,

Chronic Shut-Down/ Hypo-Arousal States

Example Symptoms: Fatigue, Lethargy, Low Mood, Weakness, FaintingRanjbar & Erb 2019

Mitigating Influences

• Education• High quality parenting programs, primary prevention• Wide-spread MB self-care skills training• Buffer: safe, stable, nurturing relationships and environments

for all children and their families; for all impacted by ACEs• The valence of your patient/provider (person to person) interaction is

a key feature in therapeutic outcomes

Metzler et al. (2017) Adverse childhood experiences and life opportunities: Shifting the narrative. Children and Youth Services Review (72), 141-149. https://doi.org/10.1016/j.childyouth.2016.10.021 © Embody Your Mind, LLC

https://doi.org/10.1016/j.childyouth.2016.10.021


PCEs – Positive Childhood Experiences

The PCEs score included 7 items asking respondents to report how often or how much as a child they: (1)felt able to talk to their family about feelings; (2)felt their family stood by them during difficult times; (3)enjoyed participating in community traditions; (4)felt a sense of belonging in high school (not including those who did

not attend school or were home schooled);(5)felt supported by friends; (6)had at least 2 nonparent adults who took genuine interest in them; and(7)felt safe and protected by an adult in their home.

Bethell C, Jones J, Gombojav N, Linkenbach J, Sege R. Positive Childhood Experiences and Adult Mental and Relational Health in a Statewide Sample: Associations Across Adverse Childhood Experiences Levels. JAMA Pediatr. Published online September 09, 2019. doi:10.1001/jamapediatrics.2019.3007

PCE Study – Results/Relevance

• A dose-response association with adult mental and relational health, analogous to the cumulative effects of multiple ACEs

• PCEs may have lifelong consequences for mental and relational health despite co-occurring adversities such as ACEs

• Supports the salutogenic model and WHO’s definition of health as reflecting well-being despite the presence or absence of illness, injury, disease, or adversity

• A joint inventory of ACEs and PCEs, such as the positive experiences assessed here, may improve efforts to assess needs, target interventions, and engage individuals in addressing the adversities they face by leveraging existing assets and strengths


Asking as treatment?

• Biopsychosocial evaluation (asking the questions in medical examination) → ↓35% in DOVs* – n=130,000 patients*

• Comparison - only 11% reduction in DOVs* in a sample of 11,000 patients for traditional biomedical evaluation where the elicitation of the context of life history is not a part of the subjective/intake

• *Felitti, V.M. (2017). Future Applications of the Adverse Childhood Experiences Research. Journal of Child & Adolescent Trauma, 10, 205–206.

• Recent: California implementing widespread screening 2019-2020 (Dr. Burke-Harris)

*DOV=doctor office visits

CulturalCollectivist Influence

Language

Traditions Values

BeliefsHistory

Existential

Structural/PhysicalCommunity/Society

Built & Natural EnvironmentOrganizational/Institutional

Systemic/Policy

RelationalInterpersonal

Social

IndividualExperience

PhysicalCognitiveEmotionalSpiritual

Description: Individuals are embedded within various constructs of “environment” (social, structural, physical, cultural) with all layers having complex interactions within the whole of their experience. Cultural-Ecological Model

Image Credit: worldreliefdurham.org

Shame?• Deep, often subtle/unconscious, painful emotion• A sense of being fundamentally flawed, inferior,

inadequate, “wrong at one’s very core”• Linked to blame/fault in one’s experience• Universal, though experientially & culturally influenced• If history of childhood abuse, stress, trauma, bullying,

marginalization, unstable emotional environment, etc. – likelihood for shame as an unconscious informant to one’s experience is increased

• Normalize experience – listen, validate, enactive compassion, non-fixing stance, presence…



Trauma-Informed Care Practical ApplicationsHistory Taking

• ”Look back, but don’t stare…”• Scope of practice• Resourcing, orienting, grounding skills • Application of awareness, expression and regulation skills

influences and re-educates trauma biology without directly addressing/”treating” the trauma content

• If it arises…


How to inquire?• Presence, relaxed confidence/comfort, and functional education are

critical… • Remember from the subjective overview: “Even if you think it has

nothing to do with your present concern, I am wondering if you’ve experienced any accidents, injuries, or trauma…” (ACEs included…)

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Image credit: http://www.slideshare.net/JaneGilgun/resilience-adult-attachment-in-cases-of-child-trauma/24

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Image credit: http://www.slideshare.net/JaneGilgun/resilience-adult-attachment-in-cases-of-child-trauma/13

64Image credit: http://www.slideshare.net/JaneGilgun/resilience-adult-attachment-in-cases-of-child-trauma/13

Historical Trauma

65Image credit: https://laramieharlow.files.wordpress.com/2013/12/historical-trauma.png

Historical Trauma

66

•

•

•Pain that is not transformed... gets transmitted

• Richard Rohr

67

Is ABI considered an ACE?

Common Causes of ABI

• Strokes• Lack of oxygen to the brain• Blows to the head-- AKA traumatic brain injury (TBI).

Common Causes of TBI

• Road traffic accidents• Falls• Sporting injuries• Violence • Violent physical child abuse

Consequences of ABIs

• Impairments to physical, mental, cognitive, emotional & social functioning

• Symptoms sometimes readily observed, but many times subtle and can go undetected

• Hemiplegia • Epilepsy• Anxiety and depression• Executive dysfunction and cognitive difficulties• Personality change

Consequences of ABI, Cont’d

• Potential indirect consequences: • Unemployment• Social isolation• Relationship breakdown• Substance use • Homelessness• Other mental health conditions

ABI during development

• Many potentially traumatic elements of pediatric injury during the “event” & beyond

• Injury events are often sudden, painful, and potentially life-threatening.• Injury can occur from intentional and unintentional sources, spectrum of

traumatic elements and meanings for each person• Immediate aftermath of injury may have additional traumatic stressors

including treatment course

Early Assessment and Intervention

• Need to identify those at risk for developing PTSD after injury• Injury severity is not a good indicator of PTSD risk;• Time constraints in emergency and acute care preclude in-depth

assessment of emotional status of all injured children. (Screening of ASD symptoms and other risk factors can be useful.)

• There is a need for practical, effective ways to screen in the emergency and medical settings

ACEs and ABI

Prior ACEs impacts recovery from TBI

• Exposure to adverse childhood experiences is associated with increased risk of traumatic brain injury.

• Specific types of ACEs associated with risk of TBI: childhood physical abuse, psychological abuse, household member incarceration, and household member drug abuse

• Clinicians and researchers should inquire about adverse childhood experiences in all people with traumatic brain injury as pre-injury health conditions can affect recovery

Persons with prior ACEs increases risk for TBI

• Those who experienced sexual abuse, physical abuse, household mental illness and had incarcerated household members in childhood had greater odds of reported TBI, after adjusting for age, race/ethnicity, gender & income

• Those reporting 3 ACEs (AOR=4.16, 95% CI (1.47 to 11.76)) and 4 or more ACEs (AOR=3.39, 95% CI (1.45 to 7.90)) had significantly greater odds of reporting TBI than those with zero ACEs

• Prevention of early adversity may reduce the incidence of TBI; however, additional research is required to elucidate the potential pathways from ACEs to TBI, and vice versa.

Guinn, A. S., Ports, K. A., Ford, D. C., Breiding, M., & Merrick, M. T. (2019). Associations between adverse childhood experiences and acquired brain injury, including traumatic brain injuries, among adults: 2014 BRFSS North Carolina. Injury prevention, 25(6), 514-520.

Purpose:

• Acquired Brain Injuries, caused by a range of illnesses and injuries, can lead to long-term difficulties

• for individuals; mental health problems, cognitive and executive impairment and psychosocial

• problems including relationship breakdown, substance abuse and potentially homelessness. The study

• aimed to seek and gain a more definitive understanding of the inter-relationship of Acquired Brain Injury,

• substance abuse and homelessness by identifying key themes associated with the inter-relationship

• between these variables.

Materials and methods:

• The study recruited eight participants through homeless organisationsand treatment centres. Participants were screened for suitability (Brain Injury Screening Index; Drug Abuse Screening Tool; Alcohol Use Disorders Identification Test and then participated in recorded semi-structured interviews, transcribed and analysed using Interpretative Phenomenological Analysis.

Results:

• The study identified five master themes: Adverse Childhood Experiences and Trauma; Mental Health; Cognitive Decline and Executive Function; Services; Relationships.

Conclusion

• Healthcare professionals need to engage with children, their families, and adults, who have been exposed to adverse childhood experiences and should employ routine screening tools for brain injury to ensure their presence is factored into developing appropriate models of intervention.

IMPLICATIONS FOR REHABILITATION

• Need person-centred approaches to intervention for those with acquired brain injury who are homeless

• and have substance abuse issues.• Need to screen for the presence of acquired brain injury when

engaging with individuals who are• homeless or have substance abuse.• Need screening of acquired brain injury and adverse childhood

experiences to improve access to• services post-brain injury.

• Focusing in on the peri-trauma phase will help improve understanding of how parents’ own appraisals of the child’s medical event and coping assistance may influence how children appraise and cope during the medical event. By improving understanding of these factors, preventive interventions can be better tailored and thereby more effective.

Trauma-Informed Care


• Three key elements of trauma-informed care:

• (1) realizing the prevalence of trauma; • (2) recognizing how trauma affects all individuals

involved: patient, provider, and/or within any program, organization, or system, including its own workforce;

• (3) responding by putting this knowledge into practice


Organizational structure and treatment

framework

Involves understanding, recognizing, and

responding to the effects of of trauma

Emphasizes physical, psychological and

emotional safety for both consumers and

providers

Helps survivors rebuild a sense of control and

empowerment.

87http://www.traumainformedcareproject.org/

http://www.traumainformedcareproject.org/

Healing Centered Engagement

• TIC can be expanded following integrative principles• Trauma is not just individualistic, it is collectivist • Must address the social determinants to health• Ultimately must focus on possibility rather than pathology• Involve culture, spirituality, civic action, group/collective healing• Integrative wisdom - moving beyond a focus on details/content/“why” to “what’s

right with me”, “what am I learning”, and how can I be in the best possible relationship to my experience

Post-Traumatic

Growth

Purpose & Meaning

Spiritual Context

Motivator for Change

Seed for Compassion

Seeking Relationship

Cultivates Resilience

Caregiver Factors

Overview of caregiver stress

• Since 1970s research has explored the short/long-term impact of TBI on caregivers

• Example mental health consideration: Informal/non-professional caregivers play a key role in preventing suicide among people with moderate to severe brain injuries Caregivers are most often female and there is a heavy reliance on informal networks to provide support

Blake, Holly. “Caregiver Stress in Traumatic Brain Injury.” International Journal of Therapy and Rehabilitation 15, no. 6 (June 1, 2008): 263–71Kuipers P, Lancaster A (2000) Developing a suicide preven-tion strategy based on the perspectives of people with brain injuries. J Head Trauma Rehabil15(6): 1275–84Chan J (2007) Carers’ perspective on respite for persons with acquired brain injury. Int J Rehabil Res30(2): 137–46

High impact• Research has focused more on psychological impact:

• Psychological symptoms are common and may include depression, anxiety, stress, and burden

• Caregivers’ physical health may also be affected• Underscores mind-body (psychophysiological) mechanisms and the importance

of mind-body integrated self-care and support

• ~48–60% of caregivers experience depression • Feelings of strain and depression may not lessen over time

Role changes• Changes to social roles, disturbances in relationship with the patient,

decreases in leisure time, and reduction in social circle/engagement• Loneliness and social isolation are frequently cited problems (Romano, 1974;

Lezak, 1988).

• Caregivers often assume ↑ domestic workload and/or take on greater responsibilities such as looking after children, becoming a ‘bread winner’ or dealing with finances (McKinlay et al, 1981; Brooks and McKinley, 1983; Kreutzer et al, 1994). Caregivers also report that the caregiving role can often prevent them from obtaining gainful employment (Chan, 2007).

Factors influencing level of caregiver stress• Level of behavioral and cognitive change

• Cognitive and behavioral problems in the brain-injured person are more likely to be associated with high levels of strain for the family than problems with physical functioning (Thomsen, 1984; Allen et al, 1994; Watanabe et al, 2000).

• Patient coping strategies• Pre-injury family functioning

• Appears to be a significant factor in how caregivers and relatives cope. • Differences in long-term adaptation and coping efficacy are related to pre-TBI family

characteristics (Wesolowski and Zencius, 1994). • Characteristics of well-functioning families include: strong cohesion, understood

identity, firm boundaries, and open communication (Sachs, 1991). • ‘Vulnerable’ families show less of these characteristic and can be seriously damaged by

the occurrence of TBI in the family (Wesolowski and Zencius, 1994)

Caregiver characteristics (Blake 2008)

• Certain characteristics in the caregiver may add to the stress/burden of caregiving:

• Expressed emotion • Higher levels of expressed emotion were associated with greater anxiety, although levels of

expressed emotion were best predicted by caregiver status, with sole caregivers exhibiting greater expressed emotion than joint family caregivers. (Flanagan (1998))

• Coping strategies• Capacity for/use of cognitive restructuring or reframing, maintaining enjoyable activities,

and pursuing emotional support through organized family support groups • Appraisal of the situation• Strength of social support

Positive Effects?• Some caregivers report positive effects including personal reward from

the caregiving experience, although greater personal reward is reported by parents of TBI patients than spouses (Allen et al, 1994).

• Study of 180 significant others of people with TBI, Machamer et al (2002) m

• Majority of caregivers reported positive aspects to caregiving, such as being happy to have had the opportunity to care for the person with TBI (93%) and feeling good about their ability as a caregiver (92%)

• Measured both positive and negative effects of caregiving on the Modified Caregiver Burden Scale

An Integrative Approach to Assessment&

Treatment

What is Integrative Psychiatry?

Lake J, Helgason C, Sarris J, MHSc. Integrative Mental Health (IMH): Paradigm, Research, and Clinical Practice. 2012; 8.

Traditional Interventions to support ABI

• Needs assessment • Therapeutic education• Respite• Community-based services• Family interventions

• Include elements of assessment, educational workshops, follow-up work-shops, individualized family support and individual and/or marital/couples counseling

• Rehabilitation programs

Building Blocks of Wholeness

Self-regulation Sound nutrition Sound sleepHealthy

relationships with family and peers

Connection with nature

Fun MovementSound decision

making and wisdom

Spirituality (sense of meaning and

purpose)

Therapeutic Approaches to Traumatic Stress

• Cognitive Processing Therapy (CPT)

• Prolonged Exposure• Trauma-Focused Cognitive

Behavioral Therapy (TF-CBT)• Dialectical Behavioral

Therapy (DBT)• Acceptance and Commitment

Therapy (ACT)

Desensitization and Reprocessing (EMDR)

• Mind-body Skills Groups (MBSG)Accelerated Resolution

Therapy (ART)Somatic ExperiencingNeurofeedbackNutritional supplements

Nutrition and TBI

• Enteral or parenteral• Calories, protein, electrolytes, vitamins, minerals, trace elements and fluids. • ”Nutritional goals should be achieved within 5–7 days of injury”• Enteral nutrition -- reduce the incidence of ventilator-associated pneumonia• Perioperative period

• Immune-enhancing additions (glutamine, alanine, omega-3 fatty acids and nucleotides), may improve surgical outcomes.

‘Carney N, Totten AM, O'Reilly C, et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery 2017;80:6–15Heyland DK, Novak F, Drover JW, et al. Should immunonutrition become routine in critically ill patients? A systematic review of the evidence. JAMA 2001;286:944–53.Peng R, Li H, Yang L, et al. Immunonutrition for traumatic brain injury in children and adolescents: protocol for a systematic review and meta-analysis. BMJ Open2020;10:e037014. doi:10.1136/bmjopen-2020-037014

Nutrition and ABI

• Omega-3’s?• Vitamin D?• Zinc?• Glutamine?• Broadspectrum micronutrients?

Scrimgeour, A. G., & Condlin, M. L. (2014). Nutritional treatment for traumatic brain injury. Journal of Neurotrauma, 31(11), 989-999.Lewis, M. D. (2016). Concussions, traumatic brain injury, and the innovative use of omega-3s. Journal of the American College of Nutrition, 35(5), 469-475.

Nutrition and TBI

Kaplan, B. J., Leaney, C., & Tsatsko, E. (2016). Micronutrient Treatment of Emotional Dyscontrol Following Traumatic Brain Injury. Ment Health, 4(5), 1078.

Mind-body medicine (MBM) focuses on exploring and supporting the relationships among the spirit, mind,

brain, body, and behavior.

…supports all levels within each person’s being: physical, emotional, mental, social, behavioral, environmental,

historical, and spiritual factors…

Mind-Body Medicine…

“…regards as fundamental an approach that respects and enhances capacity for self-knowledge and self care.”

National Center for Complementary and Integrative Health

A quick overview of the science…

Caring for Other, Self, & “Co-Regulation”

We are only as effective in facilitating others’ stress reduction and healing as we are in our own awareness, expression, and ability to regulate our bodies and minds...

If we do not know what we feel, we will not be able to know what others feel…

Community/relational based healing – co-regulation and attunement

The Science of Connection: Oxytocin• Associated with social engagement,

attachment, bond formation, social and emotional processing circuitry (ventral vagal complex), has anxiolytic effects, enhances parasympathetic response and increases heart rate variability (Ellingsen 2015)

• The importance of healthy relationships; considered part of the pain/healing environment...

• Administering oxytocin intranasally increases recognition of both positive and negative emotion in others, increases empathizing and cooperation with in-group others*

Keeler et al. 2015 - The neurochemistry and social flow

of singing: bonding and oxytocin

Biofeedback - Biosquares

113

Biosquares(c) 2017 Center for Mind-Body Medicine

Autogenics & Biofeedback

(c) 2017 Center for Mind-Body Medicine 114

Wilderness & Trauma Science

115

Lessons from the Wild

116

http://www.slideshare.net/bwitchel/pcaworkshop2014

Experiential ActivityShaking and Movement

Mind-Body Medicine Techniques

• Meditation• Biofeedback• Guided Imagery• Autogenics• Creative expression• Movement & Music• Mindful Eating & Nutrition• Group Support

Expanding Evidence for Individual Modalities

• ≈ 462,000 citations in CAM/IM subset of PubMed database

• Meditation (stress reduction, immune function, cancer, HTN, attention, brain structure, insomnia)

• Guided Imagery (stress reduction, immune function, post-op outcomes, PTSD, cancer, pain)

• Group Support (HIV, cancer, immune function, chronic pain, insomnia, CHD)

• Hypnosis, Autogenics & Biofeedback (cancer, chronic pain, immune function, migraine, mood, stress reduction)

• Creative expression (headaches, trauma, chronic pain, stress reduction)

• Mindful Exercise (CVD, DM, cancer, depression, chronic pain, immune function, stress reduction)

• Mindful Eating and Nutrition (Cancer, CHD, obesity, hyperlipidemia, immune function)

Staples, J. K., Abdel Atti, J. A., & Gordon, J. S. (2011). Mind-body skills groups for posttraumatic stress disorder and depression symptoms in Palestinian children and adolescents in Gaza.

Mind-Body Skills Group

3 main components to each session:• Psychoeducation• Experiential• Sharing

Mind-Body Skills Group

• Randomized Controlled PTSD Study with Kosovar high school students

• Students in the intervention group (n=38) had significantly lower PTSD scores following participation in 12-session mind-body skills group program than those in the control group (n=40)

• Scores remained significantly decreased at 3- month follow-up

Journal of Clinical Psychiatry 2008; 69 (9): 1383-92

Mind-Body Skills Groups

• Mind-body skills groups have demonstrated effectiveness on reducing burnout in medical students and physicians

• Offering trainings and groups online since COVID

West CP, Dyrbye LN, Rabatin JT, et al. Intervention to Promote Physician Well-being, Job Satisfaction, and Professionalism. JAMA Intern Med. 2014;174(4):527.Gordon JS. Mind-body skills groups for medical students: reducing stress, enhancing commitment, and promoting patient-centered care. BMC Med Educ. 2014;14:198–198.

Lots of Free Websites and Apps

http://medicalcenter.osu.edu/patientcare/healthcare_services/integrative_medicine/clinical-services/Pages/Mindfulness-Practices.aspx

What does co-regulation mean?

Integrated, Biopsychosocial Care

• … an approach to care that puts the patient at the center and addresses the full range of influences that affect a person’s health.

• …beyond solely the amelioration of symptoms • …support each person to explore all levels and possible factors within

the spectrum of: • ~life – well-being - health – illness – disease – death~

• Acknowledges the complex inseparability of biological, behavioral, psychosocial, spiritual, cultural, historical, and environmental influences


Social Determinants of Health

• Conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks

• Conditions may be broken into components found in “place”:• Social• Economic• Physical


Examples of socioeconomic determinants

• Availability of resources to meet daily needs (e.g., safe housing and local food markets)

• Educational, economic, and job opportunities

• Access to health care services• Transportation options• Social support, norms &

attitudes (e.g., discrimination, racism, & distrust of government)

• Exposure to crime, violence, & social disorder (e.g., presence of trash, lack of cooperation in a community)

• Socioeconomic conditions • Access to mass media and

emerging technologies (e.g., cell phones, the Internet, & social media)

• Culture• Language, immigration status


Examples of physical determinants• Natural environment, such as green space (e.g., trees and grass) or

weather (e.g., climate change)• Built environment, such as buildings, sidewalks, bike lanes, and roads• Worksites, schools, and recreational settings• Exposure to toxic substances and other physical hazards• Physical barriers, especially for people with disabilities• Aesthetic elements (e.g., lighting, fountains, artwork, benches)


Resources that enhance quality of life can have a significant influence on population health outcomes.


Resources

• www.nctsn.org • www.cmbm.org• www.traumahealing.org• www.aacap.org• www.acceleratedresolutiontherapy.com• www.awcim.org• https://www.youtube.com/playlist?list=PLjAbmS83087mS0AJYD6p6VSLDy7SKQZsy• https://www.youtube.com/watch?v=iCvmsMzlF7o&t=5s

http://www.cmbm.org/http://www.cmbm.org/http://www.traumahealing.org/http://www.aacap.org/http://www.acceleratedresolutiontherapy.com/http://www.awcim.org/https://www.youtube.com/playlist?list=PLjAbmS83087mS0AJYD6p6VSLDy7SKQZsyhttps://www.youtube.com/watch?v=iCvmsMzlF7o&t=5s

With special Thanks to:

• Matt Erb, PT• James Gordon, M.D. and The Center

for Mind-Body Medicine

Questions?

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ACEs and ABI: �A Trauma-Informed Approach Disclosures��The presenter has no financial conflicts of interest to disclose.Learning ObjectivesOverviewCase Example of ABI and ACEs: AnaPre-ABI Medical and Developmental HistoryPre-ABI Family HistoryPre-ABI Social HistoryABI Treatment CoursePost-ABIPost-ABI, Cont’dSome questions to consider:Stress, ACEs & TraumaStressSlide Number 15Trauma��-“injury”— to our mind, body, and spirit�Slide Number 17Who Does Trauma Affect?Post-Traumatic Stress DisorderPost-Traumatic Stress Disorder Post-Traumatic Stress DisorderForgotten or hidden trauma?Understanding TraumaTrauma and the BrainTrauma Physiology Trauma Physiology, Cont’d Hormonal ChangesHormonal Changes - CortisolChronic/excess Stress Influences the Onset and Course of Virtually All IllnessThe Polyvagal TheorySlide Number 31Slide Number 32Slide Number 33“Tend and Befriend” Modifies Fight/Flight/Freeze ResponsesSlide Number 35Childhood or Developmental Trauma Slide Number 37�Adverse Childhood Experiences Study�(ACES)ACE – List of StressorsExperiential ActivitySlide Number 41Experiential ActivitySlide Number 43ACE – Key FindingsACE – Key FindingsACE score ≥6 associated with:�DemographicsSlide Number 48Expanded list of ACEs may include:Mechanisms still being elucidated:Shared Neurophysiological MechanismsSlide Number 52Mitigating Influences�PCEs – Positive Childhood Experiences �PCE Study – Results/RelevanceSlide Number 56Slide Number 57Slide Number 58Shame?Trauma-Informed Care Practical Applications�History TakingHow to inquire?Slide Number 62Slide Number 63Slide Number 64Historical TraumaHistorical TraumaSlide Number 67Is ABI considered an ACE?Common Causes of ABICommon Causes of TBIConsequences of ABIsConsequences of ABI, Cont’dABI during developmentEarly Assessment and Intervention ACEs and ABIPrior ACEs impacts recovery from TBIPersons with prior ACEs increases risk for TBISlide Number 78Purpose:Materials and methods:Results:Conclusion IMPLICATIONS FOR REHABILITATION�Slide Number 84Trauma-Informed CareTrauma-Informed CareTrauma-Informed CareSlide Number 88Healing Centered EngagementSlide Number 90Caregiver FactorsSlide Number 92Overview of caregiver stressHigh impactRole changesFactors influencing level of caregiver stressCaregiver characteristics (Blake 2008)Positive Effects?An Integrative Approach to Assessment& TreatmentWhat is Integrative Psychiatry?Traditional Interventions to support ABIBuilding Blocks of WholenessTherapeutic Approaches to Traumatic StressNutrition and TBINutrition and ABINutrition and TBISlide Number 107Mind-Body Medicine…A quick overview of the science…Slide Number 110Caring for Other, Self, & �“Co-Regulation”�The Science of Connection: OxytocinBiofeedback - BiosquaresAutogenics & BiofeedbackWilderness & Trauma ScienceLessons from the WildSlide Number 117Mind-Body Medicine TechniquesExpanding Evidence for Individual ModalitiesSlide Number 120Mind-Body Skills GroupMind-Body Skills Group Mind-Body Skills GroupsLots of Free Websites and AppsSlide Number 125Slide Number 126Integrated, Biopsychosocial CareSocial Determinants of HealthExamples of socioeconomic determinantsExamples of physical determinantsResources that enhance quality of life can have a significant influence on population health outcomes. ResourcesWith special Thanks to:Questions?BibliographyBibliography, Cont’dBibliography, Cont’dBibliography, Cont’dBibliography, Cont’dBibliography, Cont’dBibliography, Cont’dBibliography, Cont’dBibliography, Cont’dBibliography, Cont’dBibliography, Cont’dBibliography, Cont’dBibliography, Cont’dBibliography, Cont’dBibliography, Cont’dBibliography, Cont’d

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ACEs and ABI: A Trauma-Informed Approach · 2020. 11. 12. · Noshene Ranjbar M.D. University of Arizona. November 11, 2020. Disclosures The presenter has no financial conflicts of