PCMS_Philadelphia_Medicine_Summer2017 - 29

p h i l a m e d s o c .o rg

TRAUMA IS AS TRAUMA DOES: HEALING VICTIMS OF VIOLENCE

of Violence
The CT scan was cancelled. The youngster was moved to a regular
room. His neck was cleared clinically and he was up and drinking
liquids within an hour. The med students stood there, scratching
their heads, trying to figure out what just happened to him.
"What happened to you" is the exact question that we needed
to ask, instead of "what's wrong with you." Using this approach,
we can learn what occurred in the past that triggered him to
"freeze" in our presence, like a deer caught in headlights. It is an
all-too-common reaction in kids who have had very bad things
happen to them. Their "fight or flight" response goes into high gear,
sometimes producing the "freeze" - an unexpected, emotional
reaction to the trauma that brought them to us, along with the
fears that center around what we do or are about to do to them.
In the medical profession, understanding these phenomena is part
of what we now call being "trauma-informed."
Violence is one of the most common traumatic experiences that
set up our young patents for severe traumatic responses. Up to
40% of our nation's children are in some way exposed to violence
during their upbringing. From early childhood experiences of
domestic violence, to severe bullying, to the kind of group fights
that occur in our city's schools each day, the loss of that feeling of
safety can create lasting changes in the way the body's hypothalamic
-pituitary axis and counter-regulatory mechanisms function.

through multiple generations. Although certainly reversible, these
physiologic alterations can have a deep impact on a child's future
successes and accomplishments, affecting their children and their
children's children. Research suggests that adverse childhood
experiences (ACEs) are associated with cardiac and chronic lung
disease, diabetes, and a host of other medical or psychological
maladies. People with 6 or more ACEs have an average of a 20year shorter lifespan.
So, what are we to do? You might be thinking, "For God's sake,
Jim, I'm just a doctor!" First, just knowing about ACEs that our
patients and families suffer, is a start. Within the medical home,
shared knowledge about social determinants of health can lead to
discussion with our patients about resources, referrals, and general
support needs. In addition, we can provide recommendations for,
and access to, mental health specialists. Finally, and perhaps most
importantly, just understanding that the reactions and behaviors
that we see in our patients, and exhibit in ourselves, often reflect
the impact of our prior experience rather than who we want to be.
Food, shelter and safety are basic rights for all of us, and the
threat to any of these can rattle the foundation that supports
normal child development and success in adulthood. That said,
many of our most sentient and trusted societal contributors have
overcome significant obstacles and barriers.

Early research in Adverse Childhood Experiences (ACEs) estabThe thread running through their stories likely describes a
lished 10 household factors that mapped poor health outcomes caring adult who took the time to learn about their life and help
in strength and incremental "dosage." These outcomes could them through it.
be categorized as various types of child abuse as well as parental
The medical community cannot be all things to all people, but
dysfunction such as intimate partner violence, alcoholism, drug
it
can
be the conduit through which our most vulnerable patients
use, mental illness or criminal activity. Recently we have begun
feel
cared
for, listened to, and supported. When nature and
to expand this list to include environmental exposures such as
environment
combine to cause violent outcomes for our patients,
being bullied, witnessing or experiencing community violence,
our
informed
approach to their trauma adds to that spoonful of
or feeling unsafe in the neighborhood, and experiencing racism.
sugar
that
helps
our medicine "go down." *
Recent studies demonstrate that these experiences can lead to
dysfunction of the hypothalamic-pituitary axis, cortisol response,
and immunologic protective mechanisms. Epigenetic changes have
been described, with animal studies demonstrating persistence

Summer 2017 : Philadelphia Medicine 29

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