Adverse childhood experiences and trauma informed care for chiropractors: a call to awareness and action

In chiropractic, trauma often refers to an incident leading to acute and sometimes serious physical injury. Similarly damaging, trauma in a psychological context can be defined as an emotional response to a distressing traumatic event (such as abuse, assault, or neglect), which challenges an individual’s sense of justice, safety, and environmental predictability [1]. When exposed to stressful circumstances, an individual can experience that stress and recover (coping), or experience it as trauma (unable to cope) [2]. Exposure to increasing numbers of ACEs increases the risk of mental health illness [1]. For this commentary, ACEs will be used to illustrate the value of trauma-awareness and informed care for chiropractors.

Childhood living environments and family networks play significant roles in shaping an individual’s health throughout their lifespan [3]. ACEs are traumatic life events that occur before age 18 [4]. ACEs include direct experiences, such as child abuse (physical, emotional, verbal, or sexual) and neglect, or indirect experiences, such as parental divorce, mental illness, substance abuse, and/or incarceration [4‐8]. ACEs, as originally defined, is only a small subset of all childhood traumas. Bullying, poverty, natural disasters, civil unrest, racism, and medical trauma are also childhood traumas, though not represented in the original ACEs research (Table 1) [4, 5, 8‐10]. ACEs are found with greater frequency in higher health risk populations where reduced access to healthcare and socioeconomic deprivation are found [11‐13]. ACEs are a recognized public health crisis that necessitate this call to awareness and action by the chiropractic profession [26‐30]. ACEs are highly prevalent, with 1 billion children affected annually, worldwide [14]. Sixty-four percent of U.S. adults and children self-report exposure to at least 1 ACE; 15% self-report a history of 4 or more [15, 16]. The populations who self-report 4 or more ACEs are at a significantly higher risk of experiencing mental health illness and associated comorbidities [11, 17].

ACE-affected persons may have endured substantial trauma and suffering in childhood and/or adolescence. Individuals with ACEs are often encumbered by physiologic changes that may negatively impact their lifelong health, social and emotional well-being, and lead them to seek healthcare. [4, 11, 17‐32] Those who experience at least 3 or more ACEs report higher rates of chronic pain, depression, anxiety, and may be more likely to engage in risky behaviors, including: smoking, heavy drinking, sexual promiscuity, or other such self-endangerment [4, 17, 19, 20, 23, 29, 33]. The Centers for Disease Control (CDC) suggests that at least 5 of the 10 leading causes of death are associated with ACE-driven behavioral changes [15]. Higher rates of chronic pain in ACE-affected populations suggests psychosocial factors behind some chronic pain patients [34, 35]; a population commonly seen in chiropractic clinics [36, 37].

Trauma Informed Care (TIC) is the recommended approach for all healthcare professionals who work with people affected by ACEs, and other traumatic experiences [5, 38‐42]. TIC guidelines recommend practitioner-specific knowledge of, and appropriate responses to, individuals with trauma during care using a patient-centered framework [43, 44]. TIC concepts have existed within the medical and psychological literature for decades [7, 39, 45, 46], with more recent research and dissemination into other fields of healthcare [38, 47, 48], including chiropractic adjacent fields [40, 42].

Healthcare fields, including psychology, medicine, and nursing, promote greater awareness of the long-term harms of ACE trauma among their practitioners and advocate for healthcare systems to deliver care in ways to prevent re-traumatization of ACE-affected individuals [4, 5, 38, 39, 49]. Chiropractors rely upon physical touch, such as palpation and spinal manipulation, to assess health status and render treatment to their patients. Persons with a history of ACEs may have negative situational perceptions of unfamiliar physical touch and difficulty with trust during routine clinical care, which is an important consideration for the chiropractic profession [38, 49‐53]. By developing a greater understanding of the health and social effects of ACEs, chiropractors may more readily recognize the need for using trauma-informed practices with all of their patients given the hands-on nature of chiropractic care modalities. The aim of this commentary is to inform chiropractors of the public health crisis of adverse childhood experiences, and possible safety concerns for patients with a history of ACE trauma in a chiropractic office. TIC requires all healthcare professionals to understand the impacts of trauma and know how to respond to people presenting with trauma-based concerns, which includes referrals of patients to health and social service professionals with specialized training in managing the medical and psychological needs of patients with a history of trauma. In this article, we provide chiropractors with a broader awareness of ACEs (one type of trauma) in adult patients and discuss why chiropractors might consider integrating TIC approaches into chiropractic settings, based upon the evolving research about TIC in the greater healthcare arena. We present pertinent information about TIC using the 4R’s Model as one example of how trauma-informed principles may be applicable in general patient care. We provide an overview of the physiologic effects and health impacts of ACEs and offer practical examples of delivering trauma-informed chiropractic care, including options for additional training, considerations for ACE screening and referral for multidisciplinary care.

This call to action for the chiropractic profession encourages chiropractors to adopt trauma-informed care (TIC) as a standard of practice.

What is trauma-informed care? While originating from the psychological literature, the principles of TIC are recognized across most healthcare professions [5, 38, 45, 48, 54]. Guidance on the long-lasting health impacts of trauma released by the Substance Abuse and Mental Health Services Association (SAMHSA) of the U.S. Department of Health and Human Services spurred the development of several TIC models, variously described as the: a) 6 key principles [45], b) 5 key ingredients [49], c) 5 principles [41], and d) 4R’s [5]. Collectively, these models acknowledge that persons with a history of trauma may experience poorer health and social outcomes over their lifetimes and describe ways to interact with those affected persons. All TIC models recognize the unique perspectives of an individual who has experienced trauma, including their perceptions of healthcare delivery. Each model also articulates biopsychosocial approaches to caring for people with a history of trauma, including ACEs [55]. Refer to Appendix A for definitions related to TIC.

Why might chiropractors consider adopting a TIC approach to healthcare delivery? Chiropractors are often portal of entry providers in their communities. They serve an important role in healthcare, as well as public health and safety, in diagnosing, triaging, and referring patients when necessary for treatment outside their scope of practice [56‐58]. In addition, chiropractors often see patients over long periods of time engendering rapport and trust, which may lead to trauma disclosure [59]. By increasing awareness of TIC principles, chiropractors can incorporate trauma-informed concepts into the delivery of care with all patients using patient-centered approaches to maximize patient comfort and choice, and minimize potentially traumatic experiences.

With trauma-informed chiropractic care, patients could receive appropriate screenings for past trauma or ongoing abuse at the discretion of trained practitioners, which may include the chiropractor or another healthcare provider. Chiropractors could refer patients with unresolved complaints and history of traumatic experiences for additional evaluation within a trusted network of healthcare professionals [58]. In addition, trauma-informed chiropractors could recommend multidisciplinary care that addresses a patient’s unresolved trauma to complement or replace chiropractic care, as indicated. [38, 39, 42, 43, 48] While trauma-informed care is an evolving concept in chiropractic, TIC is well studied, widely adopted, and increasingly integrated across many professions and healthcare settings [8, 38, 48, 49, 60‐66]. However, concerns about the potential impacts of trauma screening do exist, such as the limited research on long-term outcomes of asking patients about their trauma history [67, 68]. Thus, chiropractors considering adopting trauma screening as part of their TIC practice are encouraged to complete formal training on TIC as well as ACE screening implementation prior to use in practice. [9, 64, 69]

To introduce the concept of TIC, this commentary uses the 4R’s Model as one framework that might guide care of patients with histories of trauma. The 2014 SAMHSA report, Concept of Trauma and Guidance for a Trauma-Informed Approach introduced the 4R’s as a comprehensive model to engage professionals, organizations, and communities in creating cultures and sustaining systems in which trauma-informed care is the standard of practice. Realize, Recognize, Respond and Resist Re-Traumatization are the 4 critical components of the 4R’s Model of TIC as originally described:

A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices; and seeks to actively resist re-traumatization. [45]

Figure 1 depicts the 4R’s Model of TIC [5, 45]. While little evidence is available about the use of TIC in chiropractic care settings, research has demonstrated that concepts from the 4R’s model can support the implementation of TIC-informed practice in varied patient populations [5, 70]. This commentary applies the 4R’s Model to adult patients with a history of adverse childhood experiences seeking care in a chiropractic setting. We use ACEs as a window to see into a larger issue that is trauma, its impact, and ways for chiropractors to respond to improve patients’ feelings of safety and security. Chiropractors who identify past or ongoing abuse or neglect in children, adolescents, or dependent adult patients must follow regional laws and regulations regarding any mandatory reporting requirements. The following sections use the 4R’s Model to offer suggestions for implementing TIC in chiropractic practice.

Trauma informed care models illuminate ways of caring for those who have experienced trauma, including ACEs. Keep in mind, ACEs are only one of many types of traumas that may affect your patients, currently or earlier in life. Each type of trauma may present in patients differently, and further training on various types of traumas (intimate partner violence, PTSD, rape, etc.) is suggested to identify these in your patients. As healthcare providers, chiropractors share an ethical obligation with other providers to support patients who have experienced trauma through appropriate identification, treatment, and referral [58, 59]. Whilst ACE-awareness and TIC are emerging topics in chiropractic, awareness and application with chiropractic patients impacted by trauma are aligned with recent efforts within the profession to increase awareness of suicide detection, and recognition and referral for intimate partner violence [146, 149, 150]. Our aim is not that chiropractors perform the psychological aspects of their ACE-affected patients' care, but to realize, recognize, and respond to their patients who do have these needs, without re-traumatization. Research to inform TIC practices in different healthcare settings, including chiropractic, are necessary. Chiropractors will require additional training to identify psychosocial factors impacting their patients and to recognized the signs of abuse or trauma [52, 149, 150].

For U.S. chiropractors, SAMHSA guidelines recommend structural changes in 10 domains of healthcare organizations to support TIC, emphasizing implementation at the (1) Governance/Leadership and (2) Policy levels [45]. SAMHSA outlines subsequent levels of integration as (3) Physical Environment, (4) Engagement and Involvement, (5) Cross Sector Collaboration, (6) Screening, Assessment, and Treatment Services, (7) Training and Workforce Development, (8) Progress Monitoring and Quality Assurance, (9) Financing, and (10) Evaluation of Skill [45]. Within these guidelines, domains 3–10 fall upon the chiropractor to implement within a clinical practice, and guidance as to how to implement such practicewide changes are largely absent from the literature. Integration of TIC profession-wide will require involvement of regulatory bodies, educational institutions, health systems, practitioners, and support staff. As noted in a recent scoping review on ACEs, adopting TIC should be done in ways that are congruent with the evolving evidence, and in ways that prevent re-traumatization of patients, are acceptable to practitioners, and do not overburden clinical practices or health systems [68, 71].

Yet, ACEs, and trauma more broadly, are well-established contributors to many behavioral patterns and physiologic maladies that lead to health complications over a lifespan [4, 17, 19]. Promising areas for future research include studying how resilience training may impact health and social outcomes among persons with ACEs and related traumas, and understanding those seemingly unaffected by their trauma [97]. Trainings aimed at mitigating negative effects of screening are available and measures outlined therein should be in place prior to screening. These trainings, among others, are currently available to all practitioners [9]. Discussed previously, triggering patients or practitioners is a potential unintended consequence of trauma screening and an important consideration when deciding whether to implement it into practice [97]. Some concerns that have been raised against the implementation of screening and principles of TIC implementation are: the triggering nature of trauma screening, confidentiality of collected screening data, effects on the patient-doctor relationship, focusing too much on the negative effects of trauma as opposed to reinforcing peoples' resilience, lack of evidence based information on how to deal with trauma-affected individuals after screening [97].

The original ACE study results were based on a primarily white suburban middle-class population, thereby reducing the global generalizability of the results [4, 141]. Also, given the retrospective nature of the data gathering, and potential misinterpretation of what constitutes “abuse” by participants, the ACE study was likely reporting conservatively on the portion of the population affected by ACEs and long term health effects [151]. The original ACE study brought attention to child abuse and household dysfunction, and all screening results reflect that small subset of all potential childhood traumas. The higher prevalence of ACEs in socioeconomically deprived and minority populations, and the traumas that exist therein, are not represented in ACE screening or the original study, potentially making the white middle-class population originally studied a conservative representation of overall ACE-affectedness [2, 11, 152]. The feasibility, acceptability, and satisfaction with ACE screening in chiropractic is not known. Negative unintended outcomes of trauma screening may be possible. It is at the discretion of the chiropractor if or when screening is appropriate, and only after sufficient training in chiropractic schools or accredited training programs, and exposure to literature on TIC and handling of ACE screening reported in other healthcare professions [9, 116]. The potential exists that ACE screening will not be appropriate in all chiropractic offices and settings. In cases of family-practice chiropractors, working extensively with children and populations known to experience greater levels of trauma, it may be more appropriate to screen to gain a better understanding of chronic health conditions than in other types of practices. An ACE score may provide a chiropractor with information to improve care for ACE-affected individuals where psychosocial factors are a major contributor to their condition or perpetuation of chronic pain. This too, is presumed based on discussion and application of ACE screening in other healthcare fields [116, 136, 142‐145]. Patients with chronic pain disorders, including fibromyalgia, are often seen in chiropractic offices, and the condition has been associated with psychosocial causes, improving with psychological therapies. [80, 111, 112] In this example, identifying ACEs in connection with fibromyalgia would indicate a referral to a psychological professional.

Increasing awareness of ACEs and TIC in chiropractic education and practice is a first step in addressing these public health and safety concerns within the chiropractic profession. Suggestions for the future of trauma-informed chiropractic care are to: (1) include trauma informed care and other facets of patient-centered care in licensure training, through professional development and seminars from approved by accrediting bodies; (2) develop TIC guidelines and health organization policy and practices based on the experience and success of other healthcare professions; (3) conduct research to better understand TIC application; (4) conduct qualitative research on the perception of chiropractic care by ACE-affected individuals and provider perspectives on barriers and facilitators of TIC; and (5) develop interprofessional networks and attend interdisciplinary workshops to integrate TIC into chiropractic from the experience of other professions.

Furthermore, it falls to practitioners to recognize potential trauma responses of their own [153], and prevent those responses from interfering with patient care. Practitioner trauma responses, including compassion fatigue, can include professional burnout and vicarious traumatization [39, 49]. In these instances, chiropractors are encouraged seek support from the appropriate professionals to address their own unresolved trauma. Whether a chiropractor decides to screen patients for trauma or not, they must be a steward of patients’ experiences, but avoid counseling, commiserating, or consoling them [39].

The evolving nature of TIC research, and the modest number of interventional studies about ACEs, means our suggestions in this paper, while evidence-based, are primarily at the promising and supported levels of quality, rather than strongly supported by systematic reviews of well-designed, randomized controlled trials. While evidence exists in other healthcare fields, the chiropractic profession is in the beginning stages of studying TIC principles in clinical education and practice. Further research about the prevalence and presentation of trauma history among chiropractic patients may be warranted. In addition, differences in scope of practice across various jurisdictions may limit the extent to which individual chiropractors might apply TIC in their clinical practices. Research exploring any negative effects to patients from trauma screening is also needed, as well as whether patients follow through on referral recommendations.

Much of the research on ACEs and TIC were conducted in North American populations, limiting the generalizability of those results worldwide. Furthermore, the ACE-10 item scale was developed for research purposes, rather than for clinical use, suggesting the need for further testing, including in a clinical setting. That same 10-item screening only covers traumas of direct abuse and household dysfunction which excludes significant adversities children face resulting from poverty, racism, and weak social supports. The original ACE study was done on one middle-class Caucasian US-based population and may not be generalizable worldwide, and contains implicit sampling biases [152].

The ability to identify and respond to ACE-affected patients with trauma-informed care is a valuable skill for all healthcare professionals, including chiropractors. The 4Rs Model of TIC—Realize, Recognize, Respond and Resist Re-Traumatization – encourages chiropractors to understand the prevalence and effects of ACEs, identify health conditions and behaviors associated with trauma, and generate safe and positive therapeutic experiences for patients. Creating and maintaining an environment of safety, trust, and transparency is an important component of TIC. Screening for ACEs can help identify a person’s history with ACEs, though may not be appropriate for all patients. If opting to screen patients, the proper training and referral network are required.