Effect of Adverse Childhood Experiences

Podcast Transcript

Intro: Neuro Pathways, a Cleveland Clinic podcast, exploring the latest research discoveries and clinical advances in the fields of neurology, neurosurgery, neuro rehab, and psychiatry.

Glen Stevens, DO, PhD: Traumatic early life events like emotional, physical, and sexual childhood abuse, and exposure to substance abuse, mental illness, domestic violence, and other adverse experiences have been found to be strongly associated with suicidality, alcoholism, depressive disorders, illicit drug use, and chronic medical diseases in adulthood. In today's episode, we address the effect of adverse childhood experiences, for greater awareness and management of predisposed patients. I'm your host, Glen Stevens, Neurologist, Neuro-oncologist in Cleveland Clinic's Neurological Institute. I'm very pleased to have Tatiana Falcone join me for today's conversation. Dr. Falcone is a psychiatrist with Cleveland Clinic's Department of Psychiatry and Psychology and Epilepsy Center. Tatiana, welcome to Neuro Pathways.

Tatiana Falcone, MD: Thank you so much for the invitation.

Glen Stevens, DO, PhD: So, we'll get started with the first question. What does the research tell us about the link between severe childhood trauma and the long-term mental health and social problems?

Tatiana Falcone, MD: Chronic trauma, severe trauma, emotional trauma, and no trauma, look at the incidents of depression, anxiety, PTSD, and look at the levels of this protein and we found that in those too in which the trauma was severe the levels of the protein was certainly higher.

Glen Stevens, DO, PhD: So we'll get back to the protein in a minute, but let's look at the long-term physical and mental health impacts of children that have been traumatized. Can you discuss that for us?

Tatiana Falcone, MD: Yes. Trauma has an important effect on development. So when is traumatized early on their life, you might see effects, even when they're 50, 60, some of the long-term longitudinal studies have demonstrated that people who are traumatized as children are more likely to have heart attacks later, are more likely to have hypertension, are more likely to engage in high-risk behaviors, like smoking, even when they look at the BMI and compare later on is higher. That's from the physical perspective, from the emotional perspective, they're more likely to develop depression, anxiety and PTSD. They're definitely more likely to used alcohol and other substances too.

Glen Stevens, DO, PhD: So, can emotional trauma cause long-term changes in the brain itself.

Tatiana Falcone, MD: So, there are some studies looking at the long-term impact in the brain and... there is different trajectories, some studies have demonstrated that there's some changes. We might not know specifically what these changes mean, but there were changes related to the age where the trauma was, and also what kind of trauma for what gender. So for example, for boys between eight to 10, sexual abuse was huge, and had a huge impact later on, for girls bullying between like 14 to 16, had a huge term impact later on. So they were looking at different areas of the brain like they did fMRI in these kids and they look at their fMRI later, and they saw some, according to what type of trauma they saw different trajectories of changes in the brain. But I think it's currently still kind of in study.

Glen Stevens, DO, PhD: So I have seen some data suggesting that you can see with childhood trauma later in life, you can see changes in the hippocampus,

Tatiana Falcone, MD: And the amygdala...

Glen Stevens, DO, PhD: which is probably not surprising that the amygdala and the limbic system would be effected. And also the frontal cortex, which I guess wouldn't be surprising with its function. Any other areas of, of significance that have been reported?

Tatiana Falcone, MD: Yeah. Temporal lobe, like the hippocampus is probably like the one that is most reported and changes in the amygdala, when they are doing also MRI studies. And even they put different images that might've been unpleasant in people who were traumatized before versus people who were not traumatized.

Glen Stevens, DO, PhD: So let's go back to the S100 beta in 2003, we published a paper in cancer and we were trying to use it as a marker, sort of a liquid for brain tumors, and our hope was that instead of doing MRIs on everybody, that we could maybe have a liquid biopsy that we could follow and just do a blood test and tell when their tumor was progressing or changing. And well, it's an astrocytic marker. It's not sensitive enough to tell us those types of things, but it looks like it's coming back around and having a lot of life in the psychiatric field. Are you using it personally in your patients? I mean, if a patient comes to see you, will you do a blood test on them and if you do, how will it help you?

Tatiana Falcone, MD: We’re still in like that phase where he's trying to validate it. So we replicated our initial study. So we need one study looking at suicidality depression in patients who are admitted to hospital and look at the levels of these proteins when they were admitted. And when they were discharged, our hope was that we'd did these sort of sample, we will be able to predict which patients were at risk. And I think it has a strong signal. We are looking, our follow-up data study right now. He's been studying like several places for like these purposes, especially looking at the link between the levels of S100B and other inflammatory markers to try to predict suicide. Have I used it? Yes, I have used it and we can actually order it as a test at the clinic. And we see these protein elevated when someone is very depressed or they're having suicidal thoughts. And we also see highly elevated in kids who are having psychotic symptoms.

Glen Stevens, DO, PhD: Some people have suggested that the protein itself is analogous to the C reactive protein. And it's just a general marker of inflammation. Do you think that's true?

Tatiana Falcone, MD: Yeah, I thought that was really interesting article, the CRP of the brain. When I started trying to do this study, initially I wanted to do it in patients with schizophrenia, right. So I wrote my grant and ask the NIH, and the NIH said, but how this was going to happen depression. So then we need a study in patients with depression and it was high. Then we send the grant again and we asked, can we do it?, the patients were depressed. And they said, what's the difference between the depressed and the bipolar patients. So then, we did all bipolar patients and when the patient was depressed, he was high too. So we see that in the last study we corrected for the diagnosis, so it depended if the patient had PTSD, depression, anxiety, even the patients who were suicidal, it was high. It actually showed a quantitative signal that it was really interesting to us.

So we saw that when it was above 0.12, patients were like five to seven on the suicidality scale. So that was the one that make us think, okay, we want to try to see, can this become a biomarker for suicide? So, when you call the emergency room, can we do this test? And no, do we need to admit the kit in order to just ask them, are you having suicidal thoughts right now? And so, we did this study for years and just finished it. So we're looking at the data right now, and is full of markers. The S100 is one of them, but we're also looking at IL1-b, IL-6, TNF-alpha. And some markers from the kynurenine pathway.

Glen Stevens, DO, PhD: Well, we'll be looking forward to the data coming out and maybe having a back and you can tell us, it'd be great if there was a biomarker that would help, wouldn't it?

Tatiana Falcone, MD: Right, yes.

Glen Stevens, DO, PhD: So it would seem obvious that children that are affected by adverse experiences, it's easy to say to remove the child and not have it happen in the first place, but of course, these things happen, so let's move to treatment. What can we do for these children?

Tatiana Falcone, MD: Yeah. So the first most effective treatment is to make sure that the trauma continue. Then second to give the kid enough tools to cope with what's happening. So, there's a lot of different kinds of therapy, but the most effective therapy for kids who have been exposed to trauma is... Trauma-Focused Cognitive Behavioral Therapy, and different from other therapists is that it doesn't have to be three years, it could be three months teaching the kids so many specific tools to manage the symptoms associated with this experience, right? That's our first step, to do therapy, to try to teach tools, to manage the symptoms. So let's say the patient is doing this and three months pass and we're still having a lot of symptoms. So sometimes, we also use medication when the patient is having depression, anxiety, PTSD.

Glen Stevens, DO, PhD: I guess if they are having problems in their frontal lobe and their hippocampus related to these adverse effects in childhood, going to be a lot more difficult to manage that if they have structurally related to changes, would there be any thought that you could reverse that with treatment or is that unknown?

Tatiana Falcone, MD: So really there were some studies looking at MRIs on kids who have trauma focused CBT and their activity in the amygdala before and after, and after the three month, the reactivity of the amygdala decreased. So, they saw some improvement, in the brain, after the treatment, so that was great.

Glen Stevens, DO, PhD: So that's encouraging, I'm happy to hear that. What should I do when I have a patient that comes to me, that I'm concerned has had these problems and they're now 60 years old.

Tatiana Falcone, MD: So first is to give them the opportunity to talk about it, right?. Sometimes is one of the hardest things to talk about and it might come in the most unusual circumstances. So you might be seeing a therapist for three years and never mentioned anything about this. Or you might suddenly come to emergency room for a broken bone. And for some reason, when the patient connects with you and trust you to a point that they want to bring this up, I think it's very important to give them the space, the privacy and the time to let it do it because it's really hard. And I think assessing trama is one of the most important things that we do when we see someone to look at different mental health issues. Right? Because that could be one of the main triggers for some of the symptoms that we're seeing.

Glen Stevens, DO, PhD: And any considerations or differences in approaching adolescents versus adults that you can share with us.

Tatiana Falcone, MD: Yes, when you're interviewing an adolescent is very unlikely that they will report anything, if the parent, or like the adult is in the room, we have to ask the guardian or the parent to give them some space. Because as you know, a lot of people who have been traumatized, they feel like the victim and they don't, they don't want to share that with their parents. So I think it's very important to open this space for them. And even not only about trauma, but in general, is always very important in kids who are 12 and older, to give them like 10 minutes of their appointment, where you're just talking with them one-to-one.

Glen Stevens, DO, PhD: And what if the parent doesn't want to leave the room?

Tatiana Falcone, MD: You slowly start teaching the parent why this is important, right? How can these be helpful? And I think the parents will warm up to the concept. I also do consults in the hospital for kids who have neurologic disorders. I would say 30% of the parents feel comfortable leaving your kid to interview alone, but I think the more than you talk to them and you explain them that this is actually going to help you, because it's very unlikely that the kid will be open, if you're here, then you're building these rapport and trust and they end up agreeing. So now that we've seen a lot of our patients virtually, that's one important consideration that we have to think, when you are asking these sensitive questions, we have to ask the parent, can you please give the patient some privacy? And what I see a lot the parent might move the computer, and take the camera out of their face, but they're still sitting next to the patient, right? So what I actually do is, I say, okay, can you take the computer to a different room or the phone to a different room? Because one of the most important parts I have is to have this 10 minutes with the patient where I can openly ask and they can openly respond without being worried about what is my parent thinking about what I'm gonna to say.

Glen Stevens, DO, PhD: Tatiana, I wanna thank you for joining me today. This has been a very insightful conversation. Thank you very much.

Tatiana Falcone, MD: Thank you very much for the invitation.

Outro: This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, ClevelandClinic.org/neuropodcast or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. And don't forget you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our consult QD website. That's consultqd.clevelandclinic.org/neuro or follow us on Twitter @CleClinicMD, all one word and thank you for listening.