Harmony Healthcare International (HHI) Blog

Trauma Informed Care: Top 10 Trauma Causing Events from Childhood



Compliance • Audits/Analysis • Reimbursement/Regulatory/Rehab • Education/Efficiency Survey

“Childhood Trauma leads to a Shorter Lifespan.”

Thank you for all the comments and notes on the Medicare Minutes. Many of you are seeking more information on Trauma Informed Care. As I have said since the draft RoP Requirements of Participation was published, (I read it in a Cambridge Massachusetts Hotel while my daughter Savannah wrote her college application essays), CMS is on top of their game and ahead of the curve.

The Skilled Nursing Industry is working diligently to understand how to provide care to an individual with Trauma. Trauma can be caused by a multitude of events within a lifetime. However, it is prudent to educate staff on root causes from childhood events.

This is not only important for identifying the etiology of the trauma of the Skilled Nursing Patient, but this is vital to help with preventing trauma in other human beings.

The mind is complex, and studies have shown that childhood is the most vulnerable phase of development and the highest phase of risk for any individual.

The Top 10 Events associated with Childhood Trauma include:

  1. Abuse: Physical
  2. Abuse: Emotional
  3. Abuse: Sexual
  4. Neglect: Physical
  5. Neglect: Emotional
  6. Family Dysfunctional: Mental illness
  7. Family Dysfunctional: Substance abuse
  8. Family Dysfunctional: Domestic Violence
  9. Family Dysfunctional: Caregiver Incarceration
  10. Family Dysfunctional: Separation from a Caregiver

The Adverse Childhood Experiences Study (ACEs) was conducted in 1997 by Dr. Vincent Felitti at Kaiser Permanente and Dr. Richard Anda at the CDC.  They reviewed the health history and current help of 17,000 adult patients (mostly white, middle aged and middle class).  They asked each participant to identify how many adverse childhood experiences they have experienced before the age of 18. Each participant was assigned an ACE score equal to the total number of adverse experiences.  

When the Adverse Childhood Experiences Study (ACEs) score was 4 or higher, the individual was:

  • Twice as likely to smoke cigarettes.
  • Seven times more likely to be an alcoholic.
  • Ten times more likely to have injected street drugs.
  • Twelve times more likely to have attempted suicide.
  • Three times more likely to experience chronic depression.
  • The risk for hepatitis and sexually transmitted diseases is 240% greater.
  • The risk for COPD was 390% greater.

The findings revealed that Adverse Childhood Experiences Study (ACEs):

  • 64% of adults have experienced at least one ACE.
  • 12% had experienced 4 or more ACEs.
  • In general, women experienced more ACEs than men.

Childhood Trauma leads to an Early Death.

Dr. Felitti and Dr. Anda developed a model to illustrate the mechanism by which childhood experiences influence health and well-being throughout the lifespan. Negative experiences lead to a disruption in neurodevelopment and ultimate shorter lifespan.  

Disrupted Neurodevelopment
Social, Emotional and Cognitive Impairment
Adoption of Health Risk Behaviors
Disease, Disability and Social Problems
Early Death


Trauma and toxic stress refer to intense experiences that threaten the safety and security of individuals.  Traumatic experiences can have short and long-term affects.  

All stress generates physiological and behavioral responses.  

  • Physiologically, the body responds with elevated blood pressure and increased heart rate with a surge of the hormones cortisol and adrenaline. 
  • Behavioral Responses are the reactions that allow the body to react and prepare for “fight or flight” i.e., the ability to save ourselves during a threatening situation.  These responses are critical for survival but are not meant to be activated for long periods of time. 

When the physiological and behavioral responses to stress persist for an extended period, there can be negative consequences for the individual’s health and well-being.  

Brain Science 

Brain Science has proven that the physical environment and social interactions play a role in the brain’s growth and the maturation of:

  • Cognitive Skills
  • Social Skills
  • Emotional Skills

In addition, it is completely fascinating that the environment and social interactions influence human development by chemically altering genes and these changes in the “genetic blueprint” can be passed from one generation.  Therefore, some individuals have a propensity for anxiety, depression and other DSM-5 related diagnoses simply due to genetics. 

There are two critical developmental periods, early childhood and adolescence.  

During both periods, specific areas of the brain are undergoing significant growth and maturation.  Thus, these two periods represent windows of vulnerability and windows of opportunity for human brain development where both positive and negative experiences are particularly impactful at these times.

The impact of trauma during childhood, especially early childhood and adolescence, can be profound.  Early, chronic and toxic stress can “hard wire” the brain to respond as if trauma is ongoing in the present leading to traumatic stress disorders such as PTSD, Anxiety and Depression. 

Brain Development

Adolescence is a time of enormous opportunity and vulnerability.  The rapid physical, emotional and neurological changes that take place in adolescence are similar in scope to early childhood.

Pre-Frontal Cortex (Executive Function like the CEO of your body)

The pre-frontal cortex is the final portion of the brain to develop and the period of most intense growth and maturation takes place during adolescence.  This area of the brain is responsible for “executive function” which includes:
  • Focused Attention
  • Problem Solving
  • Anticipating Consequences and
  • Emotional Regulation.  

Early Adolescence

During early adolescence, the pre-frontal cortex begins a prior of rapid growth.  These is an explosion of new neurons and new connections between neurons.  

This increased capacity is influenced by the environment.  

“If the environment is threatening and unsafe, or the brain is in a state of constant alarm due to previous chronic stress, the maturation of the pre-frontal cortex will be derailed.”

Middle Adolescence

In middle adolescence, the pre-frontal cortex undergoes a process of “pruning.”  This process involves removing neural connections that are infrequently used and strengthening those connections that are more frequently used.  

For example, 

  • If neurons associated with weighing pros and cons of situations are used regularly in response to the environment, they will be strengthened.  
  • While if neurons and neural connections associated with a high level of reactivity are more frequently used, they will be strengthened.  

The pruning process is directly connected to the individual’s experiences and environment.

Amygdala (Emotions and how you Respond to Life)

Another active area of the brain during adolescence is the amygdala.  The amygdala is the central part of the brain that develops early in life.  It is the emotional center of the brain.  

The amygdala is an almond-shaped part of the brain that plays important roles in autonomic, unconscious functions as well as in memory formation, learning, and emotions such as fear.

The amygdala becomes more active during adolescence due to increased hormonal levels in the body. 

  • If hormones associated with stress (cortisol and epinephrine) are high, the amygdala will respond by readying the individual for fight, flight or freeze responses.  
  • The amygdala also processes hormones associated with pleasure, fear and safety.  
  • It communicates with other parts of the brain to elicit responses appropriate to the emotional/hormonal inputs.  
  • If there are more fearful messages from the amygdala, those responses will become more “hard wired” in the pruning phase of the pre-frontal cortex development.

Myelination (Nerve Insulation and enhances nerve conduction)

A final and related process that occurs during adolescence is myelination.  This refers to a process whereby a fatty sheath is deposited around the neurons and neural connections.  This layer of fat serves as an insulator and increases the speed and efficiency with which neurons communicate with each other.  Myelination increases the “hard wiring” effect of pruning by further enhancing those neural connections that are frequently used.

Adolescence is a critical period for brain development.  The specific functions and capacities that are developed and “hard wired” in adolescence become the default way that an individual respond to new situations and challenges.  Those default responses can be altered later in life, but it is more difficult.  Adolescents can develop and hard wire a host of adaptive cognitive, emotional and social skills that will lead to healthy and successful adult lives.  

They are also vulnerable to developing fear-based and maladaptive patterns that lead to impaired physical, emotional and social functioning and may lead to early death.


The Substance Abuse and Mental Health Services Administration is a branch of the U.S. Department of Health and Human Services. It is charged with improving the quality and availability of treatment and rehabilitative services in order to reduce illness, death, disability, and the cost to society resulting from substance abuse and mental illnesses. The Administrator of SAMHSA reports directly to the Secretary of the U.S. Department of Health and Human Services

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

The concept of trauma-informed care is new to the long-term industry.  Compliance requires ongoing staff training and refined policies and procedures on all aspects of trauma informed care. 

Harmony Healthcare International (HHI) is available to assist with any questions or concerns that you may have.  You can contact us by clicking here.  Looking to train your staff?  Join us in person at one of our our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 

 harmony20 October 29-30 2020 Encore Boston Harbor

Topics: trauma-informed care

Kris Mastrangelo, OTR/L, LNHA, MBA


Kris Mastrangelo, OTR/L, LNHA, MBA

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