< Previous10 PRECEPTOR PRINCIPLES: DON’T JUST SURVIVE, THRIVE BY B.T. MURRAY Why do people go to college? Or university? Or enroll in any other form of post-secondary education? Why did you? Were you the first in your family to go? Was there pressure from your parents to go because they wanted you to be whatever it is/was that they are/were such as a doctor or lawyer? Maybe you really had no idea in high school and just tried to find something that fit your personality. “Oh, that looks like fun! Let’s give that a try!” I’ve heard that one from students myself who simply wanted to do something fun that came with an adrenaline rush. For many other students, it’s been because they have had some type of exposure to emergency services while they were growing up and have naturally gravitated towards the career. Making the initial decision to pursue this career at the post- secondary level is the easy part. Succeeding is a whole other story. SETTING GOALS Many inspirational books or articles that have been written talk about setting goals as a way to keep a person’s motivational levels high for a prolonged, if not indefinite period of time. Setting goals is something that can work for anyone because it can be applied to any setting, or any endeavor, big or small. A person can go as big as setting goals for their lives, or they can go as small as setting a goal to pick up milk on the way home from work. New students entering a paramedicine program can do themselves a favour by thinking about their future and setting out some goals, both short term and long. They should also think about why they are doing what they are doing. What is the purpose? After the initial goal of just being accepted into college has been accomplished, many short-term goals will automatically kick in for all students. If you’re moving you have to find a place to stay. If you’re staying at home, you have to have reliable transportation to school. Tuition needs to be paid, books need to be bought and a reliable, quiet workspace needs to be created for you to work and study. That is for all students. But what about paramedic students in particular? What short term goals should they focus on? Short term goals for first year paramedic students revolve around acceptance and open mindedness. First year students need to accept that they are going to be BOMBARDED with information in the first semester of school and for most of these students, surviving (aka – passing) is the goal. This is understandable. No one wants to pay so much of their, or their parent’s money and have it completely go to waste. To prevent that from happening, everyone needs to start with an open mind that help may be needed along the way and there is no shame in asking for it. He was not my preceptor, but a number of years ago I knew a paramedic who loved to throw out the comment “Keep it simple stupid.” He always found ways in situations or conversations to get the last word in and he would use this phrase to continuously make his point. To the other veterans he worked with it was more than annoying. The younger, more impressionable that were around him however could not help but have that phrase implanted in their brain because of how often he repeated it. He was someone who very inadvertently helped me mature in my thought processes. He helped me to develop the wherewithal to look past a personality when I needed to, in order to understand what that person was trying to say. Once in school, set a goal of listening to everyone you come in contact with. There is a lot to be learned from just doing that. Answering the question ‘Why am I taking this program?”, will lead you into being able to set long term goals for yourself. You may not know the answer to this question at the beginning of the program, but you should know the answer by the end. As mentioned earlier, there will be enough on your mind at the start of the program and you will have to stay within each and every learning moment in order to be successful. However, if/when it becomes clear that you are doing just fine and will graduate, thinking about the future will become necessary. It does not mean you have to act on those goals immediately. Everyone lives life at their own pace. But setting your goals and having one eye on the future will help to stay motivated for success. GIVE YOURSELF A CHANCE There are three key factors that can and will make the difference between success and failure of a paramedic student. Time management, work ethic, and a proper attitude towards advice and learning. Time management is all about work/life balance. In the regular workforce, having an even work/life balance has become a much talked about and more important issue over the past decade. Work used to be everything and people would fit in their hobbies around work. Today there is so much stress related burn out, especially within the health care workforce that workers are demanding that employers make compromises and allow for a better balance. Employers are slowly learning that managing the workload and time on-the-job is now a critical factor in both the retention and overall success of their employees. Developing and using sound, consistent time management skills during school will kick start your ability to work as an effective, shift working paramedic. Developing a fundamental work ethic ties in directly arm-in-arm with the development of your time management skills. If you can manage your time wisely throughout the course of an individual day, a week and even over the length of the program, that will lead to having a strong work ethic. If the proper work/life balance is created so enough down time, sleep and exercise are had then this will mean when you go to sit down to study, or practice a new skill or scenarios that you will have more energy and focus. An even amount of energy and focus over the course of your program will set you up for success at understanding the material at hand and obtaining competence, if not mastery of the studied skills. What has been noted over time is that many students who have not been successful during their on-the-job-training (OJT) have completely taken for granted or simply ignored two very important areas and they both involve the art of listening. Yes, listening is an art and it is not one that is easily mastered by most. The main reason being too many tend to begin speaking before the person they 11 are speaking with are finished what they are saying. It is a proven theory that you cannot listen and speak at the exact same time. Therefore, if you are speaking while someone else, such as your patient, is speaking you cannot actively hear and take in the information you are receiving. A skill every student must learn is to have patience after they ask a question and wait for the patient to answer prior to moving on to the next question. This is called a soft skill but is in fact extremely hard to master because so much of the learning that is done is focused, and rightfully so, on learning what questions to ask in the first place. The place where this, and other soft skills will be taught and learned is during the OJT, but only if the student has the proper attitude. The proper attitude is one of open mindedness and the willingness to take in information from all sources. When a student is on their OJT they will have an almost endless supply of possibilities for obtaining information about how to do the job they are preparing for. They just have to look around, and be curious. The preceptors are the primary sources along with their regular partners, but other paramedics are always around as well. It should be encouraged by preceptors to seek out opinions of others and not just theirs as different points of view can be invaluable in the learning process. The veteran twenty-year paramedic who has seen so much may handle a situation very differently than a paramedic who has been out of school for two years. Do not be afraid to obtain both opinions. As someone new to the profession, there is something to be learned from each one. Nurses and doctors at the hospitals can be an excellent source for students as well. The clinical time is all about learning. They are there for you and will help you along the way. These are some topics and issues that preceptors need to consider in order to help students manage their first exposures to the profession of paramedicine. While it is true that preceptors are not there to act as a student’s mother or father, they will have the most direct influence on the level of success that a student achieves during their schooling. If a paramedic does not truly care about the level of success of their student, then they should not be a preceptor. We do not just want our students to survive, we want them to thrive. ABOUT THE AUTHOR B.T. Murray lives on the far east coast of the beautiful country of Canada. He is quite old and is not going to admit how long he has been a paramedic. Any opinions put forward in his articles, unless otherwise stated, are his alone and do not necessarily reflect those of his employer or anyone associated with him.12 THE EFFECTS OF EARLY ATTACHMENT AND ENVIRONMENT ON SUBSTANCE USE DISORDERS BY DEBORAH COOPER Our understanding of substance use has grown enormously over the last two decades. From the Regan era “war on drugs” to the current work to de-stigmatize substance use, we now grasp that human use of psychoactive molecules - from plants, other animals or compounds we’ve made ourselves - is as old as history itself. Altering our minds with substances is sociological, personal, cultural, spiritual and psychological. While most people who use substances do so within the bounds of a more-or- less socially-accepted lifestyle - raising a glass of champagne to toast the New Year, perhaps - some people will face problems with substance use. Substance use disorders (SUDS) is the appropriate catch-all diagnostic term within health care, used to describe certain symptoms of problematic substance use. As paramedics, we see SUDS often. Empirical research clearly shows us that punishment for problematic substance use has been an overall failure as a deterrent. If we take incarceration as an example of one of the major punishments meted out in Canadian society over the last century (before that, mind-altering drugs were not criminalized), we see that the number of people jailed with concurrent problematic drug use is estimated at a staggering 75% (1). At both the federal and provincial levels in Canada, programs and services to aid people in jail to work through problematic use are few, and those that exist are hard to access. The trend of jailing people with problematic drug use continues despite our knowledge of risk factors and treatment (2). Sometimes, as we are caring for our patients we, too, hold onto old feelings that punishment is a deterrent to substance use and a solution for SUDS. Unfortunately, our paramedic education and life experience doesn’t always deliver to us the knowledge of why people develop and live with substance use disorders or addiction. Without this understanding, we are left grappling for answers. Paramedics and other health professionals end up frustrated at what may look like poor life choices and bad behaviour when we don’t have a better, truer rationale: substance use disorder and addiction are health problems, not behavioural ones. ORIGINS OF SUDS AND ADDICTIONS Childhood has been proven to be an incredibly impactful time for the development of an individual’s personality, and the environment in which a child develops is one of the most significant factors in the development of the adult personality (3). Childhood maltreatment has the potential to cause structural, behavioural, and hormonal changes in the individual. These alterations can lead to personality traits that put the individual at a great risk of developing a substance use disorder, whether as a means to cope or as an effect of their personality. Around the turn of the last century, researchers at the Kaiser Permanente Hospital in the United States performed a landmark research trial. The large longitudinal study examined the impact of Adverse Childhood Experiences (ACEs) on the whole health of approximately 17,000 participants (4). The term “disorder” is more medically accurate than “addiction” and helps to signify substance use disorders as a legitimate medical condition. Its use is only appropriate in cases where the individual meets the conditions required for diagnosis of a substance use disorder specified in DSM-V. Substance use disorders can be diagnosed according to severity (low, moderate or severe). The term “addiction” has historically been adopted to describe the severe end of substance use disorders. Many substances and behaviors can become addictive; however, addiction itself is not, and has never been, an independent diagnosable condition. (10) The Kaiser-Permanente study found high rates of Adverse Childhood Experiences among the 17,000 participants.MASTER OF ADVANCED HEALTH CARE PRACTICE (PARAMEDICINE) The Master of Advanced Health Care Practice (Paramedicine) offers an opportunity to extend your practice with advanced techniques, advance your leadership and research skills to take the next step in you career. ENTRY REQUIREMENTS With the choice of online or face-to-face delivery the Master’s offers the quality and recognition of a Monash University graduate degree with the flexibility required by working professionals. The Master of Advanced Health Care Practice (Paramedicine) is available to experienced practicing paramedics, nurses or doctors who meet the following criteria: DURATION 1.5 years (full time) 3 years (part time) INTAKES First semester only (February) COURSE STRUCTURE The Master of Advanced Health Care Practice consists of either 12 units of study (72 credit points) or 8 units of study (48 credit points) depending on potential credit (previous qualifications and experience). PATHWAYS Graduation from this course may provide a pathway to the Doctor of Philosophy (Paramedicine) or other Postgraduate Programs at Monash University. An undergraduate degree or diploma in a relevant clinical discipline. ■ Professional registration to practice as a health care professional in a relevant clinical discipline. ■ At least two years of full-time experience in a relevant clinical discipline. ■ CONTACT DETAILS AND ENQUIRIES Further details about our Postgraduate courses can be found at the Department of Paramedicine Postgraduate website: monash.edu/study/courses/find-a-course/2022/advanced-health-care- practice-m6001#overview-1,Advanced_paramedic_practice Contact Us Professor Brett Williams E: brett.williams@monash.edu CRICOS provider: Monash University 00008C Produced by: Monash , August 202114 The results were stunning. The study found a distinct connection between ACEs and addiction or SUDS, but it didn’t stop there. It turned out that health concerns such as heart disease and diabetes were also associated with ACEs. What’s more, researchers noted that the risk for disease, SUDS, and mental illness increased significantly with each additional ACE that a participant reported. When attempting to conceptualize experiences that would impact the child’s emotional, behavioural, and physical development, the Kaiser-Permanante researchers offered a long list of ACEs that included abuse of the child (sexual, physical, and emtional), household challenges (substance use in the household, mental illness in the household, (step)mother treated violently, parental separation or divorce, and incareceration of a household member), and neglect (emotional or physical). Since this initial study was published, many more have supported the findings. Some studies have expanded on the impact of ACES while others have provided us with reasons why ACEs have such an impact on the individual. UNDERSTANDING ACES’ IMPACT One way to conceptualize the why behind the impact of ACES is to understand how the childhood environment impacts the development of certain personality traits that have been positively linked to SUDs. Notably, “childhood maltreatment may not only trigger the development of maladaptive emotion regulation skills but also disrupt goal-oriented self-regulation skills and delay the development of prosocial behavior” causing significant, persistent changes to a person’s adjustment system and negative effects on their personality traits and behaviour (5). Such changes impact the formation of pathological personality traits such as instrumental aggressiveness, thought disorder or unrealistic beliefs, impulse control problems and acting out tendencies. The human body, in its glorious ability to adapt, makes adjustments to the very neural pathways of the developing child who has been exposed to trauma and adversity. The effect of childhood trauma has been noted in both the hormonal system through the hypothalamic– pituitary–adrenal axis, and to the structural and functional systems of the hippocampus, amygdala and cerebellum (6). These neurobiological changes are thought to occur in childhood as a reaction to adverse events. And, importantly, the changes persist into adulthood. Some of the neural structures affected play large roles in controlling aggressive behaviour, like the cerebellum and amygdala. Others are key in behaviour and behavioral inhibition such as the hippocampus. If ever there was an example of adding insult to injury, the affected individual appears to be at greater risk for other trauma after these changes in personality and behaviour occur, as these maladaptive traits increase the likelihood of more negative life events. EARLY CHILDHOOD ATTACHMENT Looking at how ACEs alter our physiology is only one of the fields of research that’s showing promise. Other research has focused on the impact of early attachment as the guiding principle behind the behavioural changes related to ACES (7). Attachment theory postulates that in the first years of life, human children seek to find attachment in their caregivers. Securely attached children experience caregivers who (relatively) consistently meet their needs with security and love. When children’s needs are not met consistently, and with insecurity and lack of safety, they respond with anxious/ resistant or anxious/avoidant behaviours. When bids for attachment are met with inconsistency from caregivers, disorganized attachment behaviour follows. Caregivers who sometimes respond caringly and sometimes ignore children or even respond with mistreatment, are priming children for disorganized attachment. In instances where the child does not have a consistent caregiver due to neglect, abandonment, or other unstable relationships, disrupted attachment occurs. Many of the caregiver behaviours that occur with insecure attachment intersect with those of the ACES study. Neglect, inability to be present with the child physically or emotionally, and abuse can be seen in both ACES and negative attachment experiences. BRINGING NEW KNOWLEDGE TO PARAMEDICINE The medical community’s understanding of SUDS has evolved considerably over the past two decades. Yet, in paramedicine we’ve been slow to incorporate this new knowledge into our assessment and treatment planning when caring for people who use substances. What does bringing this new information into paramedicine look like? One possibility is that we examine our own lives and experiences. It’s possible that our own personal experiences with ACEs or trauma can impact how we appraise the behaviour of others. We may have developed our own coping mechanisms or behavioural traits that impact our approach to others. It may also be that our experiences with years of ineffective anti-drug campaigns have vilified those who use substances as losers and criminals, people who cannot be trusted or valued. Such moralizing is an effective social tool for marginalizing people whose behaviour isn’t understood. But, now that we have much more Studies about ACEs have shown an association between childhood experiences and a range of adult health issues. 15 knowledge of the mechanisms that introduce substance use disorders into peoples’ lives, we can critically look at our approaches to health and substance use to see if they align with this new knowledge or if they are merely beliefs. As medical professionals we have a duty to provide appropriate care for our patients, and this includes working to better understand the current knowledge of SUDS. REFERENCES 1. McKiernan, A. (2017). Supporting Reintegration in Corrections by Addressing Problematic Substance Use, Ottawa, Ont.: Canadian Centre on Substance Use and Addiction. https://www.ccsa.ca/sites/default/ files/2019-04/CCSA-Reintegration- Corrections-Problematic-Substance- Use-Environmental-Scan-2017-en. pdf 2. Chandler, R. K., Fletcher, B. W., & Volkow, N. D. (2009). Treating drug abuse and addiction in the criminal justice system: improving public health and safety. JAMA, 301(2), 183–190. https://doi.org/10.1001/ jama.2008.976 3. Tilson, E. C. (2018). Adverse childhood experiences (aces). North Carolina Medical Journal, 79(3), 166–169. https://doi.org/10.18043/ ncm.79.3.166 4. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., Marks, J. S. (1998). Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. American Journal of Preventive Medicine,14(4), 245-258. doi:10.1016/s0749-3797(98)00017-8 5. Centers for Disease Control and Prevention. (2021, April 6). About the CDC-Kaiser Ace Study |Violence prevention|injury Center|CDC. Centers for Disease Control and Prevention. Retrieved December 6, 2021, from https://www.cdc.gov/ violenceprevention/aces/about.html. 6. Choi, J. Y., & Park, S. H. (2018). Childhood Maltreatment as Predictor of Pathological Personality Traits Using PSY-5 in an Adult Psychiatric Sample. Journal of Personality Disorders,32(1), 1-16. doi:10.1521/ pedi_2017_31_282 7. Pos, K., Boyette, L. L., Meijer, C. J., Koeter, M., Krabbendam, L., & Haan, L. D. (2016). The effect of childhood trauma and Five-Factor Model personality traits on exposure to adult life events in patients with psychotic disorders. Cognitive Neuropsychiatry,21(6), 462-474. doi:1 0.1080/13546805.2016.1236014 8. Jamieson, K. (2021, July 16). Aces and attachment: Why connection means everything. Center for Child Counseling. Retrieved December 7, 2021, from https://www. centerforchildcounseling.org/aces- and-attachment-why-connection- means-everything/. 9. Lanius, R., Vermetten, A., and Pain, C. (2010). The Impact of Early Life Trauma on Health and Disease: The Hidden Epidemic. Cambridge University Press 10. Public Health Agency of Canada. (2020). Communicating ABout Substance Use in Compassionate, Safe, and Non-stigmatizing Ways. MInister of Health. https://www. canada.ca/content/dam/phac-aspc/ documents/services/publications/ healthy-living/communicating- about-substance-use-compassionate- safe-non-stigmatizing-ways-2019/ guilding-rinciples-eng.pdf ABOUT THE AUTHOR Deborah Cooper, BA, MA, RP (Qualifying), PCP, has been a paramedic in Kingston Ontario since 2003. She recently completed her Masters in Counselling Psychology and is a Registered Psychotherapist (Qualifying). Between working as a paramedic and seeing psychotherapy clients, Deb shares her advocacy for marginalized populations wherever possible. Contact Deb at deborah_e_cooper@icloud.com16 EPIGENETICS- IMPLICATIONS FOR MENTAL HEALTH BY CHRIS FARNADY Epigenetics is the field of study concerned with cellular variations triggered by external and environmental factors that toggle genes “on” and “off”. The changes occur in the phenotype of genetic expression without associated changes in the DNA sequence or genotype. The term “epigenetic” was coined by biologist C.H. Waddington in the 1940s in an effort to describe how “growing cells acquire and maintain their identity through changing developmental stages” [1]. Considered for a moment muscle cells, once differentiated, they continue to divide into muscle cells, kidney cells into kidney cells, despite having all started from one universal cell; in the end they carry the same DNA after cell division is completed [1] and because all cells continue to have the same chromosomes, the same set of genes, as well as the same DNA sequencing, Waddington speculated there existed an “epigenetic” effect [1]. The term “epigenesis” draws its roots from a Greek noun meaning “extra growth” and dates back to the seventeenth century. The concept of extra growth became the basis for Waddington’s use of the adjective “epigenetic” in relation to the additional observed effect beyond the basic genetic effect. [1]. In the decades that followed, scientists were able to answer Waddington’s central questions by discovering that cells remember their states (e.g., muscle states, kidney states) through specific types of attachment to their DNA. There exist several mechanisms through which epigenetics operate: DNA methylation, histone modifications and non-coding RNAs [2, 3]. DNA METHYLATION DNA methylation was first recognized in the 1970s and is the most well- characterized epigenetic modification and the best-studied epigenetic modification in the context of altered environment [2, 3]. This modification common in mammalian genomes, Zheng and Xiao (2016) state that DNA methylation “constitutes a stable epigenetic symbol that can stable alter the expression of genes and transmit through DNA replication as cells divide and differentiate from embryonic stem cells into specific tissues and is essential for normal development [2]. It is also associated with a number of important processes, some of which include genomic imprinting, X-chromosome inactivation, the suppression of repetitive elements and carcinogenesis. Histone Modification Histone modification can influence gene expression by altering chromatin structure. Modifications are suggested to have an effect on chromosome structure as well as function, especially during the process of transcription and chromatin remodeling. Zheng and Xiao (2016) note that core modifications of histones may also act on DNA templated processes, such as replication and transcriptional processes and effect nucleosomal structure [2]. NON-CODING RNAS MicroRNAs (miRNAs) and Non-coding RNAs are noted to be the most recently discovered and important epigenetic modification. The modulations of miRNAs can facilitate some key developmental processes such as cell proliferation, cell line differentiation and programmed cell apoptosis, cell cycle control, and cellular metabolism [2]. Numerous studies have investigated the relationship between miRNA and epigenetic regulations in diseases such as cancer, diabetes, diseases of neurologic and inflammatory etiologies as well as aging. Despite a lack of clear understanding in the underlying mechanism, miRNA dysregulation has been noted in all of the stated pathologies. The hypothesis is that miRNAs contribute to the formation of disease via epigenetic regulations, leading to miRNA modulation as a new therapeutic approach currently being extensively investigated in various disease processes [1, 2, 3]. FETAL PROGRAMMING HYPOTHESIS The relationship between the quality of early life environment and future risk of disease in later life was first proposed by Forsdahl in 1977. Forsdahl discovered that the infant mortality rate positively correlated with an increased risk of cardiovascular diseases in middle age. However, it wasn’t until 1989 that Baker and his colleagues noted an inverses relationship between birth weight and increased cardiovascular mortality [2]. The most important studies to reveal the extent of epigenetic modification resulted from the infamous Dutch famine during the winter of 1944-1945 at the end of World War II. These studies examined the impact of maternal stress during this period, medical records revealed that female offspring exposed to a low-nutrient diet prenatally during the mother’s first trimester had a higher risk for both schizophrenia and breast cancer as adults. However, if the low-nutrient diet occurred during the second trimester, the offspring had a higher rate of lung and kidney issues. Additionally, low-nutrient diet occurring in the late stage of gestation brought about lower birth weight as well as an increased risk of obesity, cardiovascular disease, insulin resistance and hypertension later in life compared with unexposed individuals (442 adults who, lived through the famine versus a control group of 463 adults) [1,2, 3, 4 – Kennedy et al., 2014). THE MENTAL HEALTH CONTEXT Epigenetics in the context of mental health is the basis for transgenerational trauma. There exist many studies that have examined the offspring of adults with histories childhood abuse, survival of war, and other forms of trauma leading to post-trauma stress revealing a heritability effect. For example, Yahyavi, Zarghami and Marwah (2014) reported in their work that, “the offspring were more likely than others to develop PTSD through adverse 18 maternal epigenetic- related experiences during pregnancy” [5]. Yehuda et al. (2014) revealed in their study of 38 women who were pregnant at the time of the World Trade Centre attacks in New York City on September 11, 2001 and who witnessed the events, “demonstrated greater susceptibility to PTSD and lower levels of cortisol than members of a control group” [6]. It was also noted that their offspring were found to have had lower levels of cortisol, an important hormone that assists recovery from trauma [6]. INDIRECT TRANSGENERATIONAL EPIGENETICS INHERITANCE The previously-noted studies demonstrate for us that epigenetic effects can be observed in the offspring of parents who have survived or witnessed stressful experiences, notably events such as the Holocaust, the Hungarian revolution of 1956, the September 11 attacks, famine and other disasters. However, is it possible for those effects to be passed on to a third or fourth generation? In short, the answer is yes. In order for direct biological effect to occur, the affected DNA would have to be located in the “germ” cell – either the sperm or the egg. Furthermore, according to Hackett et al. (2013), the DNA within the germ cell would also have to survive what is described a the “reset” at conception [7]. Tang et al. (2015) note that under usual circumstances there are two known “cleansing and resetting” stages which remove all tags. The first stage occurs during the generation of the germ cell, the second stage occurs just after fertilization, before the implantation of the embryo [8]. While the success of the “cleansing” and “resetting” stages are noted to be rare, the multi-generational epigenetic effect that is most important in the context of mental health is the concept, “that methylation of DNA in a traumatized parent may result in behaviours around the offspring that cause similar methylation patterns anew in one or more generations” [1]. The studies that best support this concept often examine Holocaust survivors involving effects on their grandchildren. For example, Yehuda (2011) demonstrated that the children and grandchildren of 32 men and women who had survived the Holocaust were compared to descendants of Jewish parents who lived abroad during the Second World War. The members of the first group of parents had been tortured, imprisoned in concentration camps, or had remained hidden for several years. The members of the second parental group however had not experienced any of these traumatizing events. The findings of the comparison revealed that the children and grandchildren of Holocaust survivors demonstrated symptoms of post- traumatic stress disorder; more so in the cases where the mother had been the only survivor, but even if the father (and not the mother) had been oppressed by the Nazis [9]. The explanation provided by Yehuda with respect to the epigenetic effects on the grandchildren of Holocaust survivors noted that, “one region of a gene has been associated with the hormone cortisol, associated with the ability to recover from stress and trauma. Hypomethylation of this gene was found for both the children and grandchildren, but not members of a control group.” [9]. It was also noted however that these children and grandchildren were being raised within their respective families, therefore it is possible the epigenetic markers had been reinforced by behavioural interactions with the affected parents [9]. DIRECT TRANSGENERATIONAL EPIGENETIC TRANSMISSION OF TRAUMA The most frequent demonstration of direct epigenetic transmission by germ cells across multiple generations has been noted to occur through toxic exposures. For example, men who begin smoking before puberty are noted to have a higher chance of fathering obese sons versus men who started smoking after puberty [1]. Epigenetic effects have also been documented as a result of environmental toxins, for example vinclozolin – an endocrine disrupter; Krippner and Barrett (2016) noted a DNA methylation pattern of the sperm for three generations following the initial exposure. DNA had been altered at specific promoter regions. Furthermore, third generation epigenetic alteration of sperm was also observed following exposure to pesticides, plastics, dioxin, and jet fuel. Perhaps more relevant to the concept of transgenerational effects of trauma can be drawn from a mouse experiment conducted by Dias and Ressler (2014) and highlighted by Krippner and Barrett (2016). Their goal was to examine how the olfactory experience of male parent mice may influence their offspring. The parent mice were noted to have been conditioned to manifest fear when they smelled cherry blossoms. The investigators accomplished this by pairing the odor with a shock to the foot, subsequently the fear changed the organization of the animal’s nose which led more cells becoming sensitive to that particular smell. The resulting structural changes was then noted in future generations as a “fear-generated “startle” when the mice were exposed to the odor” while their reaction to other odors was not affected [1]. Dias and Ressler (2014) noted that the pups of these parent mice were found to be afraid of the odor and passed that fear down to their pups, suggesting that, ‘the experiences of a parent, before conceiving offspring, markedly influence both structure and function in the nervous system of subsequent generations” [1]. Implications for Evolution and Mental Health Treatment We understand that genes contained in DNA are the standard way that biological information is transmitted from one generation to the next. However, there is mounting evidence pointing epigenetic “tag” attachment to DNA deepening the mechanism for inheritance. Furthermore, transgenerational transmission of epigenetic programming is said to not violate the major theses of biological evolution. The mechanisms of DNA methylation and histone modification are noted to still be “inherited under the aegis of natural selection” while at the same time the rate of change due to epigenetics can potentially be more precipitous than rates due to adaptive mutation [1]. The behavioural effects of epigenetics are noted to be a rapidly growing area of research leading to the emergency of many implications over the next several decades. With respect to mental health treatment, the most important consequences currently pertain to psychotherapy in the conceptualization that psychopathology is, “the knowledge that severe trauma may be passed along through direct germ line alterations rather than simply through parenting”. This is an important concept to consider for anyone working with children adopted out of warzones or dysfunctional families because these patients may be reacting to the trauma experienced by their parents even if the children have not been raised by their parents [1, 9]. Currently, there are not human treatment implications However, there may be some on the horizon soon. One such study has already demonstrated that maternal stress in mice affecting subsequent generations can be “erased” through the infusion of l-methionine – a widely available amino acid in oral form found at health food stores. L-methionine was noted to eliminate both hypomethylation patterns in DNA and the trauma-produced behaviours in 19 offspring mice. This finding has significant implications for human dietary and pharmacological intervention in the face of pending and future studies. Furthermore, methylation studies of cortisol-associated genes or micro-RNA attachment may in fact become a way of assessing whether therapeutic interventions are working [1]. In the meantime, we should focus our attention on understanding transgenerational trauma and lend more empathy towards the patients and clients (as well as ourselves) we encounter in our everyday practice. “In the real world there is no nature vs. nurture argument, only an infinitely complex and moment-by-moment interaction between genetic and environmental effects” – Dr. Gábor Maté REFERENCES 1. Krippner S, Barrett D. Transgenerational Trauma: The Role of Epigenetics. Journal of Mind and Behavior [Internet]. 2019 Dec 1 [cited 2021 Dec 1];40(1):53–62. Available from: https://search-ebscohost-com. ezproxy.tru.ca/login.aspx?direct=true &db=phl&AN=PHL2387309&site=eds- live&scope=site 2. Dincer Y, Zheng J, Xiao X. EPIGENETIC MODIFICATIONS AND DEVELOPMENTAL ORIGIN OF HEALTH AND DISEASES (DOHAD). In: Epigenetics: Mechanisms and clinical perspectives. New York, NY: Nova Biomedical; 2016. p. 1–14. 3. Dincer Y, Baykara O. EFFECTS OF OXIDATIVE STRESS ON EPIGENETIC MECHANISMS. In: Epigenetics: Mechanisms and clinical perspectives. New York, NY: Nova Biomedical; 2016. p. 17–30. 4. Kennedy BK, Berger SL, Brunet A, Campisi J, Cuervo AM, Epel ES, et al. Geroscience: linking aging to chronic disease. Cell [Internet]. 2014 Nov 6 [cited 2021 Nov 30];159(4):709–13. Available from: https://search- ebscohost-com.ezproxy.tru.ca/login.as px?direct=true&db=mnh&AN=2541714 6&site=eds-live&scope=site 5. Yahyavi ST, Zarghami M, Marwah U. A review on the evidence of transgenerational transmission of posttraumatic stress disorder vulnerability. Revista Brasileira de Psiquiatria [Internet]. 2014 Jan [cited 2021 Nov 30];36(1):89–94. Available from: https://search-ebscohost-com. ezproxy.tru.ca/login.aspx?direct=tru e&db=a9h&AN=94937415&site=eds- live&scope=site 6. Yehuda R, Daskalakis NP, Lehrner A, Desarnaud F, Bader HN, Makotkine I, et al. Influences of maternal and paternal PTSD on epigenetic regulation of the glucocorticoid receptor gene in Holocaust survivor offspring. American Journal of Psychiatry. 2014;171(8):872– 80. 7. Hackett JA, Sengupta R, Zylicz JJ, Murakami K, Lee C, Down TA, et al. Germline DNA demethylation dynamics and imprint erasure through 5-hydroxymethylcytosine. Science. 2013;339(6118):448–52. 8. Tang WWC, Dietmann S, Irie N, Leitch HG, Floros VI, Bradshaw CR, et al. A Unique Gene Regulatory Network Resets the Human Germline Epigenome for Development. Cell [Internet]. 2015 Jun 4 [cited 2021 Dec 1];161(6):1453–67. Available from: https://search-ebscohost-com.ezproxy. tru.ca/login.aspx?direct=true&db=eds elp&AN=S0092867415005644&site=e ds-live&scope=site 9. Yehuda R. Are different biological mechanisms involved in the transmission of maternal versus paternal stress-induced vulnerability to offspring? Biological Psychiatry. 2011;70(5):402–403. ABOUT THE AUTHOR Chris is a graduate of Loyalist College’s Primary Care Paramedic program (Bancroft, ON), Durham College’s (Oshawa, ON) Advance Care Paramedic and currently pursuing his Bachelor of Health Science from Thompson Rivers University. Chris began his prehospital care career in 1997 working as an EMR in Alberta’s oil and gas industry and has enjoyed the privilege of working as a Primary Care and Advanced Care Paramedic in Ontario, Northern Manitoba and Alberta. In April 2018 Chris accepted a position with Advanced Paramedic Ltd. and returned to Northern Alberta as an Advanced Care Flight Paramedic for Alberta Health Services’ transport medicine program. In his time away from work, Chris enjoys being at home with his wife and two children. Chris can be reached for comment at chris.farnady@gmail.com.Next >