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California unveils ACEs Aware initiative to screen for trauma

 

Will screening for adverse childhood experiences (ACEs) in California be mandatory? No, but it’s recommended.

Will there be training for physicians and staff on how to screen? Yes.

Who will be reimbursed for screening patients in California? Physicians who serve patients in the state’s Medi-Cal program — for now.

For more answers to these and other questions that surfaced during a Dec. 4 webinar introducing Californians to a new statewide initiative, read on.

Come January 1, California will become one of the first states in the country to reimburse doctors to screen their patients for adverse childhood experiences. In preparation for this sea change, California’s Surgeon General, pediatrician Dr. Nadine Burke Harris, and the Department of Health Care Services Medical Director Dr. Karen Mark unveiled the state’s newly-launched ACEs Aware initiative, and laid the groundwork for why this new recommendation is a call to action.

For each child and adult in the state’s Medi-Cal program who are screened for ACEs, physicians will be eligible for a $29 supplemental payment. (For information on training and screening tools, visit the ACEs Aware initiative website.)

And why would doctors want to screen their patients for trauma? Burke Harris, a trailblazer promoting universal ACEs screening for children, referred to the study and data that had upended her own approach to patient care, which she chronicled in her book The Deepest Well and her Ted Talk on ACEs.

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Dr. Nadine Burke Harris

“Here in California 62.7 percent of Californians have at least one ACE,” she said. ACEs refers to adverse childhood experiences, a term that came from the landmark 1998 CDC/Kaiser Permanente ACE Study, which tied 10 types of childhood adversity — such as physical, emotional or sexual abuse or living with a parent who abuses alcohol or is diagnosed with depression or other mental illness — to an increase in chronic disease, mental illness, violence and being a victim of violence in more than 17,000 adults. Based on a subsequent statewide study, 17.6 percent of Californians, she explained, have an ACE score of 4 or more. Most US states have done their own ACE surveys, and the data are comparable across the country.

Burke Harris pointed to data that show the link between ACE scores and health risks, noting dramatic increases in risk among those with ACE scores of 4 or more in nine out of the 10 leading causes of death. An ACE score of 4 or more, she explained, doubles the risk of heart disease, more than doubles the risk of cancer, and the risk of chronic respiratory disease.

But, counseled Burke Harris, those health risks need not be destiny. With early detection through ACEs screening and interventions, she explained, they can be reduced or prevented. The culprit, according to research, explained Burke Harris, is toxic stress: “The science shows us that the mechanism by which early adversity leads to health, mental health, and social outcomes has to do with the toxic stress response,” the result of repeated activation of the “fight, flight and freeze” response.

In response to a question asking if private insurance will be required to reimburse for ACEs screening in the future, Burke Harris said, “Recognizing that this is a pretty groundbreaking initiative, we wanted to start by offering an incentive payment for providers in the Medicaid population. But we recognize that this is only a first step. Ultimately, we want ACE screening to be the standard of care for everyone.”

For more information about the initiative, visit: ACEsAware. Here is a link to the webinar recording.

 

 

 

 

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To screen for ACEs, the CDC lists the SEEK as a screening that peds can do  in the office. I have done SEEK formally and ACEs informally. I think SEEK is easier and would be far more acceptable to patients especially if the screening is set up to be more assembly line.  

Does California allow doctors to screen with the SEEK and be compensated for screening? 

https://www.cdc.gov/violencepr...eventingACES-508.pdf

 
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The intrauterine time period and the first two years of life  (The First 1000 days, a phrase from the AAP) are the most important to preventing childhood adversity because of the essential role of the early right brain development (emotion regulation) during the first years of life especially intrauterine and year 1. 

As a pediatrician who did not have an attuned caregiver  (she suffered incest and complex PTSD)  who's brother was misdiagnosed with schizophrenia when actually suffering from the developmental effects of severe abuse and neglect and the resulting disorganized attachment in the first year of life (he also amassed a high ACE Score because he lacked a protective or interested caregiver), I know from lived experience how difficult it is to recover from this.  Prevention has to include in some way, helping primary caregivers of infants (mothers) regulate strong emotional responses to their baby when she cries (or laughs).  I do wonder what pediatricians will do with the kids who screen positive on the 10 question ACE screening?   In my experience, it is not enough to send kids who have been traumatized in the parent-child relationship  to treatment as usual at most non-specialized CMH services.  The effects of attachment trauma are too complex for psychotropic drugs (or poly-pharmacy) to treat and this trauma is stored in the non-verbal right brain so how can a cognitive therapy, especially a time-limited, manualized approach treat this kind of trauma?  

It is important for all pediatricians to be aware of the affects of trauma on the developing right brain.   We would do so much better if we knew about the work of Dr. Schore.  This is my honest belief.  

It is the interactive relationship  between the infant and the mother (or primary caregiver, generally the mother) that determines the function of the executive system, emotional regulation, the limbic system, the neuroendocrine and immune systems, and the ultimate outcome of child development for good or for bad.  

The roots of violence and so much pain and suffering come from our earliest years.  Violence is basically the result of an inability to regulate strong emotions.  The ability to regulate strong emotions comes from a secure attachment in infancy. 

Here is Dr. Willis (he used to be at the Children's Clinic in Portland, Director of VHN at HRSA) replying  to Dr. Schore's presentation.  https://www.youtube.com/watch?v=qkJe1dwmbM4

And here is the presentation of Dr. Schore's that he is referring to....   " All our sons: The developmental Neurobiology and Neuroendocrinology of Boys at Risk. 

https://www.ncbi.nlm.nih.gov/pubmed/28042663

 

https://www.youtube.com/watch?v=P451kiWSBic

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