Customizing ACEs Screening for High School Students in Santa Rosa, CA

Elsie Allen High School student Anabel (l), and Erin Moilanen, school health clinic nurse practitioner (r)

 

When students show up for an appointment at the Elsie Allen Health Center, which is located on the Elsie Allen High School campus in Santa Rosa, CA, one of the first things they do is answer 16 questions about the trauma they’ve experienced during their lives.

 

That’s because research has shown a direct link between adverse childhood experiences — ACEs – and the adult onset of chronic disease, mental illness, violence and being a victim of violence. The CDC-Kaiser Permanente Adverse Childhood Experiences Study (ACE Study) — which has been replicated by 29 states — also show that ACEs create mental and physical health risks that continue to crop up over a person’s lifetime if not adequately addressed.

 

These can include developmental delays early in life, mental health and academic achievement issues in childhood, involvement in the juvenile justice system, and alcohol and drug abuse as a youth and adult.

 

The original ACE Study measured 10 types of childhood trauma, those that occurred before the age of 18. They are physical, verbal and sexual abuse; physical and emotional neglect; a household member with mental illness, or who has been incarcerated or is abusing alcohol or other drugs; witnessing a mother being abused; losing a parent to divorce or separation. (Got Your ACE Score?)

 

The researchers found that the higher a person’s ACE score, the greater the risk of health and social issues. For example, compared with someone who has an ACE score of zero, a person with four ACEs is 12 times more likely to attempt suicide, seven times more likely to become an alcoholic, and twice as likely to have heart disease, according to the data.

 

At Elsie Allen Health Center, the students answer 16 questions instead of the original ACE Study 10-question survey.

 

That’s because the questionnaire was designed by the clinic staff to address the kinds of experiences – such as homelessness and pregnancy – that are common in their students.

 

Seventy percent of the students at Elsie Allen High School are Latino, and most of their parents work in low-income jobs. Most of the school’s 1,100 students are covered by insurance and Medical, and there is a sliding scale for older teens. The clinic is part of Santa Rosa Community Health Centers.

 

Erin Moilanen, a family nurse practitioner, is one of the core staff, which also includes two therapists, a pediatrician, and a physician assistant. They began taking students’ ACEs histories a year and a half ago when Kaiser Permanente Northern California Region awarded the clinic a $50,000 grant to do trauma-informed care.

“We started with a six-question questionnaire called the Childhood Traumatic Events Scale, but we realized it didn’t cover a lot of traumatic experiences, and it didn’t ask specific questions. The kids are very concrete, and some didn’t even understand what trauma meant,” says Moilanen.

 

The result was that in the second year of the program – which was funded again with $50,000 from Kaiser – the staff modified the questionnaire to include 16 questions relevant to the experiences of the students they had seen the first year. (Here are the  ACESquestions they ask.)

 

Moilanen says that 20 students come into the clinic each day, but typically only between one and three of the students are new. They are asked their ACEs history on their first appointment, and then yearly. A therapist explains the ACEs form to them and why it is important: “Difficult things that happen to us can affect our choices and our health in the future.”

 

The kids get it, she says. Responses include “a lot of head nodding in agreement, looks of dawning understanding, and some ‘yeahs.’”

 

Moilanen says this is how she explains ACEs to the teens: “So I say something like, ‘We, the medical community, now know that when difficult things happen to us when we’re young, it can actually affect our health in the future, so we’re trying to ask kids when they’re younger to try to prevent some of the bad things from happening and help them have healthier lives.”

 

She adds, “I feel that the kids answer honestly. We all like to talk about ourselves, and a lot of these kids don’t have people who are listening to them.”  Asking kids about their ACEs has had a greater impact on her work than any other information they ask the students for, such as asking about STDs or dental health, she says, because it helps develop better relationships with the students.

 

Because of construction issues that kept the clinic closed for a few months last year, only 200 students were asked about their ACEs history. This year, Moilanen says, they’ve had far more new patients since they were open during the summer. They have neither the time nor the money to analyze the data, which they have turned over to Kaiser.

 

As a result of asking students about their childhood adversity, however, the entire staff is “a bit more understanding about some of the behaviors of the kids. And I think we encourage counseling a lot more than we ever did before,” says Moilanen. The staff has also done their own ACE scores and talked about handling vicarious trauma. Information for staff counseling is posted throughout the clinic as a result.

 

“There’s a different level of honesty and connection with the kids,” adds Moilanen, who trained, along with the other grantee staff, at Kaiser workshops on trauma-informed care. “It feels like it’s going to make a bigger impact. Thinking back to my own experiences as a teen, it’s far more important to talk about these experiences earlier and prevent negative results from happening in the future.”

 

The clinic is just starting to get the school itself involved by getting permission to speak to the teachers about ACEs. Additionally, the clinic is turning a large room into a lounge area for the 100 or so students who visit the clinic each day so they’ll have a place to talk, get a free condom, or piece of fruit, and to share their experiences.

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It sounds like such a positive direction. And because it's big picture it has far more effects in other areas.

Proof again why ACE screening should be at the top of the list.

 

"The ACEs screen has had greater impact on her work than any other screening done in the clinic used in the past, such as screens for STDs or dental health, she says, because it helps develop better relationships with the students".

 

When the nurse practitioner said explaining the ACE study can take too long to explain and the kids don't really care, I wonder if having students or clinical staff making a video about it that others in the school can access could help? It's the slow dawning of the implications that takes a while to really sink in.

Hi I cannot find the attachment for the 16 questions.  Are there any logistical problems. I ask because when our FQHC put counsellors in the local schools, the teachers sent over kids who seemed to be having trouble and there were cases where the counselor found out "Jamie is being mollested by Uncle Jim".   Some parents became irate and now the parents have to first consent to counseling. Our area is very rural, very high poverty,  no mental health services and 3-4 hours away from any, very few folks make a high income and a very conservative culture (lots of Fox News) so just tring to see how this could be used or not here I have been to Santa Rosa and the culture is very different. Can I see the 16 questions being asked? Thank you

Since you asked, here is the 16-part questionnaire used by the clinic at Santa Rosa High School. I'm including a version in Spanish as well.

 

Health and wellness can be affected by difficult life experiences. We want to help you if you answer yes to any of the questions below.

It’s ok not to answer any questions that seem too much for you. We promise to keep your answers confidential, unless there’s actual physical or sexual abuse taking place (or past sexual abuse that wasn’t reported).

1. Have you experienced being sworn at, insulted frequently, or been put down verbally? Yes/No

2. Has your parent ever experienced being pushed, grabbed, slapped, or had something thrown at them, or been hit so hard that they were injured or had a mark? Yes/No

Did you see this happen? Yes/No

3. Have you been the victim of violence (physical abuse, mugged or assaulted)? Yes/No

4. Has anyone fondled, touched you inappropriately, or sexually abused you? Yes/No

5. Have you often felt that no one in your family loved you, or looked out for you, or felt close to you? Yes/No

6. Have you ever experienced not having enough to eat, had to wear dirty clothes, or had no one to protect you? Yes/No

7. Have you ever lived with someone that was a problem drinker or alcoholic, or had a drug addiction problem? Yes/No

8. Were your parents/guardians ever too drunk or high to take care of you? Yes/No

9. Were your parents/guardians ever separated or divorced? Yes/No

10. Have you ever had a household member who was mentally ill, depressed, or committed suicide? Yes/No

11. Have you ever had a household member go to jail/prison or be deported? Yes/No 12. Have you ever experienced homelessness or been in foster care? Yes/No
13. Have you had to move or change schools a number of times? Yes/No
14. Have you experienced the death of a very close friend or family member? Yes/No 15. Have you been extremely ill or injured? Yes/No

16.Have you ever been pregnant or gotten someone pregnant? Yes/No

17. Is there anything else you’d like to tell us? _______________________________________________________________________________________________________

If you had one or more of these experiences, we can help you. Your provider or staff member may go over these questions with you and offer support and resources to help you. Please ask if you feel you may need more information or help.

Name: _________________________________________________________ Birth date: _______________________________

La salud y el bienestar se pueden ver afectados por haber pasado experiencias difíciles en la vida. Queremos ayudarle si su respuesta es sí a cualquiera de estas preguntas.

Está bien si no contesta cualquier pregunta que pueda ser demasiado para usted. Nos comprometemos a mantener sus respuestas de una forma confidencial, a menos que haya abuso físico o que esté ocurriendo abuso sexual (o abuso sexual en el pasado que no fue reportado)

1. ¿Alguna vez ha pasado por situaciones donde le han maldecido, le han insultado con frecuencia, o le han menospreciado verbalmente (le han dicho que usted no tiene ningún valor)? Sí/No

2. ¿Su madre/padre alguna vez pasó por situaciones donde fue empujado, agarrado, cacheteado, o le tiraron algo encima, o le pegaron tan fuerte que le lastimaron o le dejaron marcas en el cuerpo? Sí/No

¿Usted vio cuando esto pasó? Sí/No

3. ¿Ha sido usted víctima de violencia (abuso físico, asalto para robarle o asalto para agredirle)? Sí/No

4. ¿Alguien le ha manoseado, tocado de forma que no es apropiada, o ha abusado sexualmente de usted? Sí/No

5. ¿Ha sentido con frecuencia que ninguno en su familia le ha querido, le ha cuidado, o se ha sentido cercano a usted? Sí/No

6. ¿Alguna vez ha pasado por situaciones donde no tuvo suficiente para comer, tuvo que vestirse con ropa sucia, o no tuvo a nadie que le protegiera? Sí/No

7. ¿Alguna vez ha vivido con alguien que es problemático cuando bebe alcohol, con un alcohólico, o con alguien que tenía un problema de adicción a las drogas? Sí/No

8. ¿Alguna vez estuvieron sus padres/encargados demasiado borrachos o drogados como para cuidar de usted? Sí/No

9. ¿Alguna vez estuvieron sus padres/encargados separados o divorciados? Sí/No

10.¿Alguna vez hubo un miembro en su familia que estaba mentalmente enfermo, deprimido, o que se suicidó? Sí/No

11. ¿Alguna vez ha sido un miembro de su familia enviado a la cárcel/prisión o fue deportado? Sí/No

12.¿Alguna vez ha estado sin hogar o con una familia bajo cuidado temporal (foster care)? Sí/No

13.¿Ha tenido que mudarse de casa o cambiarse de escuelas muchas veces? Sí/No

14.¿Se le ha muerto un amigo muy cercano o un miembro de su familia? Sí/No

15.¿Alguna vez ha estado gravemente enfermo o lastimado? Sí/No

16.¿Alguna vez ha estado embarazada o ha dejado a alguien embarazada? Sí/No

17. ¿Hay algo mas que desea decirnos? _______________________________________________________________________________________________________

Si usted pasó por una o más de estas experiencias, nosotros podemos ayudarle. Su proveedor o un miembro del personal puede revisar estas preguntas con usted y ofrecerle el apoyo y los recursos para ayudarle. Por favor pregunte si siente que necesita más información o ayuda.

Nombre: ________________________________________________ Fecha de nacimiento: _________________________ 

Thanks for the questions they are really great and I know you all really don't need my suggestions but I'd be curious about food insecurity, seeing siblings beaten and the first question would get at home emotional abuse and school verbal abuse, cyber bullying though would also be interesting.  Thanks so much for putting out the questions!!!

Great first step - what services are you offering when a number of ACEs are identified?  Have you considered NACoA's  Celebrating Families! program?  It has been used in several schools in the Bay Area.  

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