Dr. Heyman Oo, a 34-year-old primary care pediatrician, first learned about the science of adverse childhood experiences in medical school at a grand rounds held around 2012 at Rady Children’s Hospital in San Diego, which she attended from 2009 to 2014. The presenter was none other than Dr. Nadine Burke Harris, a pediatrician who went on to become California’s first Surgeon General. The founder and former director of the Center for Youth Wellness drew millions of views for her TED talk on ACEs science and its effect on children.
The term ACEs, which stands for adverse childhood experiences, comes from the groundbreaking CDC-Kaiser Permanente Adverse Childhood Experiences Study (ACE Study), first published in 1998 and comprising more than 70 research papers published over the following 15 years. The research is based on a survey of more than 17,000 mostly white, middle- and upper middle-class adults with great heath care, and was led by Drs. Robert Anda and Vincent Felitti. The study linked 10 types of childhood adversity — such as living with a parent who is mentally ill, has abused alcohol or is emotionally abusive — to the adult onset of chronic disease, mental illness, violence and being a victim of violence. Many other types of ACEs — including racism, bullying, a father being abused, and community violence — have been added to subsequent ACE surveys. (ACEs Science 101; Got Your ACE/Resilience Score?)
The ACE Study, which is an epidemiological analysis of childhood adversity, is one of the five parts of ACEs science, which also includes how toxic stress from ACEs affect a child’s brain, the short and long-term health effects of toxic stress, the epigenetics of toxic stress (how it’s passed on from generation to generation), and research on resilience, which includes how individuals, organizations, systems and communities can integrate ACEs science to solve our most intractable problems.
Oo was born in Burma (now Myanmar) and moved with her parents to Santa Clara, CA, when she was four. She and earned a bachelor’s at Yale in psychology and neuroscience, a medical degree at UC San Diego, and a master’s in public health at Harvard University’s T.H. Chan School of Public Health. Sitting in that grand rounds presentation, Oo remembers thinking “that the work the Center for Youth Wellness was doing — trying to break the cycle of trauma and work upstream to prevent long-term negative health consequences — was awesome.”
“What I remember from my entire pediatric rotation," she continues, "was how focused physicians were on preventing illness before it occurs, the celebration of the resilience of childhood, and the idea that advocacy — whether it was for developmental support services in schools or healthier food options in the community — was part of the DNA of being a pediatrician.”
Oo’s work has come full circle from that single presentation from Burke Harris. In 2017, the Marin Community Clinics, a non-profit that serves the low-income communities of Marin County, CA, with several clinics throughout the area, received a small grant from the Center for Youth Wellness to start screening for ACEs. Oo was the champion for this project. The pilot included a few pediatricians from each clinical site as well as members of the obstetrics department.
For pregnant women, the clinics screened mothers because of the effect of trauma — such as intimate partner violence — on the fetus. Children were screened starting at the nine-month well-child visit, then at 30 months, and then screening was expanded to include any new patients under the age of 12.
Marin Community Clinics developed a consolidated ACEs screener with simpler language that had seven questions instead of the original 10 ACEs questions to make it easier for the parents to fill out the form. Basic questions included queries about violence in the home, parental separation, and difficulty providing the child with enough food and clothing.
For two years during the pilot program, Oo says the clinics screened on average 25 children per month and had a total positive score rate of 19% over the course of the year. A positive score was considered to be 1 ACE or more, while negative scores were those reported to have zero.
“Before we rolled out the pilot,” says Oo, “we wanted to make sure necessary supports were in place for our providers. The big question and concern is always, ‘What do you do with a positive screen?’
“We are lucky to have co-located behavioral health providers for warm-handoffs. We also got a separate grant from First Five Marin to train our providers in Triple P (positive parenting program).” The clinics also partnered with local community-based organizations, including the Center for Domestic Peace, which helps families who experience domestic violence.
“Because we focused on babies in our screening,” says Oo, “we found a large number of children didn’t screen high due to their young ages. Moreover, for babies who had an ACE of 1 — say, a divorce — we found we could really make an impact and could potentially mitigate behavioral effects by educating mothers on the importance of things like positive parenting techniques, nutrition, and exercise.”
The surprising finding, she notes, was that “the fear of overwhelming the clinic’s mental health capacity was unfounded.” There were other ways to help develop resilience, support families, and educate them on the effects of trauma without a referral to behavioral health. “Not everybody wants or needs a therapist,” she says.
“Part of the healing process is about building relationships and fostering a supportive home environment,” she explains. “We have a nutrition program for kids. We have a stress management program for adults, which include modalities like mindfulness training, so parents can shore up their own sense of wellness so they can then support their kids.” Thus, much of the resilience-building revolves around education.
Marin Community Clinics has applied for a grant to extend its ACEs pilot by “using our own clinical staff and experience to develop best practices for on-the-ground training. The state ACEs training program is a great start, but there are nuances to implementing ACEs screening specific to each clinic,” says Oo. In the meantime, the clinics are conducting ACEs training for staff and then planning to hold regular, mini-debriefs. They plan to make their program a model for other community clinics in the state. The grant would allow them to scale their approach.
As for the future of ACEs, Oo says she “feels lucky to have come up in [my] career and training when the recognition of the mind-body physiology relationship is commonplace. For many years, the medical establishment had this divide between mental health and physical health. Now, it is all just health. It is quite a revolutionary idea, and I feel lucky to take for granted that it’s revolutionary, to accept that events that affect brain function, positively and negatively, can have lifelong epigenetic effects on the body.”
She adds, “It’s really inspiring to be working in primary care in the business of healing people when this shift is taking root. Addressing the social conditions that a patient brings with them into clinic — such as whether their life is so chaotic that they can’t afford to buy the food they need — is an integral part of practicing medicine.”