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Pediatric Symposium at National ACEs conference offers lessons learned and the way forward

 

To set in motion the Pediatric Symposium at the 2018 National ACEs Conference in San Francisco, Dr. Nadine Burke Harris, founder and CEO of the Center for Youth Wellness, told the audience of several hundred attendees that the American Academy of Pediatrics has made it very clear to its membership how critical it is that every pediatrician understand how toxic stress impacts the health of their patients. But, she said, when it surveyed its membership it found that only 11 percent knew about ACEs, and of those only 4 percent were screening their patients for toxic stress.

And then came the kicker: At the first National ACEs conference in 2016 very few pediatricians were screening for Adverse Childhood Experiences (ACEs), Burke Harris explained.  “Now more than 600 of you are doing this!” she said. 

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She reminded those attending, many of whom are members of CYWs National Pediatric Practice Community on ACEs (NPPC), that CYW’s “bold goal,” is essentially for a paradigm shift, one that would lead to universal ACEs screening within a decade. “My number one message today,” said Burke Harris, is:  This is doable!”

One way of building momentum around ACEs screening and intervention, according to Center for Youth Wellness Chief Medical Officer Jonathan Goldfinger is by speaking out publicly. When federal policy led to separating families, Goldfinger noted, “Nadine and [AAP President] Colleen Craft testified before Congress that this is wrong because we’re traumatizing children. We’re not saying this because we’re advocates, we’re saying this because the data is incontrovertible for health outcomes,” he relayed to a burst of applause.

And to reach the goal of universal screening another crucial piece, according to Dr. Monica Bucci, the director of research at the Center for Youth Wellness, is building scientific evidence that shows over time and with more specificity how toxic stress from ACEs harms health.  As an example, Bucci explained that research is underway into the best biomarker and behavioral measures to show the impact of toxic stress on an individual child, how feasible these tests are in a pediatric practice and how acceptable these tests are to parents. (To learn more about biomarker research, see this story.) 

While some areas of science into ACEs and toxic stress are still in process, there’s already solid research to show the benefit of building up support systems for parents to prevent ACEs in their children, according to Dr. Rachel Gilgoff, CYW’s interim clinical innovations researcher. The issue here is not the science, she explains. it’s more about raising awareness so that doctors ask parents the right questions. For example, to learn if a parent is isolated, she asks, “How often do we ask, ‘if you’re sick, who can bring  you chicken soup?’ We know that social integration has a dose-dependent health effect.”

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ACEs Screening: Lessons from pilot projects

To learn the nuts and bolts of how ACEs science works in pediatric practices, panelists from across the country who were part of the NPPC pilot study on screening for ACEs offered tips from the trenches.  “I would say get your senior leadership involved early on, and give them the science, find a champion and give them a reason to say yes,” said Dr. Andria Ruth of the Santa Barbara Neighborhood Clinics. The clinics’ Chief Operating Officer, Nancy Tillie, was also on the panel. Ruth said she had returned from the first ACEs conference declaring to Tillie “They had to train everyone in trauma-informed care.” But Tillie said she had already been won over by Nadine Burke Harris’s Ted Talk.

Dr. Mercie DiGangi did not have it as easy as Ruth in convincing leadership. Her immediate supervisor at Kaiser Permanente Southern California in Downey was all in, but then DiGangi, who is the regional chair for the Child Abuse Prevention Program, faced obstacles. ”Every group I had presented to within the Kaiser system had never heard of ACEs,” she said. The solution? Education.

DiGangi said after she gave presentations on ACEs and how ACEs affects their patients she had complete buy in. Then more pushback. They asked her, she said, ”How do we do it so providers don’t get stressed, and patients get the help they need?” DiGangi was ultimately allowed to pilot ACEs screening at her pediatric clinic, where patient’s families are educated about ACEs and offered counseling if they need support. The lesson? “Start large and scale down,” said Digangi.

 

 

 

 

 

 

 

 

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Hi Tina,

Thanks for writing in and raising valid concerns and questions. The idea of informed consent is so critical. When I interviewed Dr. Jack Shonkoff about biomarkers and behavioral markers and the work of the JPB Research Network on Toxic Stress, he raised several of the points you make about informed consent and also about how ACEs scores provide population level data. Here's the link to that story: https://www.acesconnection.com...silience-in-children.

On the question of the value of screening for ACEs, it makes sense that it would be highly problematic to screen for ACEs if the information is being used against patients.  

More random thoughts about office ACEs screening....

Everyone needs to know their ACE score - but we don’t necessarily need to be getting ACE scores in the doctor’s office only because this could put a person on a list to be discriminated against in the future or experience the violence of forced psychiatry. The ACE study is a population study and tells us that with a certain amount of trauma exposure during childhood- there is a certain amount of increased likelihood for a problem for ex - an ACE Score of 6 means you are at approximately 5000 percent increased risk for suicide, injection drug use and domestic violence - but it doesn’t tell anyone Tina’s or Nancy’s or Dean’s specific risk. It’s a population study (epidemiology) and your ACE score is not your destiny, by learning the neuroscience of trauma / adversity and the science of Resilience (Transcendence) we can heal ourselves and our communities. The greatest way to end addiction, violence and suicide is to reduce childhood adversity and increase individual, community and societal resilience. Everything we do, if we want a better world, should be thought out carefully with this goal and objective in mind. It’s doable.

 

I’m concerned about forced psychiatry on those most unable to defend themselves - those in foster care, in the courts. I see it all the time in Michigan. I also see how poorly we provide parents with truly informed consent about the benefits and risks of psychotropic drugs and as more and more kids are being cared for by PA’s and NP’s with little training in pediatrics or the art of taking the H &P - the lack of informed consent in psychotropic medication prescribing practices will likely increase as has Zithromax prescriptions increased for viral URIs. We (physicians) have a good capacity to gage the level of toxic stress an individual is exposed to with a standard psychosocial history. I learned in medicine that most of my ability to come to the correct diagnosis comes from the history. We just have to take one. We do not need to pursue how to get everyone's ACE score in the office, in fact it ultimately may not be the #TraumaInformed thing to do. Certainly, it may not follow the edict “Do No Harm.”

If you aren’t worred about forced psychiatry, great. You haven’t been violated by it but I have and it’s one of the most devastating abuses of medicine possible and is absolutely in no way #TraumaInformed. It is dehumanizing, degrading and disempowering. You have to submit to it to escape it, because you cannot possibly understand why you are panicked etc - you have a DSM -5 diagnosable condition and therefore are incapable of making medical decisions for yourself. Sounds familiar to those of you with a high ACE score I’m certain and like something we had to do to escape our abuser(s) as a powerless child racking up all those ACEs in the first place.

I can see other problems with ACE screening - since those with high ACEs are at greater population risk for early death, PTSD - folks could be denied life insurance, could be denied entry into the military and many people where I grew up have high ACEs and went into the military as the only way to escape poverty. We know ACEs are not destiny. It could be used to deny people the tight to a hunting rifle. It’s a way to classify and stigmatize others. I’m not sure this is a good idea at all. As an educational tool for people to understand their health okay but not in the medical record for all patients and certainly not for kids who can make radical changes to their environment once they become adults. 

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I’ve been starting to wonder, is pushing Pediatricians to screen for ACEs a way to increase the pharmaceutical market reach to kids? Poor urban and rural areas that have few resources generally do have one resource to “treat” behavioral symptoms associated with childhood trauma, Medicaid payments for psychotropic drugs. I believe doctors have to be very vigilant. I remember the time when pediatric bipolar did not exist. It became a thing after a Harvard physician and pharmaceutical spokes person made a CME for Peds docs.

This is at least a valid concern and needs to be discussed. 

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