California is about to launch an ambitious campaign to train tens of thousands of Medi-Cal providers to screen children and adults up to age 65 for trauma, starting on January 1, 2020. It is well-established that the early identification of trauma and providing the appropriate treatment are critical tools for reducing long-term health care costs for both children and adults. Research has shown that individuals who experienced a high number of traumatic childhood events are likely to die nearly 20 years sooner than those without these experiences.
In her book The Deepest Well, Dr. Nadine Burke Harris delves into what that means. A pediatrician who worked for years in San Francisco’s Bayview district, she recalls a 10-year-old patient whose asthma was extraordinarily difficult to control. After yet another flare-up, she sat down with the mother to scrutinize the girl’s medication regimen. Asking if there was any trigger they hadn’t yet identified, the mother mused, ‘Well, her asthma does seem to get worse whenever her dad punches a hole in the wall. Do you think that could be related?”
Burke Harris did. She went on to find out that a landmark CDC-Kaiser Permanente study and other research has found that children who have experienced domestic violence, abuse, neglect, parental mental illness and other adverse childhood experiences (ACEs) were more likely to develop numerous health problems later in life, including cancer, depression, suicide, alcohol and drug abuse, and diabetes. The more such experiences they had, the greater their risk of developing these conditions.
“As doctors, it’s our job to use that science for prevention and treatment,” Burke Harris said later in a TED talk on the issue.
Fast forward to the present. Seven years after founding the Center for Youth Wellness in the Bayview, Dr. Burke Harris left the Center to become surgeon general of California, where her dream of universal ACEs screening is almost a reality. Governor Gavin Newsom penciled in $40.8 million for screening for children and parents on Medi-Cal and $120 million for provider training on trauma screening over a three-year period in the final budget — a historic victory that the Center was thrilled to celebrate.
What exactly does this mean? It means that every Medi-Cal provider in the state can begin to ask parents or children a few questions to find out if an individual child has been exposed to violence as well as discrimination, housing instability, food insecurity, parent-child separation and other adversities in their home or community. Healthcare providers will not only be reimbursed for the time they spend doing this work, they’ll get advice on how to best screen and help families of children who have had these experiences.
This is great news. It has also stoked some anxiety among doctors, child advocates and other healthcare providers who would carry out this work. It’s time to re-ask the question: What are the unintended consequences of ACEs screening, and how can we avoid them?
Conversations about provider concerns
Worried providers and advocates have voiced several concerns. CYW has had ongoing conversations about the rollout with diverse stakeholders, who fear that screening might exacerbate an existing behavioral health access issue at a time when our nation is already struggling to deal with a rising need for mental health services for children and families.
One regional chief of pediatrics from a leading health network wrote to express a concern that screening done poorly could hurt and stigmatize patients, or even cause a flood of inappropriate referrals to Child Protective Services (CPS).
Providers have also asked:
— Is there evidence that any of the interventions work?
— Why is the state only reimbursing one screening tool?
— Will the California Health and Human Services Agency, which oversees a slew of siloed departments, issue letters guiding trauma screening that help coordinate care?
— How will trauma screening align with initiatives addressing maternal health, domestic violence, or homelessness?
All these questions, which are entirely reasonable, go to the heart of Center for Youth Wellness’s mission. They also make clear that trauma screening requires more than a clinician with a clipboard and a pencil — or an IPad.
CYW’s bottom-up approach
Today, CYW is using evidence-based and evidence-informed tools and interventions to work with individuals, families and communities exposed to childhood trauma. CYW’s approach to community readiness to address toxic stress is reflected in our trauma accessibility study in Detroit and the trainings we did with our consultant Public Profit in Fresno and Bayview-Hunters Point. Our goal is simple: to build capacity for ACEs screening and treatment and remove barriers to care.
How does this happen? CYW begins by doing research to deeply understand a community — its needs, demographics, key influencers, and potential barriers to trauma screening and treatment. In the most important part of our process, we then partner with the community’s key stakeholders in three ecosystems (providers, parents/caregivers, and community-based organizations).
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Detailed interviews and surveys with local providers, policymakers, and community-based groups help us develop our theory of action for the campaign, including its main challenges, focus, strategy, tactics and desired outcomes. The theory of action is shared with the community’s key stakeholders, who review it and make suggestions.
“It’s been a great joy to work with the Center for Youth Wellness here in Fresno,” says Artie Padilla, executive director of Every Neighborhood Partnership, which, along with the Fresno County Trauma & Resilience Network, partnered with CYW there. “Its methodology is in perfect alignment with our organization’s focus on using the assets of the very community we wish to serve. This type of cross-city collaborative partnership is a great example of leveraging both human and intellectual capital for the health of both communities.”
The key to CYW’s capacity-building work is our bottom-up approach — that is, our work with communities that are most impacted by ACEs. We work hand in hand with community members to remove obstacles and tailor a solution that works for them, with these principles in mind:
Trauma screening should support families, not stigmatize them. The purpose of the screening questions is to ensure that children who have had these harmful experiences get help. We suggest logging only the number of these negative experiences without specifying which ones they’ve been through. We believe this will alleviate the anxiety of some parents and cut down on inappropriate referrals to child welfare authorities.
There are many ways to help children and families with trauma that are supported by evidence. Parent-child psychotherapy and biofeedback have been proven effective, but there are other parent interventions that are less expensive. For example, researchers from UCLA and Cincinnati Children’s Hospital Medical Center in Ohio have found that peer-to-peer parent coaches, parental self-care, a strong support network, and creating consistent, enjoyable family routines can all help kids and families who are facing adversity and/or toxic stress.
Supporting the parent-child relationship is essential. A recent systematic review published in the American Journal of Preventive Medicine found that it’s crucial to support the parent-child relationship. The review found that parenting education, social support referrals, mental health counseling and connecting families to community-based services made a significant difference in the outcomes of children exposed to ACEs. “In other words, it’s not that hard to improve the quality of the parent-child relationship, which can reduce child maltreatment and long term [consequences],” said study author Adriane Marie Mitchell. Science also shows that the key domains of wellness — sleep, nutrition, exercise, nature, healthy relationships, mental health and mindfulness — can also help reduce and heal toxic stress resulting from trauma, so getting this knowledge out to parents is crucial.
Make the community part of the “treatment” solution. Schools, day care and related settings can play an essential role in addressing the impact of traumatic stress on students “by providing prevention, early intervention, and intensive treatment for children exposed to trauma,” according to a 2018 article in Ethnicity and Disease. Since low-income kids of color are more likely to have ACEs than whites in middle-class or affluent neighborhoods, strengthening the community is key. Bob Sege, a Tufts University professor, pediatrician and trauma expert, says that all children need safe, stable housing, adequate nutrition and sleep, good medical and dental care and a safe place to play. In addition, Sege says, to feel loved, valued and hopeful, kids need to feel connected to their community.
Reframe screening as only one part of an entire system of integrated care, which incorporates mental health, primary care, dental services and substance abuse treatment. It is considered the most effective treatment for people with multiple healthcare needs, according to federal health agencies— and it’s still better if patients can get access to all these services in the same place. Using a trauma screening tool that takes into account social inequities will help policymakers see what needs to change.
We believe that, if done well, this initiative will be seen as a first step in a larger effort to build a new and better system of care for children and families in California.
As we move forward in this exciting venture, we want healthcare providers and the public to understand why knowing your ACEs is so important. In other words, it’s not what’s wrong with you; it’s what happened to you. As we work to build capacity for ACEs screening and treatment, that knowledge will help open the door to healing.
— Jim Hickman is the interim CEO of the Center for Youth Wellness, based in the Bayview district of San Francisco. Previously, he has served as CEO of Sutter Health’s Better Health East Bay; he also worked for HHS Assistant Secretary for Planning and Evaluation David Ellwood as a staff member of President Clinton’s welfare reform task force. Jim is a member of the Advisory Committee for the Camden Coalition of Healthcare Providers’ National Center for Complex Health and Social Needs.