For the last two years, nearly all students referred for mental health services in seven school-based health centers in Deschutes County, OR, have taken the 10-question adverse childhood experiences (ACE) survey.
It didn’t take long to realize why this was good idea.
“The average ACE score for a student being seen by a Deschutes County clinician was 5 out of 10,” says Elizabeth Fitzgerald, supervisor of school-based health centers at Deschutes County Health Services.
ACE refers to the groundbreaking CDC-Kaiser Permanente Adverse Childhood Experiences Study (ACE Study). The ACE Study showed how childhood trauma is linked to the adult onset of chronic disease, mental illness, violence and being a victim of violence. It measured 10 types of childhood adversity, those that occurred before the age of 18. They are physical, verbal and sexual abuse; physical and emotional neglect; a family 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.
Of the 17,000 mostly white, college-educated people with jobs and great health care who participated in the study, 64 percent had an ACE score of 1 or more; 12 percent had an ACE score of 4 or more (i.e., four out of the 10 different types of adversity).
The researchers found that the higher a person’s ACE score, the greater the risk of chronic disease and mental illness. For example, compared with someone who has an ACE score of zero, a person with an ACE score of 4 is 12 times more likely to attempt suicide, seven times more likely to become an alcoholic, and twice as likely to have heart disease. People with a score of 6 or higher have shorter lifespans – 20 years shorter.
The study revealed a hidden epidemic: ACEs contribute to most of our major chronic health, mental health, economic health and social health issues.
The ACE Study is one part of a new understanding that’s sometimes called “the unified science” of human development. The five parts of this ACEs science include the epidemiology of childhood adversity (ACE Study), how toxic stress from childhood trauma can damage the structure and function of a child’s developing brain (neurobiology of toxic stress), how toxic stress embeds in a person’s biology to emerge decades later as disease (biomedical consequences of toxic stress), how the effects of toxic stress can be passed from parent to child and generation to generation (epigenetics), and how resilience research is showing how the brain is plastic and the body wants to heal.
Resilience research is very broad. It encompasses individual resilience — such as how exercise, nutrition, being in a safe relationship, (for a child) being in a relationship with a trusted adult, living in a safe place, and mindfulness all contribute to a healthy brain and body. Resilience research also covers organization, system and community resilience — such as how trauma-informed, resilience-building schools help students with high ACE scores increase their grades, test scores, graduation rates, sense of well being, and hope for the future.
“The ACE screen brings mindful self-compassion right into the treatment from the start,” says Fitzgerald. The shift to trauma-informed care “empowers the individual in their own treatment. Instead of them saying, ‘What’s wrong with me?’ you’re helping them become self-aware.”
Deschutes County, where Bend is the largest city, began using the ACE survey as a screening tool after Deschutes County Health Services, the schools that host its clinics, and its medical and dental sponsors used state grants to set up school-based health centers in seven schools where poverty rates of students’ families are high. At one school, says Fitzgerald, over 80 percent of the students qualify for these lunches. There are 42 public schools in Deschutes County serving more than 24,000 students.
The five clinicians who work in the seven clinics are busy. In just three months — between January 2016 and March 2016 — the team provided 762 mental health services to 180 families. At any one time, they serve between 150 and 180 families.
And since October 2015, this same team has also provided over 90 hours of prevention, education and outreach services.
“These outreach services are intended to help a student who is in distress but is not an active client and not wanting a behavioral health screening or assessment,” says Fitzgerald. “These encounters, we have learned, have value in helping us to build trust with teens or parents who may not otherwise seek services.”
Fitzgerald’s past experience made her a natural for coordinating a trauma-informed approach in school-based health clinics. After receiving master’s degrees in expressive psychotherapy and clinical mental health from Lesley University in Cambridge, MA, she worked in community mental health in Boston serving women and children in crisis and specialized in early childhood trauma. While working on an in-patient psychiatric unit in Florida more than six years ago, she struggled in an organization that often re-traumatized its clients. There she discovered the Sanctuary Model, which teaches ACEs science and how an organization can become trauma-informed. As a result, Fitzgerald trains all her team members to screen for ACEs and teaches how this is part of trauma-informed care.
“Our team has been tracking the ACE scores of students who use our services for the past two years,” says Fitzgerald. “We conducted an audit our first year and learned that the average ACE score for a student being seen by a Deschutes County clinician was 5 out of 10.” The first year audit included 115 randomly selected, open and active charts from the five operating clinics at that time.
The team also learned that the standard 10-question ACE survey doesn’t include other significant childhood trauma experienced by students, such as exposure to community violence, racism, gender discrimination, fetal exposure to drugs or alcohol, cultural and other medical traumas such as childhood cancer. However, the health center staff finds the 10-point ACE questionnaire useful because “the language of the ACE screen is easy to understand.”
“The other thing we’ve found,” she adds, ”is that individuals with significant trauma histories often struggle to qualify some of their trauma; such as denying the presence of emotional neglect or emotional abuse. We may recognize the presence of symptoms that would indicate that a child is being emotionally abused, but the individual being affected may mark this question as ‘No.’ Other times, we are seeing a pattern of significant under-reporting with children of undocumented parents. The child may be presenting with acute symptoms of anxiety or severe mood dysregulation but the family and child will deny any trauma history. Additionally, some traumas may not be revealed until well into the treatment, after the client has had time to develop trust and rapport with their therapist. “
Administering the ACE survey is “very individualized,” Fitzgerald explains. “Sometimes our first encounter with a student might not be appropriate to introduce the screen. Somewhere between the screening, assessment or first session is when we introduce the questions.”
The ACE survey can be completed by the student alone or with a clinician going over each question. Sometimes, the scoring is done with the whole family or just a parent or guardian, who could be asked about his or her own adverse childhood experiences.
Typically, after the questionnaire is completed, an assessment and treatment plan are created based on what the clinician prescribes. The clinician will meet with the student once a week and try to conduct family therapy twice monthly for several weeks or months.
“The intent of therapy with our school-based behavioral health specialists is achieving a measureable reduction or stabilization of acute symptoms,” says Fitzgerald, “so that the student can achieve a specific goal, such as increased school attendance, improved self-esteem and peer relationships or a reduction in the presence of a specific trauma-related symptom like nightmares or self-injurious behaviors.”
Results of the ongoing treatment at the county’s school-based health centers will be measured later, once a clinical outcome tool is adopted and implemented. Fitzgerald says the partners at the school-based health clinics are also looking for a resilience screen that would be as easy to use, as effective, and as widely accepted as the 10-question ACE survey.
A year ago, some Deschutes County school-based clinicians attended a workshop where Jim Sporleder gave the keynote presentation called “Catching Kids Before They Fall”. Sporleder implemented trauma-informed and resilience-building practices based on ACEs science when he was principal of Lincoln High School. The school became the focus of the documentary, Paper Tigers, directed by James Redford.
As the Paper Tigers documentary is being shown in schools around Deschutes County, it’s clear that the demand for clinicians and school-based health centers greatly exceeds the county’s resources.
“A high percentage of students seen by our medical providers are revealing behavioral health needs during their medical visits. We do not have the capacity to meet all of the need we are seeing,” says Fitzgerald.
One way to meet the capacity is to expand the knowledge about ACEs science and trauma-informed practices. Other schools in the district are introducing trauma-informed training, awareness, and practices into their schools and clinics. These include LaPine elementary, middle and high schools, in addition to the LaPine Community Clinic.
“Our LaPine-Gilchrist clinician has participated in the trauma-informed training with her site team partners,” says Fitzgerald. “This is important because what we have learned form Lincoln High is that trauma-informed implementation is often an organic process.”
“When a team trains together,” she adds, “they create a team and service-practice culture reflective of the specific and unique population they serve. We are fortunate enough to see these trauma-informed team cultures growing at each of our sites.”
Recently, a landmark trauma-informed education bill to address school absenteeism passed the Oregon legislature and was signed by the governor. The bill will direct two state agencies to develop a statewide plan to address the absentee problem in schools. It also provides a limited amount of funding — $500,000 – to develop trauma-informed approaches in schools.
A trauma-informed school not only realizes and recognizes the role of childhood trauma in school attendance and performance, it also responds by integrating knowledge about trauma and resilience practices into its policies and programs, and trains teachers and staff to develop resiliency in students.
Deschutes County Health Services are already two years ahead of the legislative mandate equivalent for health services, thanks to the guidance of Fitzgerald. With support from program management and leadership in the county’s health services department, as well as direct support and consultation from Trauma-Informed Oregon, the Deschutes County Trauma-Informed Care workgroup was formed. As a result, Deschutes County is preparing all health services providers to meet the implementation of the Oregon Administrative Rule for trauma-informed services.
Specifically, the statewide rule issued by the Oregon Health Authority defines trauma-informed services as “services that are reflective of the consideration and evaluation of the role that trauma plays in the lives of people seeking mental health and addictions services, including recognition of the traumatic effect of misdiagnosis and coercive treatment. Services are responsive to the vulnerabilities of trauma survivors and are delivered in a way that avoids inadvertent re-traumatization and facilitates individual direction of services.”