Lesson learned integrating ACEs science into health clinics: Staff first, THEN patients

Dr Omotoso
Dr. Omoniyi Omotoso

About two years ago, a team from LifeLong Medical Clinics jumped at the opportunity to integrate practices based on adverse childhood experiences   when it joined a two-year learning collaborative known as the Resilient Beginnings Collaborative (RBC). RBC began in 2018 and includes seven safety-net organizations in the San Francisco Bay Area. (Here’s a link to a report about the RBC.)

To join the RBC, LifeLong Clinics — which has  14 primary care clinics in Alameda, Contra Costa and Marin Counties — and the other collaborative teams had to agree to introduce all staff members to the science of childhood adversity and trauma-informed practices. LifeLong went full steam ahead with a 2.5-hour introductory training for more than 100 employees who work at its clinics that serve pediatric patients. Trauma Transformed, a program of the East Bay Agency for Children in Oakland, CA, did the training in October and November 2018.

LifeLong Clinics’ decision to move forward on integrating ACEs science and trauma-informed practices into its clinics is important particularly in California where a state policy has made childhood adversity a front and center issue. On Jan. 1, 2020, as an incentive to doctors who serve Californians in the state’s Medicaid program, the state began offering supplemental payments of $29 to doctors for screening the estimated 12 million pediatric and adult patients for adverse childhood experiences (ACEs).

ACEs comes from the groundbreaking Adverse Childhood Experience 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 adults 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 101Got Your ACE/Resilience Score?)

The ACE surveys — the epidemiology of childhood adversity — is one of five parts of ACEs science, which also includes how toxic stress from ACEs affects children’s brains, 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.

After it trained employees in 2018, brainstorming around workflow was provided for staff at the LifeLong Howard Daniel Health Center in Oakland, CA, in February 2019, where LifeLong plans to pilot ACEs screening in newborns to five-year-olds, said Dr. Omoniyi Omotoso, the pediatric lead at LifeLong Clinics, who led the brainstorming about workflow and additional training.

Four months into that training, in June, Omotoso showed staff the ACEs questionnaire and asked them how they thought patients would feel about it.

And that’s when Omotoso realized that they had to put on the brakes. “A lot of the staff were uncomfortable because they themselves had similar instances that they personally were triggered by as they read the [ACE] questions themselves,” said Omotoso, who splits his clinical time between LifeLong Howard Daniel Health Center and LifeLong William Jenkins Health Center. He said that LifeLong will be using the de-identified PEARLS ACE screener for its pediatric population, which asks those surveyed to write on the form the number of ACEs that apply to them. (Here’s a link to ACEs Aware, where you’ll find out more information about PEARLS, the only pediatric ACEs screener for which California providers can be reimbursed.)

Omotoso credits the realization that LifeLong had to take a step back before jumping full throttle into ACEs screening with what he observed and learned from a June 2019 visit to the Montefiore Medical Center, in the Bronx, NY. Montefiore is one of the first medical systems in the country to transform its entire workforce into embracing trauma-informed practices based on ACEs science, and introduce universal ACEs screening.

Omotoso said the visit, which was organized as part of the Resilient Beginnings Collaborative, was “mindblowing.”

“When patients come in, there are security [guards] at the front. They greet the families. They say, ‘How are you doing?’ When they’re leaving they say, ‘I hope everything was ok, you got what you needed,’” said Omotoso. “And when they notice someone is having a difficult time, they can call ahead to the front desk and say, ‘The patient walked in; they seem to be struggling with this.’ Or, when some of the security staff members have some personal issues, they’ll say to each other ‘Take a day off and we’ll cover for you.’ Just the way they became so mindful, it was very astounding to see. It made me see we had to fine-tune things. It was the impetus for saying before we do the ACEs screen, we have to be attuned to staff readiness and meet them where they are.”

So, in July 2019, 13 months after the launch of the Resilient Beginning Collaborative, Omotoso and his colleagues’ response was to pivot and provide the clinic’s staff with a deeper dive into training and support. Since July, they’ve talked every month about the transition. The topics, which were facilitated by Dr. Madeleine Lansky, a consultant with Alameda County Child Psychiatry, included discussions about ACEs science research, screenings of the Ted Talk by pediatrician and California Surgeon General Dr. Nadine Burke Harris, and the documentary Resilience. Each activity was followed by discussions about topics, such as intergenerational trauma. Staff also developed emergency self-care cards with five items they can quickly deploy to help them decompress when they’re feeling triggered or overly stressed.

“For example, for some people it could be looking at a picture of their kids or pets. Some people could take a five-minute walk. It goes in the back of your ID badge, so you could always see it when you flip it around,” said Omotoso.

Besides the deeper dive to ensure that the staff feel prepared and ready to move forward on screening patients for ACEs, LifeLong has some other pressing tasks at hand. These include setting up a new electronic health record system to record ACEs screening results and developing materials for parents about ACEs science, including resilience. An example is a “prescription card” for parents that suggests daily activities such as: “Say ‘I love you’ to your child every day. Hug your child for 20 seconds every day. Think about what you hope to see your child doing in the future,” said Omotoso.

While LifeLong continues to prepare for implementing its ACEs screening, Omotoso says that the training and work in the RBC collaborative has already shifted some aspects of LifeLong’s workplace. In every staff meeting, he says, they now incorporate a team-building activity. “We have tried to make it a lot more interactive, where staff feel like they can be heard, they can talk and speak up, and we can actually come up with solutions together,” says Omotoso. “It’s really transformed how we interact on a day-to-day basis.”

3 responses

    • Hi Susan, Sorry, I somehow missed your message. You might want to check out our sister site: acesconnection.com, a social network, where people post all sorts of resources. There is also a resource center and you can “ask the community” if you have specific questions. There are many different communities that also may be helpful to you. Thanks for writing!

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  1. “The way a society functions is a reflection of the childrearing practices of that society. Today we reap what we have sown. Despite the well-documented critical nature of early life experiences, we dedicate few resources to this time of life. We do not educate our children about child development, parenting, or the impact of neglect and trauma on children.”
    —Dr. Bruce D. Perry, Ph.D. & Dr. John Marcellus

    “This is the most important job we have to do as humans and as citizens … If we offer classes in auto mechanics and civics, why not parenting? A lot of what happens to children that’s bad derives from ignorance … Parents go by folklore, or by what they’ve heard, or by their instincts, all of which can be very wrong.”
    —Dr. Alvin F. Poussaint, Professor of Psychiatry, Harvard Medical School

    ______________

    Understanding Child Development and Parenting Science Through High School Curriculum: A Human Right for Future Generations

    I once read an ironic quote from a children’s health academic that, “You have to pass a test to drive a car or to become a … citizen, but there’s no exam required to become a parent. And yet child abuse can stem from a lack of awareness about child development.”
    By not teaching child development science along with rearing to high school students, is it not as though societally we’re implying that anyone can comfortably enough go forth with unconditionally bearing children with whatever minute amount, if any at all, of such vital knowledge they happen to have acquired over time? It’s as though we’ll somehow, in blind anticipation, be innately inclined to fully understand and appropriately nurture our children’s naturally developing minds and needs.
    A notable number of academics would say that we don’t.
    Along with their physical wellbeing, children’s sound psychological health should be the most significant aspect of a parent’s (or caregiver’s) responsibility. Perhaps foremost to consider is that during their first three to six years of life (depending on which expert one asks) children have particularly malleable minds (like a dry sponge squeezed and released under water), thus they’re exceptionally vulnerable to whatever rearing environment in which they happened to have been placed by fate.
    I frequently wonder how many instances there are wherein immense long-term suffering by children of dysfunctional rearing might have been prevented had the parent(s) received some crucial parenting instruction by way of mandatory high school curriculum.
    Additionally, if we’re to proactively avoid the eventual dreadingly invasive conventional reactive means of intervention due to dysfunctional familial situations as a result of flawed rearing—that of the government forced removal of children from the latter environment—we then should be willing to try an unconventional means of proactively preventing future dysfunctional family situations: Teach our young people the science of how a child’s mind develops and therefor its susceptibilities to flawed parenting.
    Many people, including child development academics, would say that we owe our future generations of children this much, especially considering the very troubled world into which they never asked to enter.
    Certainly, some will argue that expectant adults can easily enough access the parenting experience and advice of other parents in hardcopy and Internet literature, not to mention arranged group settings. However, such information may in itself be in error or misrelated/misinterpreted and therefor is understandably not as beneficial as knowing the actual child development science behind why the said parental practice would or would not be the wisest example to follow.
    As for the likely argument that high school parenting courses would bore thus repel students from attending the classes to their passable-grade completion, could not the same reservation have been put forth in regards to other currently well-established and valued course subjects, both mandatory and elective, at the time they were originally proposed?
    In addition, the flipside to that argument is, such curriculum may actually result in a novel effect on student minds, thereby stimulating interest in what otherwise can be a monotonous daily high-school routine. (Some exceptionally receptive students may even be inspired to take up post-secondary studies specializing in child psychological and behavioural disorders.)
    In any case, American experience and studies indicate that such curriculum is wholly useful, regardless of whether the students themselves plan to and/or go on to procreate.
    For one thing, child development and rearing curriculum would make available to students potentially valuable knowledge about their own psyches and why they’re the way they are.
    Physical and mental abuse commonsensically aside, students could also be taught the potentially serious psychological repercussions of the manner in which they as parents may someday choose to discipline their children; therefore, they may be able to make a much more informed decision on the method they choose to correct misbehaviour, however suddenly clouded they may become in the angry emotion of the moment.
    And being that their future children’s sound mental health and social/workplace integration are at stake, should not scientifically informed parenting decisions also include their means of chastisement?
    Our young people are then at least equipped with the valuable science-based knowledge of the possible, if not likely, consequences of dysfunctional rearing thus much more capable of making an informed choice on how they inevitably correct their child’s misconduct.
    It would be irresponsibly insufficient to, for example, just give students the condom-and-banana demonstration along with the address to the nearest Planned Parenthood clinic (the latter in case the precautionary contraception fails) as their entire sex education curriculum; and, similarly, it’s not nearly enough to simply instruct our young people that it’s damaging to scream at or belittle one’s young children and hope the rest of proper parenting somehow comes naturally to them. Such crucial life-skills lessons need to be far more thorough.
    But, however morally justified, they regardlessly will not be given such life-advantageous lessons, for what apparently are reasons of conflicting ideology or values.
    In 2017, when I asked a BC Teachers’ Federation official over the phone whether there is any childrearing curriculum taught in any of B.C.’s school districts, he immediately replied there is not. When I asked the reason for its absence and whether it may be due to the subject matter being too controversial, he replied with a simple “Yes”.
    This strongly suggests there are philosophical thus political obstacles to teaching students such crucial life skills as nourishingly parenting one’s children. (Is it just me, or does it not seem difficult to imagine that teaching parenting curriculum should be considered any more controversial than, say, teaching students Sexual Orientation and Gender Identity (SOGI) curriculum, beginning in Kindergarten, as is currently taught in B.C. schools?)
    Put plainly, people generally do not want some stranger—and especially a government-arm entity, which includes school teachers—directly or indirectly telling them how to raise their children. (Albeit, a knowledgeable person offered me her observation on perhaps why there are no mandatory childrearing courses in high school: People with a dysfunctional family background do not particularly desire scholastically analyzing its intricacies; i.e. they simply don’t want to go there—even if it’s not being openly discussed.)
    A 2007 study (its published report is titled The Science of Early Childhood Development), which was implemented to identify facets of child development science accepted broadly by the scientific community, forthrightly and accurately articulates the matter: “It is a compelling task that calls for broad, bipartisan collaboration. And yet, debate in the policy arena often highlights ideological differences and value conflicts more than it seeks common interest. In this context, the science of early childhood development can provide a values-neutral framework for informing choices among alternative priorities and for building consensus around a shared plan of action. The wellbeing of our nation’s children and the security of our collective future would be well-served by such wise choices and concerted commitment.”
    file:///F:/CHILDPSYCHESScienceEarlyChildhoodDevelopment.pdf

    The same study-report also noted that, “The future of any society depends on its ability to foster the health and well-being of the next generation. Stated simply, today’s children will become tomorrow’s citizens, workers, and parents. When we invest wisely in children and families, the next generation will pay that back through a lifetime of productivity and responsible citizenship. When we fail to provide children with what they need to build a strong foundation for healthy and productive lives, we put our future prosperity and security at risk … All aspects of adult human capital, from work force skills to cooperative and lawful behavior, build on capacities that are developed during childhood, beginning at birth … The basic principles of neuroscience and the process of human skill formation indicate that early intervention for the most vulnerable children will generate the greatest payback.”
    Although I appreciate the study’s initiative, it’s still for me a disappointing revelation as to our collective humanity when the report’s author feels compelled to repeatedly refer to living, breathing and often enough suffering human beings as a well-returning “investment” and “human capital” in an attempt to convince money-minded society that it’s indeed in our best fiscal interest to fund early-life programs that result in lowered incidence of unhealthy, dysfunctional child development.
    In fact, in the 13-page study-report, the term “investment(s)” was used 22 times, “return” appeared eight times, “cost(s)” five times, “capital” appeared on four occasions, and either “pay”/“payback”/“pay that back” was used five times.
    While some may justify it as a normal thus moral human evolutionary function, the general self-serving Only If It’s In My Own Back Yard mentality (or what I acronize OIIIMOBY) can debilitate social progress, even when it’s most needed; and it seems that distinct form of societal ‘penny wisdom but pound foolishness’ is a very unfortunate human characteristic that’s likely with us to stay.
    Sadly, due to the OIIIMOBY mindset, the prevailing collective attitude, however implicit or subconscious, basically follows, “Why should I care—I’m soundly raising my kid?” or
    “What’s in it for me, the taxpayer, if I support child development education and health programs for the sake of others’ bad parenting?”
    I was taught in journalism and public relations college courses that a story or PR news release needed to let the reader know, if possible in the lead sentence, why he/she should care about the subject matter—and more so find it sufficiently relevant to warrant reading on. It’s disheartening to find this vocational tool frequently utilized in the study’s published report to persuade its readers why they should care about the fundamental psychological health of their fellow human beings—but in terms of publicly funded monetary investment and collective societal ‘costs to us later’ if we do nothing to assist this (probably small) minority of young children in properly cerebrally developing.
    A similarly disappointing shortsighted OIIIMOBY mindset is evident in news reporting and commentary on other serious social issues, in order to really grasp the taxpaying reader’s interest. I’ve yet to read a story or column on homelessness, child poverty and the fentanyl overdose crisis that leaves out any mention of their monetary cost to taxpaying society, notably through lost productivity thus reduced government revenue, larger health care budgets and an increasing rate of property crime; and perhaps the most angrily attention-grabbing is the increased demand on an already constrained ambulance response and emergency room/ward waits due to repeat overdose cases.
    As for society’s dysfunctionally reared thus improperly mind-developed young children, make no mistake: Regardless of whether individually we’re doing a great job rearing our own developing children, we all have some degree of vested interest in every child receiving a psychologically sound start in life, considering that communally everyone is exposed (or at least potentially so) to every other parent’s handiwork.
    Our personal monetary and societal security interests are served by a socially functional fellow citizenry that otherwise could or would have been poorly reared—a goal in part probably met by at least teaching child development science to our high school students.

    ______________

    “I remember leaving the hospital thinking, ‘Wait, are they going to let me just walk off with him? I don’t know beans about babies! I don’t have a license to do this. We’re just amateurs’.”
    —Anne Tyler, Breathing Lessons

    “It’s only after children have been discovered to be severely battered that their parents are forced to take a childrearing course as a condition of regaining custody. That’s much like requiring no license or driver’s ed[ucation] to drive a car, then waiting until drivers injure or kill someone before demanding that they learn how to drive.”
    —Myriam Miedzian, Ph.D.

    (Frank Sterle Jr.)

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