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 101; Got 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.)

Dr. Arnd Herz

Dr. Arnd Herz, a self-described champion for ACEs science, would like nothing more than to witness a greater appreciation of how widespread adverse childhood experiences are. Herz, a pediatrician and director of Medi-Cal Strategy for the Greater Southern Alameda Area for Kaiser Permanente Northern California, would also like to encourage more people in health care to engage in a trauma-informed care approach, a change in practice that he says not only benefits patients, but also health care providers and their staff.

“It makes so much sense,” say Herz. “This is why I went into medicine. I don’t want to just click off diagnoses, but create relationships and help people by understanding them better, and trauma-informed care is just a way to bring compassion back into the care that we do.”

For the uninitiated, a trauma-informed approach includes an awareness that adverse childhood experiences (ACEs) are common, knowing how to recognize the signs and symptoms of trauma, creating a safe environment where the focus is on “What happened to you?” rather than “What’s wrong with you?”, engaging trauma survivors as equal decision-makers in their care, and offering patients referrals to supportive services as needed, according to a report by the Substance Abuse and Mental Health Services Administration and a primer by the Center for Health Care Strategies.

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Baltimore BSC faculty and planning team

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When a group of community organizations in Baltimore came together in 2015, they already knew trauma figured large in many lives. There was violence in the community, in schools, and in community members’ homes. Police brutality occurred. Many suffered the loss of loved ones to incarceration or death. There were house fires and homelessness. Much of the dysfunction was systemic and rooted in racism, according to a report on a collaborative effort to restructure city organizations and agencies. The goal was to build community resilience.

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Would pregnant women participate in surveys from their doctors asking them about whether they had experienced trauma in their childhood? In surveying moms-to-be at two Northern California Kaiser sites, clinicians discovered that the women were receptive to filling out an adverse childhood experiences (ACE) survey, according to a study that was published earlier this year in the Journal of Women’s Health.

In fact, researchers found out that the vast majority of pregnant women — 91 percent of the 375 women— were “very or somewhat comfortable,” filling out the ACE survey. Even more, 93 percent, said that they were comfortable talking about the results with their doctors. The women were surveyed from March through June 2016 at Kaiser Permanente clinics in Antioch and Richmond, CA.

ACE refers to the groundbreaking CDC/Kaiser Permanente Adverse Childhood Experiences Study that tied 10 types of childhood trauma, including living with an alcoholic family member or experiencing verbal abuse from a parent, to a host of health consequences. (Got Your ACE Score?)

The higher the number of ACEs that people have, researchers learned, markedly increases their risk for poor health outcomes, as well as social and economic consequences. Having four ACEs, for example, nearly doubles a person’s risk for heart disease and cancer, raises the risk of attempted suicides by 1200 percent and alcoholism by 700 percent.

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