Early Childhood Adversity, Trauma and Health Equity
August 26th, 2020
Dr. Dayna LongCo-Director, Center for Child and Community Health
UCSF Benioff Children’s Hospital Oakland
Learning Objectives
1. Defining terms and information on ACEs and toxic stress2. Understanding how racism and health equity are related to toxic
stress and resilience3. Algorithm to address ACE-Associated Health Conditions including
suggested clinical workflows & PEARLS screening tool4. Guidance for ways in which ACEs screening results can be used to
tailor treatment planning and follow-up5. Tools & interventions to promote resilience, including lifestyle
anticipatory guidance and work in multi-disciplinary teams
From Trauma Transformed
We acknowledge that we are in the midst of unprecedented times.
We acknowledge that we are each holding a multitude of feelings, responsibilities, fear, and joys- at the same time.
We acknowledge that are many responses to stress and uncertainty- each of them valid.
We acknowledge that there is no better opportunity to practice compassion and collective care than right now. This is the work.
We acknowledge the critical need for reflection, inquiry and prioritization of the most critical needs.
HEALTH EQUITY: “Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to healthsuch as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.”
- The Robert Wood Johnson Foundation, 2017
“The antiracists say there is nothing wrong or right about Black people and everything wrong with racism. The antiracists say racism is the problem in need of changing, not Black people. The antiracists try to transform racism.”
- Ibram X. Kendi Stamped from the Beginning
Antiracist policy is any measure that produces or sustains racial equity between racial groups. By policy, I mean written and unwritten laws, rules, procedures, processes, regulations, and guidelines that govern people. There is no such thing as a nonracist or race-neutral policy. Every policy in every institution in every community in every nation is producing or sustaining either racial inequity or equity between racial groups."- Ibram X. Kendi How To Be an Antiracist
Toxic Stress Definition: Repeated or prolonged activation of a child’s
stress response, without the buffering protections of trusted, nurturing
caregivers and safe, stable environments, leads to long-term changes in
the structure and functioning of the developing brain, metabolic,
immune, and neuroendocrine responses, and even the way DNA is read and transcribed.
For information on the clinical response to ACEs and toxic stress, visit
ACEsAware.org/provider-toolkit
http://www.acesaware.org/provider-toolkit
Positive stressBrief increases in heart rate
Mild elevations in stress hormones
Tolerable stressSerious, temporary stress
responsesBuffered by supportive
relationships
Toxic stressProlonged stress response
activationAbsence of protective relationships
J Shonkoff Harvard University Center on the Developing Child
10 Categories of Adverse Childhood Experiences
9Copyright 2013. Robert Wood Johnson Foundation. Used with permission from the Robert Wood Johnson Foundation.
10
Impact of ACES
Hughes K,, et al. The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. Lancet Public Health.
Putnam et al 2015
Disparities and COVID-19Higher rates of underlying health conditions (hypertension, asthma, etc) coronavirus exacerbates the challenges, complications often of stress
Black people are more likely to work in jobs that put workers in close contact with others who might be in poor health and that make engaging in social distancing more difficult.
Inadequate information/lack of trust/mixed messages
Determinants of health-Black Americans are also twice as likely as white Americans to live in poverty which is associated with stressors such as food insecurity and unsafe housing 2nd to structural and institutional policies
4 Reasons Coronavirus is Hitting Black Communities So Hard, The Washington Post April 10th, 2020
Stress and Racism
• Racism is a core determinant of health
• Racism has been linked to birth disparities
• Racism is linked to mental health issues
• Biological mechanism linked to chronic stress that leads to increased and prolonged levels of stress hormones and oxidative stress on a cellular level.
AAP Policy Statement the Impact of Racism on Child and Adolescent Health Pediatrics vol 144, #2, 8/2019
❑ Original categories
❑Added a 4 domain for SDOH
▪Food Insecurity
▪Housing Instability
▪Discrimination, Bullying
▪Violence outside of the home
PEdiatric ACEs Screening and ResiLiency Study (PEARLS)
Percentage of Child ACEs at UCSF BCHO
3.6%
7.1%
7.1%
10.7%
14.3%
21.4%
21.4%
28.6%
28.6%
28.6%
32.1%
35.7%
39.3%
42.9%
60.7%
Child Sexual Abuse
Child Verbal Abuse
Child Emotional Neglect
Child Physical Neglect
Child Physical Abuse
Family Medical Illness
Discimination
Housing Insecurity
Low family cohesion
Separation from Caregiver
Food insecurity
Family Substance Use
Family/Domestic Violence
Family Mental Illness
Community Violence
Pilot data from BARC 2016
• 82.1% of Caregivers endorsed 1 or more (from list of 15)• 53.6% endorsed 4 or more (from list of 15)
Registration or clinical staff reviews patient’s record to determine if PEARLS screen required for visit.^ Staff provides PEARLS tool to parent and/or patient (12+ years) in private setting
Parent and/or patient (12+) completes PEARLS
Provider provides education about how ACES and buffering practices and interventions can affect health and offers patient/family
opportunity to discuss and/or complete PEARLS screen.
Provider reviews screen with patient/family and follows appropriate risk assessment
algorithm: incomplete, low, intermediate. or high risk for toxic stress
Provider or Medical Assistanttranscribes ACE score (top box of
PEARLS tool) into EMR
Provider documents ACE score, billing code,* and treatment and follow-up
plan in visit note
Screen incomplete
Pediatric ACE Screening Clinical Workflow
^ Provider reviews ACE score, treatment, and follow-up plan prior to next visit; at next visit,
updated as needed
Screen complete
CA-Office of the Surgeon General, Clinical SubcomitteeOct 2019
Intermediate Risk High RiskLow Risk
ACEscreen(top part)
Score of 0Score of 1-3
Score of 1-
3
Provide patient education on
ACEs/toxic stress and buffering
factors
Assess
for
symptoms
Determine
follow upLink to support services and treatment, as appropriate.
No detectable
symptoms
With
symptoms
Adverse Childhood Experiences (ACEs) Screening and Toxic Stress Risk Algorithm: Pediatrics
With or
without
symptoms
Score of 4+
Provide anticipatory guidance and patient
education on buffering factors/interventions
Unknown Risk
Score unknown
(incomplete)
Provide patient education on ACEs/toxic stress and
buffering/resilience; repeat screen in 1 year
ACEs-Associated Health Conditions: PediatricsSymptom or Health Condition For > X ACEs
(compared to 0)
Odds Ratio
Increased incidence of chronic disease, impaired management,25 such as: Asthma26,33
Allergies33
344
2.2525
1.7326—2.7633
2.4733
Unexplained somatic symptoms (eg., nausea/vomiting, dizziness, constipation, headaches)25
Headaches33
3
4
Any: 9.2525
3.0333
Enuresis; encopresis5 -- --
Overweight and obesity Failure to thrive; psychosocial dwarfism5, 12, 41
4--
1.993
--
Poor dental health16,22 4 2.7922
Increased febrile illnesses Parental psychiatric symptoms
Rate ratio 1.3639
Later menarche (> 14 years) 2 (early adversities, not all ACEs)
2.3240
ACEs-Associated Health Conditions: PediatricsSymptom or Health Condition OR for > X ACEs
(compared to 0)Odds Ratio
Sleep disturbances5,31 5 (adversities, not ACEs)
PR 3.0931
Developmental delayLearning and/or behavior problems
34
1.9330
32.63
Repeating a gradeNot completing homeworkHigh school absenteeismGraduating from high school
4444
2.7615
4.0415
7.2433
0.3729
Poor impulse control; aggression—physical fighting28 For each additional ACE
1.85-1.8828
DepressionAny of: ADHD, depression, anxiety, conduct/behavior disorder
43
3.929
4.4730
Suicidal ideationSuicide attemptsSelf-harm
For each additional ACE
1.85-1.8828
1.88-2.0628
1.75-1.8328
High-risk substance use, such as starting < 14 years5,7,10 45
Alcohol: 6.27
Illicit drugs: 9.110
High-risk sexual behaviors, such as early sexual debut (
Focus: Buffers and Protective Factors
Caregiver Support
Social connections
Knowledge of parenting and child
development
Addressing Unmet Basic Needs
Social and emotional resilience of
children
Anticipatory Guidance
NOTE
❑ Note caregiver-child relationship and
strengths
❑ Offer Science
❑ Tools
❑ Empowerment
Handouts
Re-regulation:
Safety: Routines
Connection: Relationship
Purpose
Six Stress Busting Strategies
25
From the California Surgeon
General’s Playbook at
COVID19.CA.gov
https://files.covid19.ca.gov/pdf/wp/california-surgeon-general_stress-busting-playbook_draft-v2clean_ada-04072020.pdf
Stress Busting at Home
1. Awareness-How Stress is Showing up in Our Body2. Make a Plan For You3. Work Your Program
Stress Busting at Home• Things to Embrace• Each Other
• Deep Breaths
• Hydration
• Play
• Asking for Help and a Moment
• Things to Limit• News
• Substances
• High-Sugar Food
• High-Fat Foods
Follow-up: The Role of Community Based Organizations
• Learn the science & assess for toxic stress physiology & symptomology
• Provide trauma-informed care
• Address health concerns & manage
chronic conditions
• Educate patients on stress busters
• Help patients identify their strengths
& coping strategies
Follow-up: Community Health Workers and Unmet Basic Needs
✓ Education✓ Food insecurity✓Housing Instability✓ Activities✓Utilities✓ Legal Concerns✓ Child Care ✓ Education arounds ACES and
Stress✓ Internet/devices
CenteringConnectingCollaborating
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License. Source: Dovetail Learning, Inc 2020 www.dovetaillearning.org
Trauma Informed Staff Tools
https://urldefense.proofpoint.com/v2/url?u=http-3A__creativecommons.org_licenses_by-2Dsa_4.0_&d=DwMFaQ&c=iORugZls2LlYyCAZRB3XLg&r=63li-rv58-AGltXOWIyWKJDuSGvN35zTAA1YkDfgiLw&m=oLHZDz4bY-A_49oJEihDgcLFjBkRtDGaie6a1Bl3vfM&s=QgOwdJId8cH5aSsZRk9IQ40xBSQ5Q5O0fYx6LB-LnHI&e=https://urldefense.proofpoint.com/v2/url?u=http-3A__www.dovetaillearning.org&d=DwMFaQ&c=iORugZls2LlYyCAZRB3XLg&r=63li-rv58-AGltXOWIyWKJDuSGvN35zTAA1YkDfgiLw&m=oLHZDz4bY-A_49oJEihDgcLFjBkRtDGaie6a1Bl3vfM&s=xpdhwiTFOpT4_NfegieU6Y3kHfVyz7NQIEiSAPmp0MM&e=
Trauma and Burn Out
The expectation that we can be immersed in suffering and loss daily and not be touched by it is as unrealistic as expecting to be able to walk through water without getting wet.-- Naomi Rachel Remen
TRAUMA-INDUCING TO TRAUMA-REDUCINGTRAUMA-INDUCING TO TRAUMA REDUCING
Trauma Informed Systems Principles
• Understanding Trauma and Stress
• Cultural Humility and Responsiveness
• Safety and Stability
• Compassion and Dependability
• Collaboration and Empowerment
• Resiliency and Recovery
Dayna Long, MD, FAAPPrimary Care AttendingDirector, Center for Child and Community Health,UCSF Benioff Children’s [email protected]
Thank You