As evidence mounts of the detrimental effects of adverse childhood experiences (ACEs) on mental, physical and social outcomes later in life, the need for pediatricians to deliver what is known as “trauma-informed care” is becoming increasingly clear, UCLA health experts say. in the field.
In the year Seminal research published in 1998 linked ACAs to long-term health problems, mental illness, and substance abuse during adolescence and adulthood, as well as negative effects on educational and work performance. of A study of adverse childhood experiencesA study published by the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente found that 61% of adults at age 18 reported having at least one ACE—examples include assault, battery, or neglect; Witnessing domestic or community violence; A family member attempts suicide or dies; and growing up in a family with instability due to substance abuse problems, mental health problems, or parental separation or incarceration.
Nearly one in six reported experiencing four or more ACEs, and these individuals were four to 12 times more likely to experience alcoholism, drug use, depression, and suicide attempts, among other negative outcomes.
“None of this is surprising to pediatricians,” he said Moira Szilagyi, MD, PhD, Chief of the Division of Developmental/Behavioral Pediatrics at UCLA Mattel Children’s Hospital and the Peter Shapiro Chair in Child Development and Behavioral Health. But seeing all the data was a clarion call for many of us.
“Pediatricians should be able to identify children at risk and prevent this situation.”
Advancing trauma-informed care
The issue is so important that the California Department of Health Care Services (DHCS) has awarded UCLA $41.5 million to establish a multi-campus entity by 2021. UCLA/UCSF ACes Aware Family Resilience Network (UCAAN) — The State of California is implementing the ACEs Aware initiative to advance the field of ACE science and provide training, screening tools, clinical protocols and reimbursement to providers to identify children and adults with ACEs.
That funding is extended to a total of more than $150 million through 2025, with nearly half going to academic pilot projects and community grants to support trauma-informed care for children and adults affected by toxic stress.
The UCLA-UC San Francisco collaboration leverages the academic and clinical resources of both institutions to provide subject matter expertise and pilot projects to investigate ACE-related health conditions. Additionally, the UCLA Prevention Center of Excellence plays a central role in advancing the ACEs Aware curriculum and providing training and education to healthcare teams.
The initiative recently announced a major milestone: More than 1 million Medi-Cal members — both children and adults — have been screened for ACEs and assessed for toxicity. As of 2019, nearly 30,000 clinicians and other healthcare facilities have been trained to screen for ACEs.
While ACEs affect all communities, studies have shown a higher prevalence among individuals from systems-underserved communities, such as those with experience in the justice and child welfare systems. Racism and discrimination are toxic stressors with long-term health effects, but experts caution against focusing too much on select populations.
“If you look at one population too much, it will lead people to wrongly associate ACAs with certain groups,” he says. Shannon Tyne., MD, director of pediatrics at Olive View-UCLA Medical Center, director of pediatrics at the LA County Department of Health Services, and co-principal investigator of UCAAN. “While it’s true that ACEs can be elevated in some communities, anyone can suffer, and it’s not visible from the outside.”
Universal screening, which the ACEs Aware initiative supports, “offers the best chance of eliminating bias that can lead to inadequate care.”
Since 1998, growing science on brain development and the effects of stress on the body has only underscored those findings. “Trauma can change the physiology of children and adolescents, and the effects of trauma can last a lifetime,” he says. Christine TangMD, Assistant Clinical Professor of Pediatrics.
Not every individual who experiences ACEs has a good health outcome, especially when there are preventive factors, Dr. Tang pointed out, “However, trauma-based care allows us to recognize and understand the effects of trauma and respond accordingly.” The mental health crisis in our country makes a trauma-informed approach even more important.
When children present with sleep issues or difficult behaviors in the past, for example, pediatricians can counsel parents on sleep hygiene, time limits, distraction methods, and other strategies and make developmental referrals. Trauma-based care encourages providers to understand the context of their patients’ lives—both risk factors and resilience-promoting factors—and to first determine whether symptoms are related to any adverse exposure.
“I teach trainees to think about traumatic and traumatic stress when they see children or adolescents with behavioral problems struggling at home or at school,” said Dr. Tang, UCANN’s director of education and training. “Sleep problems at home or challenging behaviors thought to be ADHD at school can be the result of trauma.
“We teach our trainees to consider the types of feedback that can include a variety of responses, including physical, mental, behavioral and developmental cues.”
Testing for ACEs opens the window to further testing and evaluation of potential issues. “It allows you to take a deeper look at what’s going on with an individual patient and decide what strategies you can use to help them,” says Dr. Thein. “Many people have their own ideas of what trauma-informed care is or what suffering is, but by putting a framework around what is happening to the individual, providers have a better chance of responding in a more tailored way.”
Trauma-informed care is “family-centred, relational care that recognizes and responds to what has happened in the family’s or child’s life and supports parent and child recovery,” says Dr Szilagyi, lead investigator of the UKN pilot-project. ”
But it’s not always easy to get children or their parents to talk about bad experiences. It seeks a welcoming and nurturing environment where patients and families feel safe to share the intimate details of their lives, teaching them to be treated with respect, kindness and compassion.
“We recognize that the work of serving our patients in a trauma-informed approach to care cannot be more than supporting them in their personal growth journey, accepting patients’ full identities without judgment, and making a commitment to respond in ways that support their journey to growth. and recovery from past trauma,” he says. Adam ShikdanzMD, PhD, Assistant Professor of Pediatrics, Chair of the American Academy of Pediatrics Southern California Chapter Committee on Traumatic Childhood Experiences and Principal Investigator of the UCANN Pilot-Project
Additionally, practicing trauma-informed care requires health care providers to acknowledge their own, sometimes culpable, role in contributing to an atmosphere of mistrust among some patients.
“We need to recognize that many patients have traumatic experiences in the health care system, and we need to work to create care experiences that do not create that harm and, above all, work to help people. Their whole body feels safe in medical facilities,” says Dr. Shikdanz.
“If patients can’t feel safe about how they’re dealing with their past stressful experiences, there’s very little they can do with their health care until they feel safe again.”
In working with families to help children heal from negative experiences, Dr. Szilagy advises pediatricians to focus on the three “R’s” – Reassurance; Encouraging processes; and helping children develop coping skills by building emotional vocabulary and showing them ways to cope.
She also urges parents to hold their own emotions when they are with their children and act as “emotional buffers” in a way that helps soothe children and calm their stress responses. Resilience was once thought of as a legacy, she says, but recent research suggests that it comes from a safe, stable, nurturing and responsive caregiver.
The CDC estimates that such connections can prevent CVDs and help children reach their full potential, avoiding up to 1.9 million cases of heart disease and 21 million cases of depression.
“Children need love, reassurance and support,” says Dr. Szilagyi. “They want us to teach them and us to handle things for them. When we can do that for them, they thrive.
This article was written by Dan Gordon and the UCLA Health staff.