Doctor High Five
 

Overview of Adverse Childhood Experiences (ACEs) 

Landmark findings in the CDC and Kaiser Permanente's 1998 study demonstrated that exposure to Adverse Child Experiences (ACEs) can contribute to health disparities over an individual’s lifespan. The more adversity an individual experiences in childhood, the greater their risk for future health problems. CDC provided an update on ACES data in November 2019, which showed that 61% of adults report at least one ACE and 16% of adults report four or more ACEs. In addition, children of different races and ethnicities do not experience ACEs equally. Nationally, 61 percent of Black children and 51 percent of Hispanic children have experienced at least one ACE, compared with 40 percent of white non-Hispanic children and only 23 percent of Asian children.  This report also states that five of the top ten causes of death in the United States are associated with ACEs. This same report estimates that preventing ACEs could significantly reduce many health conditions including up to 21 million cases of depression, up to 1.9 million cases of heart disease, and up to 2.5 million cases of overweight/obesity.

Since the CDC-Kaiser ACEs study, hundreds of research papers have been written to define the types of ACEs, examine the neuroscience, and look at the long-term health effects. 

 

Key takeaways from this research are:

  • ACEs are common (64% of adults report at least one)

    • ACEs often do not occur alone (if you have one, there’s an 87% chance that you have two or more).

  • ACEs are associated with adult onset of chronic disease, such as cancer and heart disease, as well as mental illness, violence and being a victim of violence

  • Primary care can play an important role in mitigating, and even preventing negative health outcomes associated with ACEs

    • ​Discussing ACEs may increase patient adherence to treatment plans​​

    • Knowledge of how ACEs can impact the body can influence what medication and/or approach is most likely to be successful

 

Addressing ACEs in SBHCs brings the response to where youth are, which increases positive health opportunities for students at school and early in life. The Role of School-Based Health Centers in the ACEs Aware Initiative: Current Practices and Recommendations share how this work is unfolding in California SBHCs. The PACEs Connection Resource Center is a curated website of positive and adverse childhood experiences research, guides, trainings, and assessment tools that is clearly organized for further reading.

 
Children Playing Tug of War

Overview of Trauma-Informed Care 

Trauma-informed care approaches patients through the lens of “what happened to you” rather than “what is wrong with you.” This shift in perspective allows for more collaboration between patients and SBHC staff, which ultimately leads to greater understanding of the context for the presenting concerns and what treatment and next steps are most appropriate for each patient. A 2010 article combined definitions of trauma-informed care to provide a consensus definition: “Trauma-informed care is a strengths-based framework that is ground in the understanding of and responsiveness to trauma, that emphasizes physical, emotional, and psychological safety for both survivors and providers, and that creates an opportunity for survivors to rebuild a sense of control and empowerment.”

 

The Substance Abuse and Mental Health Administration describes the four Rs to describe the framework of trauma-informed care. A program, organization, or system that is trauma-informed:  

  • Realizes the widespread impact of trauma and understand potential paths of recovery; 

  • Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system;  

  • Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and 

  • Seeks to actively resist re-traumatization. 

 

A Trauma-Informed SBHC

  • Promotes an environment of safety, empowerment, and healing. 

  • Goes beyond a one-time intervention or training and instead involves a shift in perspective and a commitment over time

  • Provides a comprehensive approach to trauma-informed care adopted at both the clinical and organizational levels

    • Necessary support across the organization, including workflows, policies, and clinic atmosphere create lasting change.

    • Clinical and non-clinical staff, such as front desk workers, patient navigators, and youth educators have significant interactions with patients and can be critical to ensuring that patients feel safe. 

  • Recognizes the potential impact of the inherent power differential between medical and behavioral health care professionals.

  • Builds trust, reduces re-traumatization, and begins to foster resilience. 

    • This takes many forms, such as explaining why sensitive questions are being asked, what will be done with the information, and asking questions like “Is there anything I can do to help your feel more comfortable and safe during your visit?” 

  • Considers the context of the presenting concern.

    • Builds trust, validates, and empowers patients.

    • Provides valuable information that can inform diagnoses and treatment plans as well as referral and follow-up needs.  

 

Trauma-informed practices, extended to include Healing Centered Engagement strategies can be balanced with HOPE informed practices to create a more balanced approach to working with children and families. There are resources available to guide SBHCs in making both the clinical and organizational shift to delivering trauma-informed services and to create trauma-sensitive schools. The California School-Based Health Alliance has put together an online toolkit with practices to increase healing and trauma-informed services at SBHCs and in school communities and in school communities. More resources are found in the Resources section of this toolkit. 

 
Group of Friends

Overview of Healing Centered Engagement  

Healing Centered Engagement, conceived by Dr. Shawn Ginwright, is an extension of trauma-informed practices that moves from the trauma-informed approach framework of “what happened to you” to the lens of “what is right with you." It shows promise as a culturally responsive and strength-based approach while making space for awareness of the impact of trauma on individuals and communities. This framework considers the impacts of individual traumas as well as social-ecological traumas, especially as they relate to communities of color. It emphasizes the power of relationships and strengths to foster healthy outcomes. Ginwright uses the acronym CARMA to describe the five principles of healing centered engagement:

  • Culture and Identity: The values and norms that connect us to a shared identity and community.

  • Agency: The individual and collective power to act, create, and change personal conditions and external systems.

  • Relationship: The capacity to create, sustain, and grow healthy connections with others.

  • Meaning: The profound discovery of who we are, why we are, and what purpose we were born to serve.

  • Aspirations: The capacity to imagine, set, and accomplish goals for personal and collective livelihood and advancement.

 

Healing Centered Engagement believes:

  • Community builds resilience and community engagement is critical to heal community trauma.

    • It is through this belief that we want to engage the youth on how they want their community to be improved to build resilience through empowerment and advocacy

  • Youth need transformative rather than transactional relationships (check out this blog post for more on this topic).

    • Adults must first acknowledge their own experiences with trauma and adverse experiences, with power and privilege, with bias, with systemic oppression, and do the personal work needed to engage youth in an authentic manner.  

 

Healing Centered Engagement is a call to action. It requires individual healing to include attention to community trauma and systemic and institutional contributions to this trauma. To practice Healing Centered Engagement requires youth and adult partnerships to advocate for change in their community. By doing so, they create relationships and experience empowerment that creates resilience.   

 
Happy Children

Building Resilience by Balancing Adverse Childhood Experiences with HOPE 

 

Encouragingly, positive experiences can both prevent and mitigate the impacts of ACEs and toxic stress. New research has emerged on the importance of HOPE, Healthy Outcomes from Positive Experiences, a framework proposed by Dr. Robert Sege that promotes positive experiences for children and families to support children’s development into healthy, resilient adults, despite ACEs. This framework shifts the focus from the adverse experience toward the possibility for flourishing even in the face of adversity and the promotion of the positive experiences that children need. The data show that both positive and negative experiences and relationships in childhood have lasting impacts on adult health. SBHCs are well positioned to support patients and their families grow these positive experiences. Just as it is important to education staff about ACEs and how to include that work in patient care, it is important to do so with positive experiences and to foster interactions in which these can grow.

 

Just as with adverse events, a person's experience of positive events, especially in the face of adversity, leads to changes in brain function. The Four building blocks of positive childhood experiences  (English and Spanish PDF handouts available) that encourage positive health outcomes are:

  • Nurturing and supportive relationships

  • Safe, stable, protective and equitable environments in which to develop, play, and learn

  • Constructive social engagement and connectedness

  • Social and emotional competencies

Click on the image on the right for bilingual (English and Spanish) handouts that explain each of the

four building blocks and how they present across different ages of development.

The handouts also provide a space for parents to check if they are present for their child. 

 

 

Promoting positive health and well-being can be implemented at the individual, family, and community levels to add to the trauma-informed efforts to prevent and mitigate ACEs.  HOPE, out of Tufts University, has put together helpful handouts, videos, and training opportunities for primary care providers to use in their work with patients. Moments of HOPE provides ideas for incorporating HOPE into clinic policy, patient visits, and family education. Four Ways to Assess Positive Childhood Experiences suggests ways for primary care provides to screen for positive experiences using the building blocks of HOPE. More resources, including a self-paced online training for providers, can be found on the HOPE website