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 Hospitalsdayna.long@ucsf.edu

Thank You