Dr. Suzanne Frank has known about the impact of childhood adversity on young lives for decades. She’s seen the fallout in the faces of young people huddled in beds at a children’s shelter where she worked years ago.
She’s seen it as the regional child abuse services and champion for the Permanente Medical Group.
And she’s seen it in hospital examination rooms where, as a member of the Santa Clara County’s Sexual Assault Response Team, she’s been called in to examine shell-shocked children and teens.
Since January 2017, Frank, a pediatrician at Kaiser Permanente’s San Jose campus, has been screening her patients for adverse childhood experiences, along with fellow pediatricians. In doing so, the campus joined Kaiser Hayward and Kaiser San Leandro in a regional rollout of ACEs screening of pediatric patients. It began first at Kaiser Hayward in January 2016, which designed the protocol and is analyzing the results.
For those unfamiliar with such screenings, ACEs comes from the CDC-Kaiser Permanente Adverse Childhood Experiences Study (ACE Study), groundbreaking research that looked at how 10 types of childhood trauma affect long-term health. They include: physical, emotional and sexual abuse; physical and emotional neglect; living with a family member who’s addicted to alcohol or other substances, or who’s depressed or has other mental illnesses; experiencing parental divorce or separation; having a family member who’s incarcerated, and witnessing a mother being abused.
The ACE Study found that the higher someone’s ACE score – the more types of childhood adversity a person experienced – the higher their risk of chronic disease, mental illness, violence, being a victim of violence and several other consequences. The study found that most people (64%) have at least one ACE; 12% of the population has an ACE score of 4. Having an ACE score of 4 nearly doubles the risk of heart disease and cancer. It increases the likelihood of becoming an alcoholic by 700 percent and the risk of attempted suicide by 1200 percent. (For more information, go to ACEs Science 101. To calculate your ACE and resilience scores, go to: Got Your ACE Score?)
Other ACEs surveys include racism, witnessing violence outside the home, bullying, spanking, losing a parent to deportation, living in an unsafe neighborhood, and involvement with the foster care system. Other types of childhood adversity can also include being homeless, living in a war zone, being an immigrant, moving many times, witnessing a sibling being abused, witnessing a father or other caregiver or extended family member being abused, involvement with the criminal justice system, and attending a school that enforces a zero-tolerance discipline policy.
Following the lead of Kaiser Hayward, pediatricians in the San Jose clinic began screening 3-year-olds by having their parents fill out ACEs surveys.
The 10-question ACEs survey, adapted from one designed by the Center for Youth Wellness (see attached) asks parents to read a list of statements and write down a total number of ACEs at the top of statements that apply to their child. For example, in the CYW form, parents are asked if, “At any point since your child was born: Your child’s parents’ or guardians were separated or divorced.” Or, “Your child lived with a household member who served time in jail or prison.”
Frank said they began screening three-year-olds and expanded screening to one through five-year-olds in December. All told the results show that of the 785 children between the ages of one and five who have been screened for ACEs, 734 parents either did not fill out the form or reported a 0 ACE score for their child.
Of the remainder, 38 children scored 1; five had an ACE score of 2; two had an ACE score of 3, and two had ACE scores of 4. The results showed that 51 out of 785 disclosed one or more ACEs, said Frank.
Based on her experience with her patients, however, Frank said, the ACE survey form and the written explanation for why Kaiser is screening needs modifications. She sees it as a work in progress. That’s because, she said, it’s clearly not accurately capturing their ACE scores.
As was evident in the results, Frank said that many of her patients, simply do not fill out the ACEs survey or they put down zero. She speculates one reason may be the language used to explain the reasons for the screening may be “too medical-sounding and doctor-focused rather than patient-focused enough.”
For now, Frank doesn’t see that as a barrier to learning about her patients’ ACEs: “Even if they put zero, there they are still talking to me about ACEs — about drug use at home or about being separated or divorced. This is a tool to bring up the subject.”
Frank is eliciting answers in her chats with patients that gives her the information she needs until the glitches in the process are worked out. A seasoned pediatrician, she’s been at Kaiser San Jose since 1991 and has a good sense of her patients’ ACEs history. She’s now treating the children of many parents whom she had as patients when they were kids. They’ll respond when she asks “How are things at home? Are the kids safe? How are they sleeping? Do they have problems at school?”
And here’s the critical part of all this, Frank says: For parents who answer yes to her questions about their child having troubles at home or at school, or if the child’s ACE score is 1 or more, Frank says doctors review ACEs with the parent, discuss a resilience plan, offer to connect them with an onsite pediatric social worker, and provide them with a Connected Parents Connected Kids ACEs Safety Card, created by the organization Futures without Violence. The social worker is in the clinic part time and can often see patients on the spot to talk and provide more connections in the community, if needed.
“If we’re going to open up a can of worms, we’re negligent if we don't talk about resilience or give them resources to deal with their ACEs,” Frank said.
Frank also pays close attention to what parents say about their own ACEs. Even if the parent reports a zero ACE score for their child, if they’ve revealed to Frank in conversation their own ACE history, she’ll offer a referral to the pediatric social worker, or the on-call adult psychiatry therapist. Frank says that eventually the hope is that parents will also be screened for ACEs.
The emphasis on a two-generational approach to caring for children is not a new one. In 2003, the American Academy of Pediatrics created a Task force on the Family that embraced the concept. The HealthySteps program, used in pediatric programs around the country, is another example of providing support for parents and children.
ACEs Before it was Called ACEs
Frank is hardly new to ACEs science. She recalls that she first saw a presentation about the landmark CDC-Kaiser Permanente Adverse Childhood Experiences Study a couple years after it was first released in 1998. It gave her a framework through which to look at much of her previous work. In addition to participating in a sexual assault response team, Frank has worked at Santa Clara County Juvenile Hall and with organizations supporting domestic violence survivors.
“We knew that all these families had ACEs, we just didn’t have the epidemiology for it,” she said.
In preparation for the rollout of the screening at Kaiser San Jose, Frank provided ACEs 101 trainings to the staff and fellow health care providers, and assembled material provided by the American Academy of Pediatrics tool kit. Staff were also shown the TED talk of Dr. Nadine Burke Harris, the CEO and founder of the Center for Youth Wellness, who has made ACEs education a foundation of her pediatric practice. Her book, The Deepest Well: Healing the Long-Term Effects of Childhood Adversity, came out last month to rave reviews.
At the end of the training, Frank distributed ACE surveys to the staff and invited them to fill it out. Knowing that the experience of learning about one’s own ACEs can also be a triggering experience for staff, Frank said a social worker was available to talk to participants. The campus also offers quarterly training, she added.
Frank has recently expanded her work on ACEs education. She’s a member of Santa Clara County’s ACEs steering committee, which will be launching the first community meeting of the Santa Clara ACES Network on March 13.
The ACEs screenings that Frank and some 35 other pediatricians are conducting at Kaiser San Jose, San Leandro and Hayward are part of a three-year research project. It will look at how patients, staff, and doctors are responding to the ACE screening, the demographics of those screened, and how the screening affects workflow, according to Dr. Paul Espinas, who is leading the effort out of Kaiser Hayward.
Frank says that the ultimate goal many in her county are working towards is systems change toward integrating resiliency-building practices across sectors. “Our aim here is to do universal [ACEs] education in the county that is multi-linguistic and culturally appropriate so people are aware that things that happened to them [in childhood] are not their fault, and can impact them physically and mentally. Once we can get past shame and blame, we can all have a happier life.”
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