When Marin Community Clinics (MCC) first considered screening their patients for adverse childhood experiences (ACEs) they already had decided that if they were going to prevent children from acquiring ACEs, they had to take a radical approach.

Call it “pie in the sky,” says Dr. Caren Schmidt, a child psychologist and the clinics’ lead pediatric behavioral health provider. The idea the clinics were embracing was preventing future trauma for its young patients. MCC serves 35,000 patients, says Schmidt. It includes five medical offices and three dental offices in Marin County, CA, as well as a program for youth.

For MCC, preventing trauma means reaching out to the parents-to-be to better understand the tenor of the household into which a baby is born: “If we could identify a fetus who is at high risk, and present services to the mom and the new baby, then we could prevent ACEs,” says Schmidt, who is coordinating three different interrelated projects to help enable MCC to meet that lofty goal.

Screening pregnant women about adversities in their homes is still in the planning stages. But the clinic began rolling out its ACE survey to its pediatric population in April. It asked parents to fill out ACE surveys for their babies at well-child visits at nine months and 30 months, explains Schmidt. Those times were selected because there are fewer “no shows”, and because parents at those visits are not asked to fill out other questionnaires, so they are less likely to be overwhelmed with “screening fatigue,” says Schmidt. MCC is also screening all new pediatric patients up to the age of 12.

MCC decided to have medical assistants give the ACE survey to patients in the exam room to allow for privacy. They say something along the lines of:

“We have this questionnaire that we give to everyone so your doctor can know more about experiences your child may have had. If you don’t mind reading the questions first and if any apply to you, please write the number that applies to you in the square and if none apply, please write 0,” according to Dr. Heyman Oo, an MCC pediatrician who is leading the effort on the pediatric medical side of the pilot. MCC is also one of six pilot sites that are part of the National Pediatric Practice Community on ACEs, a program of the San Francisco-based Center for Youth Wellness. (The clinics’ pediatric ACEs screen is attached below.)

Any family who has a baby with an ACE score of 2 or higher is considered positive. Since the screening began in April, they’ve screened 85 children, according to the latest data culled through the end of July, with 11 positive scores, says Oo.

For the patients whose scores are 2 and above, says Schmidt, MCC is able to offer everything from access to a local food pantry to individual therapy and parenting groups, which are held at MCC locations and based on the Triple P parenting education model. That’s in addition to support groups for anxiety, depression, and classes in stress management.

As is typical in a pediatric practice, doctors watch carefully the interactions between parent or caregiver and child for signs of any red flags. By having the ACE screener as an extra tool, it provides doctors with added information, says Oo. “If you were to get an inkling that something was off, and you got a positive ACEs screen, I think you might be pushed a little bit more to be like, ‘Hey I notice that your child is responding with temper tantrums, or whatever it is. Sometimes you can see this kind of effect, because of the experiences your child has had based on the screener,’” explains Oo.

All of the pediatric patient families who have been offered the ACE screen have completed them. Of those eligible for an ACE screen, about 60 percent have been screened, according to Oo. “Given that we’ve only been doing it since April, that’s pretty good,” she said. She said that's because some members of the care team forgot to give them to patients. 

After testing out different version of ACE screeners, MCC realized they had to create their own. For example, says Oo, they tried out CYW’s ACE survey, which wasn’t a good fit for their patient population. “There were too many questions,” said Oo. “We have a lot of patients who come from another country with very limited education, so this model of counting out how many of the 20 statements are true and keeping track didn’t seem like it was appropriate for our population.”

The solution? Simplifying the ACE statements down to seven arranged by category. “So all of the abuse statements were categorized into one statement. All of the family separation, whether it was due to immigration or incarceration or death. That was categorized into one statement.”

The vast majority of the clinics’ patients are Spanish speakers, and have the everyday stress of barely scraping by on low wages, says Schmidt. And many of those also have stories of war and violence tucked into their histories.

“Many of the countries of origin are in the midst of full blown wars,” says Schmidt. “They’re being subjected to kidnapping, extortion, murder by gangs or governments. A family was threatened or a person in the family was murdered and they had to leave in the middle of the night and were not able to tell other loved ones.” And in some cases, the border crossings are fraught with the same devastating experiences that have been grabbing headlines in recent months. “There’s abuse, rape and separations,” says Schmidt.

While MCC is aware of the hardships that some of their patients have endured, the clinic is really clear about needing to identify families’ strengths, says Schmidt. As such, they are working on a project to determine what would be the best resilience tool to give to patients at the same time that they learn the ACE scores of their children.

“From my perspective as a child psychologist, it’s an intervention in itself, if you’re screening for resilience along with screening for trauma,” says Schmidt. “In acknowledging the strengths and resilience that they already possess, I think just sends a message that we’re seeing you as a whole person.”

The next steps for MCC, according to Schmidt, are training its 500-member workforce in trauma-informed practices, preparing to screen pregnant women about adversity in their household, and finding the best way to bridge communication between obstetrics and pediatrics once babies at high risk for ACEs are born. (For some of these efforts they will be working with the Resilient Beginning Collaborative, which is a two-year initiative involving seven Bay Area safety net clinics.)  

 Looking at the work the clinics’ have done and where they’re heading, Schmidt reflects, “It’s really exciting. I feel were on the precipice of something amazing.”