By Stephanie Guinosso, PhD, MPH | March 9, 2022
Senior Research Associate, ETR
Team Acknowledgments: Kelly Whitaker, PhD, MPA (ETR), Jessica Dyer, LCSW (California School-Based Health Alliance)
Adverse Childhood Experiences
Adverse childhood experiences (ACEs) and toxic stress represent an urgent public health issue in the United States. As we enter the third decade of research on ACEs, the science is clear that:
- ACEs are common and frequently co-occur. Findings from the 2016 National Survey of Children’s Health estimate that 46% of U.S. children under 18 years have been exposed to at least one childhood adversity, and 30% have been exposed to two or more.
- ACEs are associated in a dose-response fashion with many leading causes of poor health in children and adults. When left unaddressed or without the buffering support of safe and supportive relationships and environments, the toxic stress that results from childhood adversity can have immediate and lifelong adverse effects on social, emotional, and physical well-being, including academic success.
- While ACEs affect all communities, inequities exist along axes of race, ethnicity, class, gender, sexuality, and educational attainment. Stressors rooted in structural and systemic factors (i.e., poverty, racism and other forms of discrimination, and exposure to community violence) may increase the likelihood of experiencing other ACEs and toxic stress and reduce the availability of buffering supports.
- Safe, stable, and nurturing relationships and environments can both protect against the harmful effect of ACEs and promote child and family flourishing. ACEs are not destiny. With support, healing and well-being are possible at any age.
What are ACEs?
Adverse Childhood Experiences (ACEs) are highly stressful and potentially traumatic experiences that happen before the age of 18.
California’s ACEs Aware Initiative
California’s ACEs Aware initiative has the bold goal of reducing ACEs and toxic stress by half in one generation. The initiative focuses on prevention education, early identification of ACEs, and treatment of toxic stress through primary care settings.
One of the key elements of the ACEs Aware initiative is to ensure that available resources and tools reach community practices through training and provider engagement events, a robust set of communication activities, and the development of networks of care.
In June 2020, ETR received grant funding from the ACEs Aware initiative, in partnership with the California School-Based Health Alliance, to engage Medi-Cal providers in school-based health centers (SBHCs) to describe emerging practices and barriers and facilitators to implementing trauma-informed care and ACEs screening in these settings.
Why School-Based Health Centers?
SBHCs are well-positioned to coordinate care for some of California’s most medically underserved youth. SBHCs are located on school grounds and often employ multidisciplinary health and mental health professionals (e.g., nurses, psychologists, and social workers) who consult regularly with school- and community-based professionals to assure that students get necessary services and supports. SBHCs provide high-quality, convenient, culturally responsive, and youth-friendly care. They also eliminate many structural barriers to service use, such as transportation, cost, language barriers, available hours, and lack of confidential services for adolescents.
Despite national recommendations for pediatric clinics to screen for ACEs and treat toxic stress, the majority of pediatric clinics have yet to adopt this recommendation, and there is limited research on ACE screening implementation in SBHCs. To address this gap, our team conducted:
- Listening sessions with 110 school-based health providers;
- A virtual professional learning collaborative with nine SBHC providers;
- In-depth interviews with 10 key stakeholders across four SBHC sites; and
- A comprehensive literature review and environmental scan.
We summarized our key findings and recommendations in a recent practice paper available on the ACEs Aware website.
From the Research:
"I'm able to create these dialogues and these conversations with young people that revolve around them and things they've experienced. It has created really meaningful relationships within the clinic itself." — SBHC Medical Social Worker
What Did We Learn?
- Addressing ACEs and trauma in a clinical setting begins with an organizational culture of trauma-informed care. This requires the investment of time and resources from key champions and leadership and ongoing opportunities for training and professional development made available to all staff. SBHCs are inherently oriented towards trauma-informed care, given their orientation to youth-centered, relationship-driven care.
- There are many barriers to implementing ACE screening in SBHC settings, particularly in the context of confidential adolescent care. Barriers include lack of mental health capacity to address identified needs, lack of staff training, issues of time and paperwork, and concerns about negative unintended consequences of ACE screening.
- Engaging stakeholders early and often is essential to implementing trauma-informed screening practices that are responsive to the school community. One SBHC engaged a Youth Advisory Board prior to implementing ACE screening and learned that youth really wanted to know who would see their personal information, where it would be stored, and how it would be used. Youth gave advice on how they wanted the screening presented to them and roleplayed scenarios with clinical providers.
- SBHCs are often viewed as a trusted source of care, and despite concerns that ACE screening would negatively impact provider-patient relationships, providers commonly shared positive stories about the clinical encounter. These narratives support other research that demonstrates patients’ acceptance of ACE screening.
- Investments in collaborative care models and mental health providers are essential for addressing the holistic physical, mental, and social services needs that accompany ACEs. SBHCs credited their success at addressing student needs to integrated care teams and strong partnerships with school staff and community partners, including clinical staff dedicated to care coordination (e.g., wellness navigators, community health workers, and medical social workers).
- In addition to providing individualized patient care, SBHC providers are uniquely situated to offer universal education and interventions to mitigate the impact of ACEs and toxic stress for entire school communities. Universal education ensures all students receive beneficial education and can help health professionals build trust with and support special populations that are more likely to have experienced ACEs (e.g., justice-involved youth, youth in foster care, immigrant youth, etc.) without requiring ACE disclosure. SBHCs can also identify trends (e.g., food insecurity) that may benefit from a community intervention rather than individual interventions.
- Learning communities fill an important gap in the absence of evidence-based practices. Throughout our project, there was limited implementation research to guide early adopters of ACE screening with best or promising practices. Our team used a case-consultation model to share the emerging practices, challenges, and lessons learned, and to engage peers in collaborative problem-solving.
ETR also had the pleasure of partnering with Trauma Transformed in another grant funded through ACEs Aware, to develop an asynchronous e-learning course for clinical providers. The course explores issues of bias and medical racism, the relationship between stress arousal and bias in decision-making, and strategies to mitigate bias in ACE education, early identification, and treatment. Access the course for FREE here.
Check out a number of other practice papers developed by ACEs Aware grantees here. Several publications focus on school-based settings and adolescent populations.
For more information or questions about our work, please contact firstname.lastname@example.org.
Stephanie Guinosso, PhD, MPH, (she/her/hers) is a Senior Research Associate at ETR. She specializes in school-based trauma-informed approaches. She can be reached at email@example.com.