Screening for Childhood Trauma

Dr. Ken Epstein has been in the social services sector for nearly four decades and has witnessed firsthand the long-term effects of trauma. As both the son and father of fellow social workers, the work runs in his blood. He has been frontline staff at a residential facility for youth with severe mental and emotional challenges, a therapist, a family and couples therapy professor and director of the Child, Youth and Family System of Care for the City of San Francisco’s Department of Public Health. Now, he’s helping Bay Area health clinics screen for and address childhood trauma through the  Resilient Beginnings Collaborative (RBC), led by  Center for Care Innovations (CCI) and made possible by Genentech.

Trauma is pervasive. Studies show that one in seven children in California experience trauma by age five (Children Now, 2018), and research links adverse childhood experiences (ACEs) – incidences of abuse or neglect, household dysfunction, and community violence – to an increased likelihood of negative health outcomes. In youth, trauma can cause behavioral issues, asthma, and infections; as adults, those same individuals are at greater risk of heart, lung, and autoimmune disease, obesity, mood disorders, and substance use disorders. This is magnified when you include income disparities and the impact of systemic and structural inequities.

When the  Resilient Beginnings Collaborative (RBC) launched in 2018, Genentech and CCI’s goal was to build the capacity of safety net pediatric clinics in five Bay Area counties to prevent and heal the impacts of childhood trauma. The program supports seven sites ranging in size from the hyper-local Petaluma Health Center in Sonoma County to research giant UCSF Benioff Children’s Hospital Oakland. In total, the clinics reach over 50,000 Bay Area children from low-income backgrounds.

Given Dr. Epstein’s experience and leadership in the field, he was a natural ally. He began as an advisor for RBC, but eventually became a coach to train clinical staff on trauma, working with multidisciplinary teams of pediatricians, behavioral health staff, medical assistants, and others at each of the clinics. “I believe that pain and suffering – whether related or in response to violence, poverty, racism, or structural inequity – is trauma,” Epstein says. “It destroys relationships between individuals, within families and organizations, and across sectors.” While working with individual clinicians, Dr. Epstein keeps an eye on how to support healthy teams across whole organizations.

One important tool in identifying childhood trauma is ACEs screening, a questionnaire that asks caregivers and/or youth about adversity in their or their child’s life and is included in routine visits to the doctor. First introduced in the 1990s, screening has garnered statewide support under California Governor Gavin Newsom. In early 2019, Newsom appointed California’s first-ever surgeon general – Dr. Nadine Burke Harris, a pediatrician known for her pioneering work on screening for, researching and responding to childhood trauma, who has been an ally and partner to Genentech’s work on childhood trauma. Remarkably, Governor Newsom has allocated $50 million to train providers to administer ACEs screening and $45 million additional dollars to reimburse doctors for conducting screenings with Medi-Cal patients statewide. This new funding will qualify about 5.4 million children for screening every one to three years, while Medi-Cal-enrolled adults will also be screened once concerning exposure to adversity as a child and throughout their lives.

While many pediatricians and practitioners agree on the value of screening for trauma – early detection means a chance to mitigate often-devastating effects – few are able to do it. “The pressure of capitalization and medicalization within our current health care structure means a system built around deliverables and productivity instead of engagement,” explains Dr. Epstein. “It’s a system where the implementation of electronic health records and capping visits at 15-minutes take precedence over digging into the sociocultural factors and understanding the complexities of adversity.” Changing this mentality is key to addressing trauma.

Staffing can also be a challenge. “If we have a medical assistant to do a warm hand-off between patient and provider, the story comes out and we are able to connect a family to extra support immediately,” said Dr. Jaclyn Czaja, associate medical director for pediatrics and RBC team lead at Ravenswood Family Health Center in East Palo Alto. “But you don’t garner money from a care coordinator who meets with a patient to go over the social stuff. It’s not billable.” And while detecting adversity is a necessary first step, building the infrastructure to adequately respond is just as important. “We screen people and then make a referral to behavioral health,” said Lourdes Juarez, pediatric nurse practitioner at UCSF Benioff Children’s Hospital Oakland, another clinic participating in RBC. “But we need to make sure the systems are in place and services available. If you send people to a waiting list, you jeopardize their trust.”

Among staff at the RBC clinics, Dr. Epstein has found a desire to adopt this “trauma-informed” perspective and deep appreciation for the initiative’s combination of funding, training, and ongoing support. “My generation and the next did a lot of damage to the way we administer health care in this country,” he says. “The generation coming into medicine now is desperate for healing practices, because so much of the current medical model has nothing to do with them. A trauma-informed approach offers doctors a chance to express the reason why they got into the field in the first place.”

Dr. Epstein is seeing significant shifts in the way clinical teams are working together. “Doctors are feeling more empowered to understand what has happened to their patients,” he says. “If I have 15 minutes with a family and the mother says, ‘Johnny is jumping off the walls,’ I could say, ‘Go down the hall and see the behavioral health clinician,’ but chances are only 20% that the parent will follow up. Instead, we strive to have physicians, nurses, medical assistants and front office staff who feel like their relationship with the patient and family matters and they can connect and help frame both the impacts of stress and trauma and focus on ways to support resilience.”

For behavioral health staff, a trauma-informed lens has long been the default orientation. “But as a field, we clinicians can be arrogant,” Epstein says. “This training puts everyone on equal footing. It means that behavioral health is more understanding of the ways they need to consult with doctors, medical assistants, and patients who don’t understand. It’s helping teams take a humbler approach.”

With training and coaching resources in place, the results are encouraging. For the past year, RBC has enabled Marin Community Clinic to pilot ACEs screening at well-child visits and with new patients under age 12. “It’s refreshing to get referrals before there’s a crisis at home or at school,” says Caren Schmidt, PsyD, the clinic’s lead pediatric behavioral health provider. “By getting parents in early, we can educate them about the physiological effects of stress. They feel praised for being proactive rather than shamed for getting it wrong.”

Dr. Epstein is optimistic. He cites the formation of cross-departmental teams, how more staff are being integrated into decision-making and reflection on failures, and the enthusiasm for whole-patient care that he sees across clinics. “We have the opportunity to understand and influence whole families in a pediatric practice, particularly in the first five years of a child’s life,” he says. “Interactions between professionals, caregivers, and children can shift the course of many lives for the better.”

“Universal screening will require supplemental resources and an understanding of the overall workflow,” Dr. Epstein says. “The folks from our clinics will be content experts as new funding comes down from the state. RBC is laying the groundwork and proving how to do this work well.”