Children in Kern County and throughout California may be screened for childhood trauma and toxic stress during routine pediatrician visits starting this year.
The screenings are part of a new state initiative to identify adverse childhood experiences, known as ACEs, which a growing body of research shows can significantly increase the risk of poor health outcomes later in life, ranging from suicide, alcohol addiction, depression and drug use to heart disease, cancer and obesity.
The screening will ask a child's caregiver, or the child if old enough, to complete a questionnaire that asks about physical and sexual abuse, physical and emotional neglect and household dysfunction — situations like growing up in poverty or with a parent who is incarcerated, addicted to drugs or mentally ill. These events have been shown to induce stress in children, and in the absence of a caring adult to help the child cope, can eventually lead to problems later in life.
"There’s an effect that's gradual and progresses and later on it leads to early death," said Dr. Tintin Manuela-Abad, a pediatrician at Kaiser Permanente's Coffee Road location who has undergone special training on the topic.
By screening children, health providers hope to intervene earlier in treating their traumas and preventing chronic stressors in order to put the child on a better pathway through life. It would also cut down on a significant number of chronic illnesses and disease in the future.
GREATEST PUBLIC HEALTH THREAT TODAY
Nadine Burke Harris, who was named California's first surgeon general by Gov. Gavin Newsom, is a champion of increasing understanding of the role childhood trauma plays in people's lives, especially children. A pediatrician by training, she spoke in a TED talk about how childhood trauma is the "single greatest unaddressed health threat facing the public today."
Her advocacy is based on a significant research study in the mid-1990s by the Centers for Disease Control and Prevention and Kaiser Permanente, which found the constant overloading of the body’s stress-response system in childhood often leads to a series of health issues over a lifetime. Those afflicted are more likely to abuse alcohol, turn to injection drugs, die by suicide and contend with cardiovascular health problems. Their lifespans are significantly shorter, by as much as 20 years.
In her TED talk, Harris explained how fight-or-flight stress, the type you may experience if you encounter a bear in the woods, is a good thing. But in higher, more consistent doses, the effect is the opposite.
"What happens when this bear comes home every night and it happens over and over and over?" she asked. "It goes from being lifesaving (stress), to being maladaptive. Children are especially sensitive because they're developing."
In 2020, the state will start paying Medi-Cal providers $29 per screening, with funding from Proposition 56, the tobacco tax increase that was passed in 2016. It is recommended to assess children 18 and under each year.
LIKE LOOKING THROUGH A DIFFERENT LENS
Kaiser Permanente in Kern County started screening pediatric patients for adverse childhood events in September and pediatrician Manuela-Abad said it has changed her perspective on treating children.
"It opened my mind to the possibility to not just treat what I’m seeing because there might be some hidden thing," she said. "It’s looking through a different lens now."
She used attention-deficit hyperactivity disorder as an example. Instead of a true case of ADHD, a child exhibiting symptoms of the disorder may have experienced trauma or have issues at home that are causing those behaviors, she said.
She said parents may not be forthcoming with their child's history until they learn how it fits into the child's long-term health, and that the child's doctor is interested in knowing.
"If we take the time and tell them that someone is listening, we’ll be surprised," she said.
All Kaiser doctors in Kern County who see children have been trained to do the screening during well-child visits and there are plans to extend the screening to adults, too, because, as Manuela-Abad said, they're the ones dealing with "the full-blown affects of ACEs."
An issue providers face is what to do when a patient is found to have childhood trauma.
It's one of the first questions doctors ask when Joseph Hayes, chief medical officer for Omni Family Health, has talked about the ACEs screening program for children, which the group plans to implement this year: "If we find a high number of (ACEs), what do we do?"
A patient could be referred to therapy or counseling, or prescribed medication to treat problems, such as depression, experts say. And having a caring adult in their life is shown to have mitigating effects on trauma, studies show.
But in many ways, just the understanding alone that an individual — whether a child or adult — has past trauma affecting his or her life can help inform how a health provider approaches that person. It's called trauma-informed care and has become something of a movement in health care in recent years as the understanding of ACEs and childhood trauma has increased. It means that providers take into account an individual's past trauma and the resulting coping mechanisms when attempting to understand and treat the patient.
WHAT HAPPENED TO YOU?
Trauma-informed care means you "don’t ask what’s wrong with you, ask what’s happened to you," said Marc Thibault, who has trained dozens of people from local organizations on the topic in the past two years through a First 5 Kern program.
And it's one of the main reasons Hayes decided to implement the screening program for children at Omni — because it gives doctors exposure to the emerging movement of trauma-informed care and its relationship to childhood trauma.
"Sometimes it gives you some insight into why the person is refusing a particular procedure. If you don’t know about these things, you think they’re just being stubborn or don’t understand and you keep trying to explain to them," Hayes said. "You don’t understand the connection to their trauma."
Hayes also feels that incorporating childhood trauma screening into medical practice will provide patients the opportunity to reveal some of their past experiences and perhaps even seek therapy.
"It may open the door to some people talking about how it affects their lives and their emotions," he said.