What is trauma-informed care? The next step to health equity
‘I don't want responding to trauma to be a one-off.’
Trauma in childhood has been linked to poorer health outcomes, such as asthma, obesity, depression and cancer. Data from the California Department of Public Health’s Injury and Violence Prevention Branch show that more than 60% of Californians have experienced at least one Adverse Childhood Experience (ACE).
The sheer number of people who have experienced childhood trauma emphasizes the importance of evidence-based training, screening, and interventions, according to Shannon Thyne, MD, professor of pediatrics at the David Geffen School of Medicine at UCLA.
“A lot of people have their ideas of what trauma-informed care is or what adversity is, but putting a framework around what’s going on for an individual gives providers a better opportunity to respond in a more tailored way,” she says.
Last year, the California Department of Health Care Services (DHCS) awarded $41.5 million to UCLA to form a multi-campus entity to advance the field of ACE science and trauma-informed care by taking over implementation of the state of California’s ACEs Aware initiative, which is funded by DHCS and led in partnership with the Office of the California Surgeon General.
The University of California ACEs Aware Family Resilience Network (UCAAN), led by Dr. Thyne and Edward Machtinger, MD from UCSF, develops, promotes, and sustains evidence-based methods to screen for ACEs, treats the impacts of toxic stress and trauma, and helps patients heal.
Since 2019, DHCS has supported identifying and responding to trauma through screening and response to ACEs, and has provided reimbursement to Medi-Cal providers who engage in screening, treatment, and response activities.
What is trauma-informed care?
Trauma-informed care has been historically implemented in pediatrics, family medicine, and maternal care.
According to ACEs Aware, the framework involves:
- Understanding the prevalence of trauma and adversity and their impacts on health and behavior.
- Recognizing the effects of trauma and adversity on health and behavior.
- Training leadership, providers, and staff on responding to patients.
- Integrating knowledge about trauma and adversity into policies, procedures, practices, and treatment planning.
- Avoiding re-traumatization by approaching patients who have experienced ACEs and/or other adversities with non-judgmental support.
ACE screening is one of many ways to assess for toxic stress in a household.
“Screening for ACEs allows you to dig a little deeper into what’s going on for an individual patient, and determine what strategies you can employ to help them,” says Dr. Thyne, who is also vice-chair in the Department of Pediatrics, chief of pediatrics at Olive View-UCLA Medical Center, and director of pediatrics for the Los Angeles County Department of Health Services.
"For example, if a child lives in a household affected by mental illness and also experiences food insecurity, you can address their food insecurity by connecting the family with CalFresh,” she says. “Then, as a longer-term strategy, you can explore with the family how mental illness may be causing toxic stress. Using some of the ACEs Aware tools, such as stressbusters and mindfulness, you can support building resilience.”
An ACE score is determined by the number of “yes” answers to the 10-question ACE survey (with different versions geared toward children and adults). This score refers to the total number of categories experienced, not the severity or frequency of any one category.
“Just like when your oxygen saturations are abnormal, you put on an oxygen mask; when your trauma score is really high or your ACEs score is really high, you respond,” Dr. Thyne says. "Part of what we want to do is develop evidence-based algorithms for managing toxic stress and associated health conditions that are tailored to the individual.”
Scores are divided into ranges to inform the appropriate clinical response. The ACE score is only one component of the ACE screening, though. A more complete screening includes the ACE score, as well as looking for clinical manifestations of toxic stress and protective factors, such as social connection, nurturing and attachment, and concrete supports for parents and caregivers.
How the pandemic changed us
Framing trauma and ACEs through the lens of the COVID-19 pandemic has been a helpful tactic for Dr. Thyne and her colleagues.
“Almost everyone in the world has experienced trauma due to the pandemic, which has made people more open to discussing their trauma and seeking support,” she says.
Early on in the pandemic, Dr. Thyne met a new mother who expressed her worries of how past traumas in her own life could affect her baby. After discussing her ACE score with her, Dr. Thyne and the care team helped her create a plan to support her child and family’s health – in this case, through incorporating better sleep hygiene, increasing medical follow ups, and providing a referral to mental health care.
“After the visit, she said to me, ‘Dr. Thyne, how are you doing? This pandemic has been hard on all of us and you’ve been showing up to work every day. I hope you have support from your own doctor and hospital to help you get through this.’”
Dr. Thyne was grateful for the support and impressed by this new mother’s own trauma-informed lens, even in the setting of her personal challenges.
“The pandemic has, in some ways, leveled the field,” she says, “making us all more comfortable with addressing personal trauma in the medical setting.”
While ACEs affect all communities, studies show that there is a higher prevalence among individuals from systemically overlooked communities, such as people who have experiences with the justice and child welfare systems. Racism and discrimination are risk factors of toxic stress and have long-term health impacts.
However, toxic stress and ACEs can happen to any child or adult, from any background or demographic.
Dr. Thyne supports broad screening and cautions providers on over- or under-screening select populations.
“If you over-screen one population, that leads people to wrongly associate ACEs only with certain groups. While it is true that ACEs may be higher in some communities, anyone can experience adversity, and it is not visible from the outside,” she says. “Screening broadly provides the best opportunity to avoid bias that could lead to inadequate care.”
By having a standardized and evidence-based tool for screening, providers can improve systemic health equity, Dr. Thyne says.
“I tell our residents, if you do the same thing every time, you do your best job of minimizing bias,” she says. “This applies to screening for anemia, and to screening for ACEs. You can’t respond to something you haven’t correctly identified.”
Patient and physician resources
Through ACEs Aware, 23,400 individuals, including physicians, nurse practitioners, medical assistants, social workers, psychiatrists, trainees, and other members of care teams completed training between December 4, 2019, and May 31, 2022. At UCLA Health, more than 110 providers have completed the Becoming ACEs Aware in California training and are eligible to screen patients.
“What we really want to do is screen in a setting where we can have the capacity to support –through training and through educating yourself about the resources available in your community: food banks, mental health clinics, weight management programs, and daycares, for example,” Dr. Thyne says.
“It’s important to be ready to respond. If you screen for ACEs and you don't have a plan for what to do with those results, it's like ordering a mammogram for someone without being able to send them to a surgeon when you find a mass.”
For example, Dr. Thyne’s clinic saw a teenage patient who had significant exposure to toxic stress, and was experiencing ACE-associated health conditions, such as depression, obesity, and a pre-diabetes diagnosis.
The clinic increased the cadence of her visits, introduced her to meditation, educated her about healthy food choices, and connected her to community services. Through a trauma-informed approach, her care team has seen a drop in blood sugar and depression, and she’s entered a weight management program.
“At her last visit, I apologized for the long wait for her COVID-19 booster and she said, ‘It’s OK, I love coming here.’”
Dr. Thyne hopes that medical providers will learn to see all visits through a trauma-informed lens. This would normalize discussing underlying exposure to toxic stress, she says, likening it to taking a temperature, checking a pulse, or measuring blood pressure.
“The history that you bring to the visit, including high blood pressure, smoking, or the violence that led to your anxiety that worsened your blood pressure, would all be looked at objectively as part of how you got to that moment,” she says.
With certified training, health care providers can transform their practice to become more trauma-informed. Simple adjustments providers can make include:
- Ensuring patients have the ability to check in privately.
- Having interpreter services options and asking patients if they need those services in a way that doesn’t make them feel badly.
- Creating a welcoming space with a variety of seating options for people of all sizes and abilities.
“Talking about ACEs may seem like common sense, especially when we emerge from the pandemic, but we need a framework for successful treatment and healing,” Dr. Thyne says. UCAAN’s work, she says, has the potential to support expanded training, better screening, and a more robust response framework that extends beyond the clinical setting.
“I don’t want responding to trauma to be a one-off. I want your trauma score to be a vital sign.”
ACEs Aware offers a free, two-hour online training, “Becoming ACEs Aware in California” that educates clinicians and their teams about trauma-informed care.
Completing this training enables Medi-Cal providers to self-attest, allowing them to bill and be reimbursed $29 for each screen of a Medi-Cal beneficiary.