Is Trauma-Informed Care the Next Step Forward in Health Equity?
Childhood adversity can have lifelong impact on the mental and physical health and well-being of a child and family. By addressing it early, potentially millions of new cases of heart disease and depression can be avoided.
For confidentiality, patient names have been changed.
Sofia Ruiz knew something was amiss with her daughter, Maya, but she wasn’t getting any answers. The alarming behaviors started before Maya’s second birthday. She stopped eating solid foods and no longer spoke. She began to fixate on soft textures and to recoil at anything sticky or with a strong scent. Her anxiety levels soared — particularly when she saw insects or other flying objects. On multiple occasions, this extreme fear prompted the toddler to dart into the street, jeopardizing her safety. Ruiz didn’t know how to best support her daughter, but she knew she needed help from her pediatrician to sort things out.
Complicating matters were Ruiz’s own life circumstances. As Maya’s worrisome behaviors progressed, Ruiz felt helpless to intervene, and devoid of professional allies who could advocate for her and address her daughter’s needs. She was just 19 when she came to the U.S. from Mexico, and she spent two weeks at the border, sometimes going as long as two days without food. Once in Los Angeles, economic hardships compelled her to live with people she didn’t know well, and after one of her housemates attempted to sexually assault her, Ruiz found herself constantly looking over her shoulder, unable to trust anyone but those closest to her. One of those individuals she felt she could trust, her brother, had been her main source of support, but he died when Maya was just five months old. Through all of the turmoil, Ruiz’s inability to speak English and her undocumented status left her uncertain about where to turn and what resources might be available to help her daughter.
California’s ACEs Aware initiative aims to identify childhood adversity, as well as other social factors, contributing to poor health access and outcomes, and to address these issues with a trauma-informed approach.
Everything changed after Maya was referred to the Strong, Healthy and Resilient Kids (SHARK) program, a trauma-focused primary care and consultation clinic for children with complex medical, developmental and behavioral health needs, many of whom have experienced significant childhood adversity. The program, based at the Los Angeles County Department of Health Services’ Rancho Los Amigos facility, aims to meet the needs of children and families affected by cumulative adversity. It includes screening for 10 adverse childhood experiences (ACEs) that undermine the child’s sense of safety, stability and bonding, and it delivers care that takes into account past or present trauma experienced by parents and their children. SHARK is one of several programs that have received funding through California’s ACEs Aware initiative, a first-in-the-nation effort to identify and respond to toxic stress, which is defined as chronic dysregulation of the body’s stress-response system.
As a growing body of research points to the potential long-term health consequences of early-life adversities and the importance of parental and other supports in buffering against these negative impacts, California is leading the way in delivering what’s known as trauma-informed pediatric care — recognizing the role of previous and current life circumstances in the mental and physical health and well-being of the child and family, and responding in a way that builds resilience and promotes healing. California’s ACEs Aware initiative aims to identify childhood adversity, as well as other social factors, contributing to poor health access and outcomes, and to address these issues with a trauma-informed approach.
UCLA pediatrics professor Shannon Thyne, MD, who also is director of pediatrics for the L.A. County Department of Health Services, is co-principal investigator of the UCLA/UC San Francisco ACEs Aware Family Resilience Network (UCAAN), which since 2021 has been funded by the California Department of Health Care Services to implement ACEs Aware. The initiative offers health care provider training, clinical protocols and added reimbursement to licensed providers who screen children and adults for ACEs. UCAAN also supports academic pilot projects and community grants focused on identifying how to optimize care for children and adults affected by toxic stress. SHARK, where Ruiz and her daughter were referred for care, is one example of ACEs Aware’s programs.
Trauma-informed care puts the onus on health care providers to recognize the adverse life experiences children and their families bring to the health care setting and how these experiences contribute not only to their symptoms, but also to their relationship with the clinical team and their response to care. “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,” Dr. Thyne says. “It’s asking whether or not the family has access to a car before you send them across town for an appointment that might require four buses to get to. It’s asking if there has been trauma that would make it harder to answer questions about sexual identity, or if it’s OK to lift up the patient’s shirt to listen to their heart during an examination. These are things most of us have known were important for our entire careers, but we didn’t have the language for it,” she says.
The link between childhood adversity and poor health outcomes can be traced to an adult obesity clinic at Kaiser Permanente San Diego in the mid-1980s. There, an internist, Vincent J. Felitti, MD, had worked with a female patient who lost nearly 300 pounds in a year, but one day she came in for a follow-up appointment having backslid significantly — gaining almost 40 pounds in three weeks. When Dr. Felitti asked what had triggered the reversal, she attributed her binge eating to the trauma she experienced following an unwanted sexual advance by a coworker, which had reminded her of having been sexually abused as a child.
After seeing similar patterns with other patients who described early-life adversities, Dr. Felitti secured funding from the U.S. Centers for Disease Control and Prevention (CDC) for a study of thousands of patients designed to determine the connection, if any, between adverse childhood experiences and later-life health and well-being. The landmark CDC-Kaiser Permanente Adverse Childhood Experiences Study, published in 1998, asked Kaiser patients to fill out a confidential questionnaire about 10 ACEs, covering experiences of physical, emotional and sexual abuse; neglect; having witnessed violence in the home or community; having a family member attempt or die by suicide; and growing up in a household with substance-use problems, other mental health problems or instability resulting from parental separation of imprisonment. In the study, nearly two-thirds reported having at least one ACE, and nearly one-in-six had four or more. Among the latter group, the researchers found a four-to-12-fold increased risk, decades later, of alcoholism, drug use, depression and suicide attempts, among other negative outcomes.
By demonstrating how common these early-life stressors were — even in a relatively affluent population — and drawing such a clear association between these events and many of the most common health and social conditions in adulthood, the study sent a strong signal that pediatricians had to do more to identify children at health risk due to ACEs and help to prevent these negative outcomes.
“We always had an innate sense that what happens in childhood doesn’t stay in childhood,” says Moira Szilagyi, MD, PhD, division chief of developmental/behavioral pediatrics at UCLA Mattel Children’s Hospital and the Peter Shapiro Professor for Enhancing Children’s Developmental and Behavioral Health. “But to see all of the data was really a clarion call to a lot of us.”
Importantly, Dr. Szilagyi notes, high ACEs scores in the Kaiser/CDC study didn’t guarantee poor later-life outcomes. Subsequent research on early brain development and the biology of the stress response showed that long-term changes in the brain’s structure and chemistry could occur as a result of early trauma, but also suggested that it didn’t have to. “ACEs are not destiny. Kids handle stress pretty well, as long as they have supportive caregiving,” Dr. Szilagyi says. “When they don’t have that, it becomes toxic.”
When approaching patients with a trauma-informed lens, pediatricians are to not just treat the symptom in front of them, but also address them within the context of the child and the child’s family. “The revolution in medicine has involved changing the question when a patient comes in from, ‘What’s wrong with you?’ to ‘What has happened to you?’ so we can help them heal,” Dr. Szilagyi says.
Adam Schickedanz, MD (FEL ’16, ’18), PhD, assistant professor of pediatrics, notes that traditionally, interactions with patients and families have been oriented around providing information and treatment directives, with little consideration for how patients’ past experiences and current circumstances affect their ability to benefit from them. “Trauma-informed care centers the relationship in a way that the more transactional approach to medicine hasn’t always done,” he says. “If you’re going to ignore someone’s past abuse, for example, you’re not really treating a central issue affecting that patient. By adopting the trauma-informed care approach, we acknowledge that the work of serving our patients is inseparable from supporting them through their journey of personal growth — and that considerable opportunity for healing occurs when the care team takes into account the person’s history of trauma and psychological distress.”
For health care providers, focusing on the relationship also means acknowledging and seeking to overcome the mistrust among some patients, stemming from the health care profession’s legacy on issues that include racism, language barriers and other forms of discrimination and marginalization. “It’s incumbent on us to recognize that many patients may have had traumatic experiences with the health care system itself, and we must work to help people feel safe as their full selves in medical spaces,” says Dr. Schickedanz, who chairs the Adverse Childhood Experiences Committee of the American Academy of Pediatrics’ Southern California Chapter and was a UCAAN pilot-project principal investigator. “If patients can’t feel safe in clinic because of how they’re processing their past experiences of trauma in the context of the health care system, often very little can be accomplished through their health care.”
In the years after the Kaiser/CDC findings, Nadine Burke Harris, MD, a San Francisco based pediatrician, emerged as a leader in screening children as a way of preventing ACEs through early identification of potential risks. “Dr. Burke Harris was a champion for children who developed a pioneering trauma-informed-care clinic for kids,” Dr. Thyne says. That leadership led to Dr. Burke Harris’ appointment in 2019 as the first Surgeon General of California, a position she held until February of 2022. In that role, Dr. Burke Harris, in collaboration with the California Department of Health Care Services (DHCS), helped establish ACEs Aware, and in October 2021, DCHS contracted with UCAAN to implement the initiative, with Dr. Thyne, who had already instituted ACEs screening at UCLA-affiliated clinics in L.A. County’s safety net hospitals, as the co-principal investigator.
In the initiative’s first few years, more than 42,000 health care providers completed ACEs Aware training, and Medi-Cal clinicians conducted nearly 3 million ACEs screenings. Nearly two-thirds of the providers trained said they intended to implement changes in their practice.
Christine K. Thang, MD ’15 (RES ’18), a UCLA assistant clinical professor of pediatrics, says she has seen significant changes even since she was in medical school and residency. “In medical school, we learned a lot about whole-person wellness and social determinants of health, but we didn’t really discuss ACEs or toxic stress,” she says. “It was still very problem-focused. Now, at UCLA, these topics are integrated into the curriculum beginning in the first year.”
During her own training, Dr. Thang took a Pediatric Approach to Trauma, Treatment and Resilience (PATTeR) course from the American Academy of Pediatrics. The course was developed by Dr. Szilagyi and her colleagues. “It really spoke to me that promoting safe, stable, nurturing relationships is the foundation of what we do in pediatrics,” Dr. Thang recalls. As director of education and training for UCAAN, Dr. Thang now uses both that training course and the state’s “Becoming ACEs Aware in California” training to teach UCLA medical students and pediatric residents about trauma-informed care. “Just as we conduct surveillance of developmental milestones, we do trauma surveillance by asking if anything has changed since the last time the child was in the clinic, and whether anything scary or upsetting has happened,” she explains.
By supporting evidence-based practices through its pilot projects and training clinicians in trauma-informed care, UCAAN has helped move the focus beyond identifying ACEs to determining how best to mitigate their impacts. In addition to identifying and responding to ACEs, this approach includes identifying social factors that affect health. “If we prescribe the antibiotic amoxicillin for a bacterial infection, it needs to be refrigerated. But if the family doesn’t have a refrigerator, it’s not of any use,” Dr. Thyne says. “And it’s not just the issue of the amoxicillin in the fridge that can impact health outcomes; it’s the trauma that happened in your household when you were younger, the stress you’ve been under, your housing instability, irregular sleep, danger in the neighborhood. It is all of the things that make it harder to face your day that can affect your health.”
ACES Aware employs a tool that goes beyond the traditional 10-question ACEs survey. The PEARLS (Pediatric ACEs and Related Life Events Screener) includes both a screening for ACEs and an additional screening for other adversities, such as food insecurity, housing instability and discrimination. The caregiver completes the survey for children ages 11 and under; for adolescent patients, PEARLS is completed both as a self-report and by the caregiver. “ACEs are things that we can’t undo, but trauma-informed care can help to mitigate the effects of these related life events,” Dr. Thyne says. “Quantifying them together has helped us move toward a more anticipatory approach where we acknowledge what we can’t change and address what we can, aiming to prevent the potential consequences.”
Although certain groups are known to be at higher risk, ACEs Aware emphasizes the importance of a universal approach. Experts note that the original Kaiser/CDC study, which surveyed a relatively affluent, well-educated population, underscores the reality that children in every community can face adverse experiences. “Anyone can experience adversity, and it isn’t necessarily visible from the outside,” Dr. Thyne says. Moreover, she notes, when all patients are routinely asked about ACEs, it helps to normalize and destigmatize the questions and open opportunities for connecting with care-team members who can help support healing from early-life emotional trauma.
Even so, some children or caregivers may be reluctant to reveal adverse experiences. Training providers in trauma-informed care emphasizes the importance of fostering a welcoming and nurturing environment in which patients and families feel safe to share intimate details of their lives. For younger children, screenings are typically timed to coincide with those for developmental milestones; because adolescent life tends to be so dynamic, teens may be screened as often as every year. “Ideally, the patient or caregiver fills out the questionnaire in advance, which allows the provider a chance to review it before meeting with them,” Dr. Thyne says. “During the visit, we explain why we’re asking the questions, and the conversation tends to flow from there.”
“Most families are actually quite relieved that someone cares,” Dr. Szilagyi says. “Often, just asking the question, listening with empathy, validating that you have heard them and normalizing the response can be the first step toward healing.”
Dr. Schickedanz notes that providers must consider the context in which potentially sensitive questions are raised, and the readiness of the patient and family to have the conversations. “There is a lot we can do to set the stage and connect these topics to what people are expecting out of health care,” Dr. Schickedanz says. “On the other hand, if you begin to ask questions where there isn’t readiness, it can be perceived as threatening, stressful and potentially re-traumatizing.”
ACEs don’t tell the whole story. “Not every child who experiences these events is destined to end up with the long-term health implications associated with them,” Dr. Thang says. And on the flip side, an individual may experience trauma from an event that someone else may not experience as traumatic. “People often assume trauma has to be a catastrophic life event, but it’s how the individual experiences it,” Dr. Thang explains. “Even small changes within the household can be traumatic for a child.”
“People often assume trauma has to be a catastrophic life event, but it’s how the individual experiences it. Even small changes within the household can be traumatic for a child.”
What allows some individuals to emerge from ACEs without long-term negative impacts? Dr. Schickedanz points to the buffering effects of positive childhood experiences and resilience building. “That’s where we need to do a lot more work,” he says.
Recent research on stress physiology has made a strong case for the vital role played by caregivers and other social supports in buffering children against toxic stress. Dr. Szilagyi views the discovery of what’s known as the affiliate response to stress as one of the most exciting scientific findings for pediatricians in recent years. She explains that the “fight-or-flight” response triggered by stress releases cortisol, the body’s main stress hormone; chronic stress can result in dysregulation of the hormone, preventing it from returning to normal levels. But during the affiliate response, which is activated by social support, oxytocin is released during a significant stressor, increasing an individual’s ability to assess their safety. “If a child isn’t safe, they go into fight-or-flight and the usual stress responses,” Dr. Szilagyi explains. “But if the child looks around and has a supportive caregiver or social network, they get a flood of oxytocin, which helps them develop a more adaptive response.”
To Dr. Szilagyi, this understanding highlights the importance of pediatricians nurturing caregiver-child relationships as a foundational part of their trauma-informed care. “It changes you from going through the usual medical diagnostic process when someone presents with a symptom to asking about the person’s life, their stressors and strengths and the resources they have,” she says. “And it’s a reminder that the relationship between the caregiver and the child is also my ‘patient.’”
The CDC has stated that safe, stable and nurturing relationships and environments for children can mitigate the impact of ACEs. The potential payoff is substantial — as many as 1.9 million cases of heart disease and 21 million cases of depression could be avoided, the agency has estimated. And, while resilience was once thought of as an inherited trait, recent studies have shown it can be developed.
In advising parents and other caregivers on how they can help build their child’s resilience against the long-term impact of adverse experiences, pediatricians increasingly promote what’s known as the three “R”s. The first is reassurance. “Reassuring children that they’re safe and that you’re there to take care of them after something bad has happened is crucial,” Dr. Szilagyi says. The second is the establishment of routines, so that children know what to expect. This can involve regular meal and bedtime rituals, as well as joint activities that also have the benefit of building the relationship. The third R involves developing the child’s regulation skills, largely by setting an example. Dr. Szilagyi urges caregivers to contain their own emotions when around their children as a way to soothe and calm their stress responses. “Young children can’t modulate their emotions unless the adults in their presence are modulating theirs,” she says. “We all get dysregulated at times, but if that happens, the parent or caregiver can explain that they need a minute to settle themselves, then model healthy ways to cope.”
It’s not easy, particularly when many parents and caregivers are themselves struggling. Early in her tenure as California’s first surgeon general, Dr. Burke Harris set a bold goal: cutting ACEs and toxic stress in half within a generation. That was in February 2020 — a month before the COVID-19 pandemic severely compounded an already brewing mental health crisis. “From the get-go, it was acknowledged that the adversity experienced by an adult is conferred upon the child,” Dr. Thyne says. “The big challenge for those of us who see younger children who don’t yet have their own ACEs, but who live in an environment that has been impacted by adversity, is how we can help disrupt the intergenerational transmission of toxic stress.” Often, that means helping the parent as well, whether through a referral or by pointing them toward resources available to assist them. “If we can help the parent emerge from their toxicity, that’s benefiting the entire family,” Dr. Thyne says.
Despite the barriers to implementation that came with the COVID-19 pandemic, ACEs Aware continues to advance screening and response to childhood adversity and had extended its reach across the state over the past 18 months. More than 20 funded pilot projects from UCLA and UCSF have helped identify strategies to increase awareness and improve management of ACEs-related health conditions, and more than 25 community-based organizations have received funding to implement screening and response activities. These efforts have aligned with California’s Medicaid reform efforts, and now patients identified with ACEs have improved access to funded programs to support their health and social needs, including access to doula services, community health worker supports and engagement in expanded mental health and case management services.
After her daughter visited the shark clinic for a consultation designed to secure behavioral services, Sofia Ruiz was so pleased that she ultimately switched to the clinic and its director, Laura Figueroa-Phillips, MD, for her daughter’s primary care. Maya, now 4, is being evaluated for autism spectrum disorder. To be clear, ACEs are not a risk factor for the development of autism spectrum disorder, but children with autism spectrum disorder are more likely to experiences ACEs. “Dr. Figueroa-Phillips listened to me, and was proactive in connecting me with resources,” Ruiz says through an interpreter.
While her struggles haven’t ended, the clinic’s trauma-informed approach has given Ruiz a sense of agency as she seeks to support Maya. Joining the clinic’s family advisory board allowed her to meet other parents experiencing similar challenges and learn about how to access resources she didn’t realize were available to her. And at the clinic’s recommendation, Ruiz has started receiving mental health services to address her own trauma so that she can become a more effective parent.
“Here, I am reminded that I have a voice, and that I am my child’s advocate,” Ruiz says. “Before, I felt frustrated and hopeless. Now I feel heard.”
Dan Gordon is a frequent contributor to U Magazine. His two-part story, “Amara Yad: Erasing the Stain of a Dark Legacy,” received the Robert G. Fenley Gold Award for Excellence in Writing from the Association of American Medical Colleges.
.
