Responding to Children's Toxic Stress in the Medical Home: Embedding Lessons Learned from the ACES study into Primary Care Practice

What if primary care providers paid as much attention to hidden emotional ailments as they did physical ailments?

Photo of Jeff Shahidullah
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Founding Story: Share a story about a key experience or spark that helps the network understand why this project got started or a story about how you became inspired about the potential for this project to succeed.

Before there is chronic illness, early death, smoking, incarceration, school drop-out, and substance abuse, there are ACEs. Adverse Childhood Experiences are stressful or traumatic events (abuse, neglect, household dysfunction). The term "ACEs" was developed after a groundbreaking study found that accumulation of ACEs were correlated with adverse outcomes across the lifespan. Given the importance of early identification of these risk factors, I decided to train pediatricians in detecting ACEs.

Which categories describe you? (the answer will not be public)

  • Asian (for example: Chinese, Filipino, Indian, Vietnamese, Korean, Japanese, Pakistani)

Website

http://gsappweb.rutgers.edu/facstaff/dynamic/profile.php?ID=2562

Location: Where is your organization headquartered? [State]

  • New Jersey

Location: Where is your organization headquartered? [City]

Piscataway

Location: Where is your project primarily creating impact? [State]

  • New Jersey

Location: Where is your project primarily creating impact? [City]

New Brunswick

Problem: What problem is this project trying to address?

New Brunswick has a disproportionate number of health and social problems including high rates of school drop-out, violence, disease, and death according to a New Brunswick Community Health Assessment Report published by the Rutgers. Children growing up in the community have higher exposure rates to crime, inadequate housing, and poverty. This accumulation of ACEs puts youth in New Brunswick increased risk of maladaptive outcomes.

I have partnered with Rutgers Robert Wood Johnson Medical School to train future pediatrians to assess for ACEs in all well-child visits in pediatric primary care. This training will occur in the pediatric resident program and occur for the next several years.

Is your model focused on any of the following traditionally underserved communities?

  • Communities of color

Does your model work within any of the following sectors?

  • Child and Family Services

Year Founded

2016

Project Stage

  • Start-Up (a pilot that has just started operating)

Example: Walk the network through a specific example of what happens when a person or group engages with your solution.

Pediatric medical residents at Rutgers-Robert Wood Johnson Medical School will be trained on how to screen all children who present for a well-child visit in primary care for ACEs. They will also be trained on how to respond to needs of children who screen positive for ACEs. This often will include making a referral for mental health or behavioral health services in the community. These trainings will be built into the didactic curriculum that residents are exposed to and include lectures specifically on the ACEs study, toxic stress, and child abuse assessment and reporting. Training will also include information on helping families tap into much needed social services.

Impact: What was the impact of your work last year? Please also describe the projected future impact for the coming years.

I initially began the training curriculum with pediatric residents in another health system in a different state. Pediatric medical residents report having improved attitudes, knowledge, and skills in assessing and managing behavioral health conditions in the primary care setting. Anecdotal feedback indicates that residents are asking patients more often about adverse childhood experiences. As a result of this intentional asking of adverse childhood experiences, they are making more referrals to behavioral health so that more children are receiving needed care. This training curriculum will begin at Rutgers in August 2016. Data will be collected from all pediatric residents exposed to the curriculum and I hope to expand the curriculum to other health systems in the future.

Organization Type

  • nonprofit/NGO/citizen sector

Annual Budget

  • less than $1k

Financial Sustainability Plan: What is your solution’s plan to ensure financial sustainability?

Currently, this project requires no funding as I am delivering the trainings and collecting data on outcomes using internal funds from my employing department (Graduate School of Applied and Professional Psychology at Rutgers). I hope in the future to obtain grant funding from The Robert Wood Johnson Foundation to scale of the curriculum and expand into other sites.

Unique Value Proposition: How else is this problem being addressed? Are there other organizations working in the same field, and how does your project differ from these other approaches?

The current training that residents at RWJ medical school receive is the minimum standard required by ACGME (the medical education association in the US). Moreover, most other residency training programs only require this minimum training standard which consists of, for mental health, a 1-month block rotation in developmental-behavioral pediatrics. In sum, very little additional training occurs on mental health and specifically for addressing aspects such as abuse, trauma, and neglect.

Reflect on the Field and its Future: Stepping outside of your project, what do you see as the most important or promising shifts that can advance children’s wellbeing?

This project has the potential to emphasize the importance of university screening for emotional concens such as childhood adverse experiences that are major contributors to maladaptive outcomes throughout the lifespan. This initiative has the chance to increase rates of mental health referrals for early intervention for children with expososure to ACEs to hopefully prevent future maladaptive outcomes from occuring.

Source: How did you hear about the Children’s Wellbeing Challenge? (the answer will not be public)

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Photo of Melanie
Team

Hi Jeff,

Your ACEs-based pediatric training program sounds exciting.  It immediately creates another safety net for at-risk children. Longterm it may address behavioral/mental health concerns early enough to mitigate the negative effects across a lifetime.

Involving pediatricians also helps to "decriminalize" or destigmatize ACEs scores. When toxic stress and traumatic events are seen as a community services issue rather than simply as bad choices or lifestyle failings, the chance for meaningful change increases.

For example, women who reported partners who were violent ran the risk of having their children removed by child welfare because the domestic violence created an "unsafe home environment." This kind of "blame the victim" mentality discouraged women from reporting their abuser to the police, cut them off from receiving any supportive services, and put at-risk children at an even higher risk of harm.

I know of families who live on the margins who won't report problems like childhood asthma because they are afraid it will involve social workers and child welfare.

Punitive measures - especially when it comes to children's health and wellbeing - never work. ACEs represents a way to heal the whole family by healing the environment around the whole family. That is a big idea.  When we all buy into the idea that "it takes a village," our children - our future - will be strong and healthy. Intra-agency cooperation will help make ACEs a powerful tool for family - and social - change.

Your project is one of 5 ACEs Changemaker's proposals for Children's Wellbeing. It's awesome to see such energy devoted to a truly groundbreaking model.

Best of luck with your work. Looking forward to learning more.
- Melanie