This story is part of an occasional series where we check in with physicians who are launching ACEs screening in California. This is the first snapshot of the Solano County Family Health Service’s pilot in its Vacaville Clinic.
In 2017, Dr. Shandi Fuller, a pediatrician at the Solano County Family Health Services in Northern California, was inspired by the groundbreaking film Resilience: The Biology of Stress & The Science of Hope, which reinforced her belief in the importance of dealing with toxic stress.
"When we go through [trauma] in childhood or at any age, you don’t just brush yourself off and get over it without some healing behind it,” Fuller says. “When I watched the film, it solidified and validated that for me.” It also galvanized her into action. Her first move was to show the film at their four clinics in Vacaville, Fairfield and Vallejo to set in motion a plan to tackle trauma in their patient population.
The documentary addresses ACEs science. The term ACEs, which stands for adverse childhood experiences, comes from the landmark CDC/Kaiser Permanente Adverse Childhood Experiences Study (ACE Study) of more than 17,000 adults. The study linked ACEs to the adult onset of many chronic diseases, as well as mental illness, violence and being a victim of violence in more than 17,000 adults.
The ACE Study is one of five parts of ACEs science examined by the film, which looks at how toxic stress from ACEs affects children’s brains, the short- and long-term health effects of toxic stress, how toxic stress is passed on from generation to generation, and research on resilience, which includes how individuals, organizations, systems and communities can integrate ACEs science to solve our most intractable problems.
The original ACE Study examined 10 types of childhood traumas — including living with an alcoholic or depressed parent or experiencing abuse or neglect — in adults who were mostly white, middle- and upper-middle class, college-educated, and had jobs and great health care. The study found that ACEs are common — most people have at least one. People who have four or more different types of ACEs — about 12 percent of the population — have, among a host of consequences, a 1200 percent higher risk of attempting suicide and a 700 percent higher risk of becoming an alcoholic, compared with people who have no ACEs. Many other types of ACEs —including racism, economic inequality, bullying, a parent being deported, and community violence — have been added to subsequent ACE surveys. (ACEs Science 101; Got Your ACE/Resilience Score?)
At each screening of Resilience, Fuller talked about the ACE Study, how widespread ACEs are, and invited staff to fill out ACEs surveys to learn their own scores. “Overall it made people reflect inwardly about how trauma shaped their own lives,” says Fuller.
Fuller had another reason, however, for holding the screenings and talks. It was to gauge which of the clinics was best suited for piloting ACEs screening and ACEs science education. The Vacaville location was enthusiastic about the film and the one most ready to be on the front lines of helping their patients heal from trauma.
For Teresa DelReal, a medical assistant at the Vacaville clinic, seeing the film Resilience really struck a chord for her and added another layer to how she interacted with patients.
“I think it made me more empathetic to the challenges that patients face in their everyday life — abuse, neglect, being placed in foster care,” she says. “We see these little foster kids come in with different foster parents. It’s so sad.”
Fuller was also well aware that for any pilot to gain traction, it had to have the clinics’ leadership on board. Fortunately, that didn’t require much convincing. Oprah Winfrey provided Fuller a talking point when Winfrey spoke about ACEs science in March 2018 on a television program.
“Winfrey had talked about how important adverse childhood experiences are. And if Oprah Winfrey is talking about ACEs, this is definitely something we want to look into doing,” she wrote clinic leaders. Fuller urged the clinics’ leaders to prioritize screening for childhood trauma among the patients served by their clinics.
But before pressing on to piloting ACEs screening at Vacaville, Fuller knew the clinic had to do its due diligence — gauging and expanding awareness among staff of the interconnection of racial and cultural equity to healing trauma. A glaring example of why an equity lens is sorely needed everywhere, explains Fuller, is in the high mortality rates for Black infants and mothers. “Time and time again we hear statements from Black women who feel unheard, unseen and unvalued by their doctors as they try to advocate for themselves,” she says.
She and some of the clinics’ leaders called a town hall meeting of 200 staff members, who were required to attend. “Our main point [at the town hall] was: If we’re seeing poor health outcomes in a middle class, mostly white population (in the ACE Study), then imagine the impact on those populations that don’t have the same resources,” explains Fuller. Any screening that doesn’t take those discrepancies into account would inevitably fall short.
But initially there was pushback from some of the staff. “There was the sense of, ‘Why are we talking about this?’” she says. “I think it’s not a topic that’s been talked about in medicine until recently.”
Soon, however, people began to open up about their own experiences with race, and with their patients and fellow staff members. “We got into a conversation about cultural differences and race and how what you tell one person may be taken differently because of their background,” Fuller says. The staff spoke about the necessity of recognizing one’s own biases and learning to be cognizant of a patient’s background — or, as Fuller explains, about “how to meet [patients] where they are in order for your advice to carry weight.”
After monthly meetings, Fuller and a small team — including one pediatrician, a family medicine provider and two medical assistants — settled on screening adults, including parents, at the Vacaville clinic for the pilot, which began in the summer of 2019.
All adult patients were handed an ACEs questionnaire with the following written explanation: “None of us grew up in a perfect family. Some of us, however, grew up in very dysfunctional or unsafe homes. As your medical provider, it is helpful for me to know what you have experienced while growing up. It helps me to better understand how to support you in times or experiences that are challenging.”
But the document emphasized that adversity is only part of the story, also stating: “We find that resilience, the ability to ‘bounce back’, is just as important as adversity. We know that resilience can also be nurtured and developed with positive experiences and relationships.”
The clinic started exclusively with adults to better understand how they reacted to being asked sensitive questions about their own histories of abuse and neglect before the clinic started asking about children.
“Also,” says Fuller, “we figured that if the parent had a high ACEs score, then [we would know] there was more risk for the baby.”
The results were surprising. Sixty percent of the 205 childless adult patients reported scores of 4 or more; the average score was 3.72. Fuller and the other team members expected that parents and adults without children would have similar ACE scores, since they’re all from the same community. But the results showed huge discrepancies. “The parents were coming back with scores of 0 or 1, while most adults without kids scored 4 or more,” Fuller says. Because of the discrepancy, Fuller says the parents’ ACE score results lacked validity, so the data wasn’t provided.
“We thought maybe parents [were afraid] that if they divulged all this information, they would wonder what we were going to do with it, and that maybe Child Protective Services was going to get involved,” adds Fuller.
Pediatrician Rebekah Kim says that when she was reviewing the ACEs screen with parents, she had asked them how they were feeling, if they had any questions, and offered patients the opportunity to debrief with their social worker, who was able to see patients the same day as the screening. She thinks that perhaps one of the reasons for the discrepancy between parent and childless adult scores was fatigue. “They have two-month old infants; they’re exhausted,” she says.
Two months into ACEs screening, Fuller broke her arm and had to go out on medical leave for three months, and the pilot was put on hold. They were preparing to continue the pilot near the beginning of 2020, but then the COVID-19 pandemic hit.
Although their pilot stopped, Fuller moved forward in learning how to prepare staff on responding to trauma in patients. She began participating in “train-the-trainer” training sessions provided by Trauma Transformed, an Oakland-based program of the East Bay Agency for Children. The sessions, which began in June, focus on how to influence and change policy, leadership and practices in systems so they promote healing.
Fuller says they’ve made other changes in the clinic culture to create a more healing environment for staff, such as including mindfulness exercises during their staff huddles — informal gatherings to debrief about the events of the day; scheduling staff outings, and decompressing with the clinic’s social worker Thy Robles over a “tea with Thy.”
Still, everyone involved realized that more training was needed to help providers respond to patients who are triggered by filling out the questionnaire.
The pilot helped identify other needs that need to be tackled before they expand ACEs screening to the pediatric population. For example, providers want more time during the visit to review ACEs questionnaires with patients. And harking back to the all-staff meeting experience, Fuller and a colleague developed a two-hour equity training for medical providers. (For more information about it, contact Fuller at: email@example.com).
Kim, who will lead ACEs screening in the pediatric population, says that she’s hoping to begin this fall. But she’s not sure when that will be, partly because there’s a hiring freeze, and she and other providers at the clinic are juggling a number of added responsibilities because of the COVID-19 pandemic and wildfires in the area that caused the clinic to shut down. But they are planning to move forward as soon as things calm down.