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Iowa project aims to have all pediatricians, family docs screen for ACEs


 Dr. Amy Shriver is on a mission: to convince every pediatrician and family doctor in the State of Iowa to screen children for Adverse Childhood Experiences (ACEs).

Dr. Amy Shriver

The Des Moines-based Blank Children’s Hospital pediatrician is not alone. She’s part of Central Iowa ACES 360, a regional cross-sector coalition formed in 2011 that is working toward that ambitious goal. And they’re making substantial inroads.

Central Iowa ACES 360 has just developed a one-hour trauma-informed training modulefor clinicians and their staff about the foundations of ACEs science and trauma-informed care practices, including ACEs data specific to Iowa.

Just how did they decide to offer an online training module? It was after the group tested out a number of assumptions, and found out that outreach practices they thought would work didn’t, and that pediatricians didn’t know much about ACEs, according to Shriver.

The group’s Pediatric Project, which began in 2016, included developing an online trauma-informed care guide, surveying clinics about what they need to implement trauma-informed and resilience-building practices based on ACEs science , and hiring Shriver, a pediatrician, to reach out to practices. That involved cold-calling clinics and hospitals, and setting up meetings with administrators, in what was the pilot phase of the project.

Lisa Cushatt

That outreach effort, says Shriver, fell short. “What we learned is that it’s very difficult to get messages to practices in that way and it takes a lot of time,” she says. Central Iowa ACEs 360 had planned on reaching out to between five and 10 practices to start with and see what kind of response they received, according to Central Iowa ACEs 360 Program Manager Lisa Cushatt.

In all, Shriver and Cushatt delivered ACEs 101 presentations to around 30 people at five different practice sites. The presentations included an overview of the original CDC-Kaiser Permanente Adverse Childhood Experiences Study, brain science and toxic stress, trauma-informed practices, and content from their trauma-informed care guide.

The group also had a low response rate to its online pediatric practice survey, developed by a researcher associated with the University of Iowa, says Cushatt:  It asked for a range of responses to statements such as: “This clinic contains predictable and safe environments that are attentive to emotional transitions and sensory needs of patients,” and “The clinic has dedicated resources to implement a comprehensive trauma informed care program.”

More than that, they had incorrectly assumed that pediatricians were well versed in ACEs science, says Shriver. For example, practices that served patients with private insurance were unaware that their patients might suffer from higher ACE scores – something she attributed to a lack of knowledge about the landmark ACE Study, which comprised 17,000 mostly white middle-class patients with jobs and great health care.“If clinics served richer families they didn't think ACEs were occurring,” Shriver says.

Shriver says the first module should put to rest the misconceptions about ACEs, including that ACEs are a problem only among poor people. The ACE Study linked 10 types of childhood traumas to health outcomes. Notably, it showed that two-thirds of the participants had at least one ACE, and 20 percent had ACE scores of 3 or more. The study found a dose-dependent link between ACE scores and health outcomes. For example, a person with an ACE score of 4 is 700 percent more likely to be an alcoholic, has a 400 percent increased risk of emphysema or chronic bronchitis, and a 1,200 percent greater risk of attempted suicide than someone with an ACE score of 0.

The responses that Central Iowa ACES 360 did receive from the online surveys and from on-the-ground contact with practices helped identify some of the support that practices would need if they planned to institute ACEs screening and training staff in trauma-informed care.

One clear gap is that pediatric practices were not well versed in the resources that already exist in their communities, says Shriver. She points to the organization 1stFive, which has offices throughout Iowa, a wide array of connections with community-based organizations, and provides services to children and feedback to referring doctors. “What we found out is that many of our practices are not using that resource at all, or don’t feel like they need it, or don’t understand how to use it,” she says.

The group’s first online module includes all the elements of the in-person trainings they led—an overview of the ACE Study, brain science, toxic stress, Iowa ACEs data and trauma-informed practices, but it has two added advantages, says Shriver. It can be viewed by providers and staff at any time that’s convenient, so it doesn’t impact work flow. “And [it explains ] how we as Iowa ACEs 360 can provide technical support and help them become trauma informed.”

Central Iowa ACEs 360’s pediatric plan is a living document that will be modified and updated as the group receives feedback from the pediatric community. But the foundation of its approach is captured in its online training guide. It’s divided into four different tenets: education, assessment, resources and referrals, and climate and setting.

In thinking about what might reflect a trauma-informed climate, Shriver says, it often requires looking in a more nuanced way at office policy. For example, “What’s your late arrival policy?” she says. “Do you kick people out if they’re 15 minutes late, or is it a little bit more trauma-informed because they have to take two buses to get here?”

 If testing out their initial pediatric plan meant a slow-down as it shifted its approach from in-person training to online modules, the group has gained momentum in expanding its reach to other pediatric ACEs champions.

Dr. Resmiye Oral

Shriver joins a bimonthly phone call convened by Dr. Resmiye Oral, a pediatrician and director of the Child Protection Program at the University of Iowa Health Care. The conference call includes pediatricians, nurses, and behavioral health providers. On a recent call, Oral announced that trauma-informed trainers from Montefiore Medical Center in the Bronx, New York, will be providing training during grand rounds in the Fall. Oral has also organized — along with Central Iowa ACEs 360 — an all-day cross-sector Promoting Resiliency workshop on August 6 that will include a medical collaboration breakout session.

While Shriver has been working with Central Iowa ACEs 360 to promote ACEs screening and transitioning to trauma-informed care, she’s also been spearheading the effort in the clinic in her own hospital.

As for the next steps on engaging pediatric practices, Shriver said they are working on helping practices figure out how to make use of community resources, such as 1stFive. She also says she’s a strong believer in building on families’ strengths, and the group will be holding focus groups with physicians and patients to find out what kind of messaging and support will resonate with them. “One of the messages we’ve created hasn’t been rolled out officially, but I’m so excited about it. It’s called CC 123 for resilient families,” says Shriver.

The two Cs come from Dr. Ken Ginsburg’s 7 Cs and they’re about connection and coping said Shriver: “When you feel stress do you have your tribe, your connections?” says Shriver. “And do they need help finding connections? Because some people do.” They ask the same questions about the child. The second C is about coping skills, strategies that parents and children have or need.

The numbers translate to: 1: for parents to take one minute to stop, reflect and empathize with their child’s behavior; 2: stands for two eyes for seeing and two arms for holding. (“Your child needs physical affection and don’t forget that.”); and 3, explains Shriver, stands for “What are three ways as a parent or caregiver you can show your child that you love them every day?”

Central Iowa ACES 360 will also be assisting practices in figuring out what ACEs screening tool to use. On the point of screening for trauma, Shriver’s view is clear. “I’m a strong believer in universal screening for ACEs,” says Shriver, “Are you asking the right questions?” You don’t know who’s experiencing trauma by looking at them. You need to ask, because if you don’t ask, then you are missing an opportunity to provide care and therapy that could save that person a lot of years of their life.”




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