Using ACE Screening and Cross-Sector Referrals to Address Cumulative Adversity

A Catalyst Conversation with Dr. Ramiro Zúñiga

Vice President, Medical Director - Medi-Cal, Health Net

Catalyst Center held a series of conversations with diverse providers and trauma survivors from varied sectors to discuss how to address Adverse Childhood Experiences (ACEs), human-centered approaches to healing, and cross-sector collaboration to mitigate the toxic stress response and curb the cycle of intergenerational trauma.

Summary: This guest blog features a Catalyst Conversation with Dr. Ramiro Zuniga, Vice President and Medical Director, Medi-Cal at HealthNet, and discusses how institutional racism and disparities serve as risk factors for trauma and toxic stress, and the importance of cross-sector referrals to help address cumulative adversity.

Screening and coordinated treatment improves patient health by demystifying the impact of cumulative adversity.

Q: How has screening and coordinated treatment helped to bring out the issues that needed to be addressed or improved upon for your patients’ overall health?

A: The screening tools help us get very valuable information about our patient's history in a nonjudgmental manner. Through the implementation of universal screening for ACEs, we get a more complete picture of our patients, their experiences, and the factors that may be influencing their health.

Making the use of these screening tools routine in our practice also demystifies the process and allows patients to provide information that they may not otherwise feel comfortable sharing. This information helps us also understand factors that may have triggered or worsened medical and behavioral factors. Educating our patients and their families on the influence of ACEs in our overall health also help us draft a more effective treatment plan. The bottom line is that screening for ACEs, and addressing patients’ toxic stress, is the best way to improve their whole health.

Explaining cumulative adversity and the science of ACEs and toxic stress to patients

Q: How do you educate patients and their families on ACEs and its influence on their health?

A: We discuss with patients the traumatic events that they have been subject to throughout their lives, and how all of those other factors, like the social determinants of health, are affecting them. There is stress developing a response in their bodies and their brains, affecting their ability to function at their best, and this can accumulate, both in their physical and mental health. And we address with them how to mitigate those effects.

ACEs, Social Determinants of Health, and institutional racism are risk factors for developing the toxic stress response.  But, buffering supports can help.

Q: What can you tell me about how cumulative adversities and institutional racism are related?

A: There is a very important connection between institutional racism, which is what many of us experience because of the color for our skin, our accent, or where we came from, and we are subjected to different kinds of discrimination. Often those targets may be our parents, who were denied, such as by not being able to get a house that was in the neighborhood where we wanted to live. Or, we could not attend the right school and get a good education, and we could not live in a safe environment, where the parks and the streets are walkable and safe for us to exercise and enjoy nature. All those things lead us to a path that eventually exposes us to toxic stress. Increased risk often results in exposure to crime or being victims of crime. That exposure to several additional stress factors in our homes and environments may eventually lead to significant traumatic events.

Q: Thank you for acknowledging that institutional racism works to create downstream conditions that can lead to negative health outcomes for folks who are rendered voiceless by these systemic oppressions. (More on this can be found in the  California Office of the Surgeon General’s public health sector brief, which describes how adversity can impact health and social outcomes, and the role of the public health sector in preventing and mitigating toxic stress.)

So how can buffering supports help people heal from their ACEs and toxic stress, and why are these buffering supports so important?

A: It’s very important to remind ourselves and our patients that having a positive ACEs score and a history of many traumatic events does not necessarily mean that we are destined to have physical and behavioral health problems. We can help our patients, we can help our friends, and we can help ourselves build a better future for our health by using several preventive measures. We call this buffering supports or buffering factors. Things like having strong, trusting, and supportive relationships, exercising regularly, getting sufficient and high quality sleep, having well-balanced nutrition, spending time in nature, participating in mindfulness activities, and having access to mental and behavioral health care can help us neutralize the effects of toxic stress and minimize its negative effects on our health.

Case study: A patient success story

Q: Dr. Zuniga, please share with us a patient's story of success from having been screened and treated for ACEs or toxic stress.

A: There have been many patients, but there's one particular patient that comes to mind. I saw an adolescent who was recently reunited with her mother after many years of separation, due to immigration issues. She came to us after many visits to different physicians, with complaints of abdominal discomfort that was causing significant school absenteeism. An appropriate work-up had not revealed any plausible explanation for the symptoms. We did an ACEs screening and found a score of four with five additional positive responses in the Life Events questions. With this information, and using the principles of trauma-informed care, we were able to get additional information, identify emotional triggers for the symptoms, and jointly with the patient and the mother, we formulated a treatment plan. We were also able to determine that the mother also had a positive ACEs score. We did a warm hand-off to a culturally and linguistically matched therapist and both the mother and the patient left our office with a clearer picture of what was affecting their health, and with tools and resources to help address these issues.

It's also very important to mention the buffering factors as part of the follow-up conversation with our patients and their parents, to help decrease the toxic effects of a high ACEs score. Sometimes we forget things like having appropriate sleep, a balanced diet full of healthy foods, and that we can also spend time outdoors, in nature, which has been found to be an extremely positive influence on our health.

Connecting the dots: How cross-sector partnerships support service referrals for needed buffering factors

Q: How can partnerships from other sectors help support referrals that can provide these buffering factors?

A: Like many other health-related issues, prevention is the most effective way of dealing with toxic stress in the long term. Preventing the occurrence of ACEs and adverse life events requires a societal effort to address and eliminate institutional racism and disparities. We also need to address Social Determinants of Health, such as employment, safety, housing, food, transportation, education, and other factors.

Once we are exposed to ACEs and are experiencing toxic stress and negative effects to our health, our focus shifts to early detection and intervention. This work requires a multidisciplinary team effort and coordinated efforts between primary care and behavioral health providers, and the support of community based organizations, and other stakeholders in our community.

Dr. Burke Harris, in the CA Surgeon General’s Report on ACEs, Toxic Stress and Health, provides a blueprint for effective prevention strategies that require the work of many sectors, including healthcare, public health, social services, early childhood, education, and justice.

ACE screening reveals the true nature of a patient’s history

Q: What were you missing in the past before you began utilizing an ACE screening tools?

A: Before I started using the ACEs screening tools, I relied on the usual History and Physical questions and screening questionnaires. Now, I realize that I was missing a whole aspect of my patients’ lives that has a huge influence on their health. It is sort of lifting a veil on a huge portion of our patient’s history. Using standardized tools that can be self-administered has also made it easier to get honest answers to difficult-to-ask questions.

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