Experimentation, evaluation, and science-informed policy. That’s the approach that the 3-year coalition called Change in Mind is taking to accelerate and infuse brain science into the work of community-based agencies and to align existing policies and systems with the latest neuroscientific discoveries. Dr. Mosaico, one of our family doctors at Boyle McCauley Health Centre (BMHC)  in Edmonton, Alberta, started using the Adverse Childhood Experiences (ACEs) survey to therapeutically engage with his clients after he learned about the impact of early toxic stress on later health outcomes. He learned that the link between toxic stress in childhood and a higher burden of disease later in life has been scientifically proven, and that the implication for society and government systems is clear.

We need to prevent toxic stress in childhood, and we need to find ways to use that science in medical practice for both adults and children. Dr. Mosaico firmly believes that medical schools should be teaching students to understand more about people’s early experiences of toxic stress and that we should regard this information as important as hand-washing in every clinical setting.

Here at our Community Health Centre, we work mostly with adults who come to us with highly complex physical, social, cultural, and psychological barriers to health and resilience. Over time, many of our patients have built up long, individual histories of chronic homelessness, substance use disorders, and a variety of serious physical and mental illnesses due to repeated and long-term traumatic experiences that often start in childhood. It’s not always easy for them to feel comfortable asking for the help they need or to even feel welcome in mainstream health clinics.

Our staff are trained to understand the effects of trauma and work to limit the amount of re-traumatization that might occur during a medical or other health program visit. While this explains quite a bit about what we do at BMHC, when it comes to advocating for this population, it is still difficult to explain why multiple resources (and lots of patience!) are often needed to help our clients to progress. In order to advance the ball in terms of developing better frontline practices, sharing with the community, and improving policy we, as a country, need to start looking at ACEs and resilience together and talking about how to use it in ways that help children and adult patients get more of the care they need.

Our involvement in the Change in Mind Initiative has been a two-and-a-half year whirlwind of learning, prototyping, testing, collecting data, training ourselves and each other, and slowly reshaping our day to day work so that it is informed by the latest science. We have learned new things. And, we have learned some language that helps us explain the old things we already knew. We have been able to take our tacit knowledge about trauma-informed care and make it more explicit. Learning through rapid testing and other developmental evaluation tools has produced a merging of brain science and trauma-informed care at our CHC. This process is not over.

There are still days when we know that some people are uncomfortable about us asking ACEs questions. But that’s OK. It’s not a matter of brain science versus trauma-informed care. We have learned that we can lean in towards brain science, or trauma-informed care, or both. Here are some things we’ve done and lessons learned through our work with the Change in Mind Initiative:

How to do ACEs surveys using a trauma informed approach
We asked each team and program at the BMHC to make a plan to complete 5 ACEs surveys with clients and to tell us how it went. At this point staff had a lot of information about how childhood experiences influence health outcomes, and that resilience plays an important role in the relationship between staff and clients. Over the course of 3 months, we answered questions, provided support, and then held group interviews with each of team to ask what went well, and what didn’t.

As you might guess, successfully administering an ACEs survey had a lot to do with setting the context of an ACEs survey into the staff-client relationship. Here are the three major themes that came out of our group interviews with staff:

1. Staff need training and access to learning materials about ACEs and resilience. They also need significant exposure to trauma-informed practice. Once they have some idea of how they will need to approach patients about ACEs, they still need flexibility around when and where to introduce the ACEs survey. They will need enough time (30 minutes on average) and a space where the client can feel at ease learning about ACEs and completing the survey.
2. Once the context is explained to the client about how early experiences can shape current health, some clients may ask to be able to do the survey outright, while some express a need for varying degrees of anonymity or support. For example, one client chose to read the survey and just state what their overall score was without actually sharing which ACEs they experienced in childhood. 
3. Once the conversation is started, and the client has begun to share their score, there is an opportunity for staff to continue to build on client strengths by re-framing ACEs and talking about what makes that person resilient. Being able to shift back and forth between ACEs and resilience takes a well-developed therapeutic skill set and sensitivity to the client’s shifting needs in the moment. The result for clients and staff turns out to be worth the investment. As one staff put it, “…she [the client] couldn’t understand why she can’t get anything good happening for her. We used this survey and it really helped her to know that it isn’t all her fault.”

Staff training and orientation
Staff training and orientation on ACEs and resilience is now available to all our staff and volunteers. At first, staff were pretty leery about asking patients direct questions about ACEs.  Staff at the BMHC have always worked from a trauma-informed perspective – meaning that they take the risk of re-traumatizing patients very seriously and do what they can to avoid opening up deep emotional wounds and psychologically re-injuring people. To get to the point where staff are more comfortable with this new survey, we enlisted staff to develop training for other staff.  We played the Brain Architecture Game, watched videos, and shared insights and resources. 

We tracked some of the effects of staff training by asking them how knowledgeable they felt before and after doing the training. By doing the training, sharing information, and focusing on a scientifically backed definition of resilience, staff started feeling more confident about trying to do an ACEs survey with select clients.

One of the positive spin offs of this is the development of relationships with clients. For example, Dr. Mosaico notes that some clients who did not want to see a psychiatrist before learning about ACEs and doing the ACEs survey are now attending visits to the psychiatrist in addition to their regular primary care provider visits at the clinic.

Collected ACEs and health data
We originally looked at the distribution of 65 patients’ ACE scores that were collected by Dr. Mosaico when he was developing a therapeutic method of incorporating the ACEs survey into his practice. We compared those 65 ACE scores to the distribution of a general population’s ACEs in Alberta. 

This enabled us to help give people a deeper understanding of the degree of health disparity our patients’ usually experience. We can now provide this comparative data for more than 130 clients. This works for us because the pattern in our data is so strikingly different from the general population. 

The bulk of the general population has scores of 3 and under. The bulk of our patients have scores of 4 and up. When we display this in a chart, people are often astonished at the sight of two completely opposite bar graphs.

Looking at our data set in depth, and teasing out the health problems of our clients with the highest ACEs has also been a great tool in helping the public, policymakers and various partners understand our work. It has also helped our staff to understand the histories of their clients and to frame stories about patients who have some of the most traumatic childhoods and the resilience and progress that has shown up in their lives both before and after becoming a patient at the BMHC.

Looking Forward

Since we started this journey, the number of ACEs surveys completed at BMHC has more than doubled and the trend remains unchanged.  We know that our clients have borne a tremendous burden of toxic stress in their childhoods compared to the general population. We know that this contributes to their individual complex health challenges today and this will continue into their futures.  But we need others to know this as well.  We need programs and policies to be informed by the effects of early toxic stress. We need other organizations to learn the language of toxic stress and resilience. And, we need more people to join in the innovation and discovery of how to get the science into our practices. 

Dedicating ourselves to truly understanding the nuances of resilience, ACEs and the effects of toxic stress on brain development brings new knowledge and new vocabulary to our understanding of health for the whole person and, in some cases, whole communities. It has the potential to help us communicate across boundaries, not only in the health care system, but across other systems as well – justice, education, children and families’ services, to name a few. This is something that Community Health Centres are already doing, as multi-sector organizations.

We imagine a system of health care where health researchers, physicians, nurses, administrators and others all understand the role of ACEs in preventing disease for future generations; grasping the role of resilience in stabilizing and maintaining relationships with clients to slow or reverse the impact of childhood exposure to toxic stress. 

The science is in on this. We know that lasting issues like poverty, lack of affordable housing, food insecurity, social isolation, family and neighborhood violence, and sexual abuse will lead to bad physical and mental health outcomes.  We need members from all corners of the health system to take up a call to action. We need to reduce toxic stress wherever we can find it in our communities so that we can see reduced suffering and lowered economic costs later.

You don’t have to wait for others to act.  You can start now by accessing the Alberta Family Wellness Initiative. They have created a comprehensive, free online course that can be used for professional development credits across many disciplines.  Some of our staff have taken the course and have learned a lot. We think everyone in the health and social service sectors should take it and think about how to change our communication and practices to address toxic stress.