CHOC leads first ED study on adverse childhood experiences and prevalence of food and housing insecurity

In the only known hospital research project of its kind in the United States, CHOC’s Emergency Department is leading a study on how food and housing insecurity impacts children’s health and environment.

The project, being conducted in collaboration with departments at UC Irvine and Chapman University, involves surveying 7,000 CHOC ED patients by September 2021, with results expected by the end of the year, says Dr. Theodore Heyming, medical director of emergency medicine at CHOC and chief architect of the effort.

Dr. Theodore Heyming, medical director of emergency medicine at CHOC

The study, which to date already has enrolled some 2,500 CHOC patients, will assess ACEs, also known as adverse childhood experiences. Most ACEs studies conducted to date by other hospitals have been limited to the primary care setting. Since July 2020, CHOC’s ED has been screening for ACEs with particular attention to the following three areas: abuse, neglect, and/or household challenges. 

“To my knowledge, we’re the only pediatric hospital that has this kind of health research project implemented in an emergency department,” Dr. Heyming says. And that makes sense, he adds.

“People don’t usually think of an emergency room as a primary care setting,” Dr. Heyming says. “However, the opposite actually is true. A lot of patients use the ER as their primary care. EDs also have the ability to potentially intervene on patients even to a greater extent than in the primary care setting, given the availability of experienced social workers.”

The potential benefits of the study, which involves questioning patients in more depth than standard ACEs screenings, are numerous, as detailed in an abstract that Dr. Heyming and his collaborators have submitted to the American Public Health Association (APHA), a Washington, D.C.-based organization for public health professionals.

For example, ED-based research has yet to investigate the extent to which neighborhood-level factors such as fast-food accessibility and a lack of healthy food options contribute to poor pediatric health outcomes.

The CHOC-led study aims to identify such neighborhood-level factors and generate valuable information that could be leveraged for public policy and advocacy efforts to improve pediatric health. That, in turn, could lead to a reduction of ED overutilization and associated healthcare costs.

Disadvantaged kids hit hardest

Food and housing insecurity disproportionately impact children in disadvantaged communities, studies show.

And children living in so-called “food swamps” — areas with an abundance of fast-food restaurants, pharmacies and discount stores that sell cheap but unhealthy food — as well as “food deserts,” areas that lack affordable food that is fresh and nutritious, are more at risk of obesity, diabetes and other adverse health conditions, as well as mental and behavioral issues and trauma, the paper explains.

The study of 7,000 CHOC ED patients comes on the heels of a smaller CHOC ED study on the prevalence of ACEs in patients that was conducted between July 2020 and February 2021. Twenty-four CHOC ED doctors were certified in state-run ACEs modules and 1,861 patients participated – the biggest cross-sectional survey that CHOC has done to date, according to Dr. Heyming.

About 20 percent of respondents in that smaller-scale survey reported at least one ACE or more — a percentage consistent with national numbers, Dr. Heyming says. In addition, the survey found that the prevalence of food insecurity among CHOC patients is about 15 percent. 

Now, in partnering with Chapman University and UCI, CHOC is digging deeper into the prevalence of food and housing insecurity with its study of 7,000 patients — and the potential neighborhood-level factors that contribute to such insecurity.

Dr. Jason Douglas, an assistant professor of public health at Chapman University, specializes in investigating social and environmental determinants of public health disparities that disproportionately impact the Black and Latinx communities. 

Dr. Douglas, who has extensive experience connecting social and environmental factors to public health disparities in Los Angeles County as well as Northern California, New York and Jamaica, will use data from the 7,000 survey respondents to analyze neighborhood-level factors that contribute to poor pediatric health.

“The goal is to identify factors that are affecting community health and well-being and inform public policies to improve health in underserved communities,” Dr. Douglas says. “To be able to identify adverse childhood experiences and food and housing security within the clinical context and use that data to garner a better understanding of how social and environmental factors may be exacerbating health disparities will allow us to develop a more holistic understanding of the deleterious impacts of these challenges on children’s lives.”

At UCI, Dr. Victor Cisneros, an emergency medicine clinical instructor and current research fellow in population health and social emergency medicine, will lead a team of investigators who will participate in follow-up phone calls with the CHOC ED survey respondents. The follow-up interviews will be conducted three and six weeks after respondents complete the survey.

“These follow-up interviews are important to assess if interventions given in the ED are effective, and if not, what barriers our patients are facing,” Dr. Cisneros says.

All CHOC ED patients up to 18 years of age and their parents or guardians qualify as potential participants in the survey, which is available in English and Spanish. The survey includes 16 questions that take about 5 to 10 minutes to complete on iPads provided by CHOC.

Patients identified as experiencing food and/or housing insecurity are directed to passive food and housing resource materials in the form of informational pamphlets and flyers.

“We’re going to potentially be able to leverage this data to help cities and the county to make informed policy changes,” Dr. Heyming says. 

“Obtaining this information will not only be great for Orange County,” he adds. “I think we’ll be able to point to the fact that pediatric EDs are a great place to conduct these screenings because there’s a high incidence of either adverse childhood experiences or food or housing insecurity.”

Dr. Heyming says pediatric EDs in the future would be able to provide patients more active resources such as gift and food cards.

Dr. Douglas says the study ideally will serve as a model for pediatric and other emergency departments across the country.

The bottom line, Dr. Cisneros says, is getting people resources they need – for example, food that restaurants now dispose of that can be “recycled.”

The ED, he says, is a perfect microcosm of the community.

“One of the beauties of this study,” Dr. Cisneros says, “is we’ll be able to identify people with housing and food insecurity and be able to refer these people to the appropriate tailored resources. In addition, we will be able to further quantify what obstacles our patients face both at the individual and community level.”

Related posts:

Embedding trauma informed care into your practice: Tips for providers

In the U.S., 34 million children have experienced an “adverse childhood event,” or ACE – a stressful or traumatic event that is strongly related to a wide range of health problems. Prolonged, pathological stress disrupts healthy brain development and creates significant lifelong implications for learning, behavior, health and adult functioning.

By understanding the widespread impact of trauma, as well as the potential paths for recovery, practitioners are empowered to respond by fully integrating knowledge about trauma into their practice. This is known as “trauma-informed care.”

Trauma-informed care understands the impact of trauma and the potential paths for recovery, and aims to respond by adapting certain practices. By viewing patients through a “trauma lens,” practitioners better understand that traumatic experiences may be contributing to somatic symptoms or challenging behaviors.

CHOC has worked diligently to embed trauma-informed care into the treatment and interaction with patients and families across locations and specialties, says Dr. Dani Milliken, director of the Cherese Mari Laulhere Mental Health Inpatient Center at CHOC.

Dr. Dani Milliken, director of the Cherese Mari Laulhere Mental Health Inpatient Center at CHOC

Here, Dr. Milliken offers three simple things providers can do routinely to begin to integrate trauma-informed care into their practice:

1. Ask “What happened to the patient?” instead of “what’s wrong with the patient?”

Changing your mindset while evaluating patients is one of the most effective ways providers can implement trauma-informed care. A shift from the typical thought process during patient evaluation to a trauma-informed thought process includes:

  • “The patient is sick, ill or bad” becomes “the patient is hurt and suffering.”
  • “Patient behaviors are immoral and need to be punished” becomes “patient behaviors are survival skills developed to live through the trauma, but are maladaptive in everyday society.”
  • “Patients can change and stop immoral destructive behavior if they only had the motivation” becomes “patients need support, trust and safety to decrease maladaptive behaviors.”
  • “We need to manage or eliminate patient behaviors” becomes “we need to provide opportunities for patients to heal from their trauma.”
  • “System of care should be created to minimize short term costs and contain immoral behaviors” becomes “system of care invests in healing trauma, saving money over the long term.”
  • “The patient is manipulative” becomes “The patient is trying to get their needs met”

2. Adjust what you say

There are certain words that can be avoided when describing patients and their behavior, such as “refused,” “resisted,” “non-compliant,” “unmotivated” and “low functioning.” By shifting away from words and phrasing that portray a patient as having difficult or non-ideal characteristics, providers can promote recovery.

Words and phrases that encourage this recovery include:

  • Declined
  • Chose not to
  • Experiencing
  • Has a history of
  • Has difficulty with

3. Adjust what you do

The way providers interact with patients matters, and a few key changes can support children who have experienced adverse childhood effects:

  • Ask before touching
  • Introduce yourself each time you enter the room
  • Explain procedures prior to performing
  • Offer choices as often as possible
  • Create a therapeutic relationship
  • Alter the environment

Learn more about the Cherese Mari Laulhere Mental Health Inpatient Center at CHOC.

CHOC awarded ACEs Aware grant funding to provide trauma-informed care training

CHOC has received $180,000 in grant funds from the Office of the California Surgeon General and the Department of Health Care Services to participate in the state’s ACEs Aware initiative.

The initiative seeks to change and save lives by helping Medi-Cal providers understand the importance of screening for Adverse Childhood Experiences (ACEs) and training them to respond with trauma-informed care.

CHOC will use its grant funds to conduct supplemental training to promote the ACEs Aware initiative among the Medi-Cal provider community in Orange County. Through this training, providers will learn the importance of incorporating ACE screenings into their clinical practice, as well as how to administer screenings, use clinical protocols to determine evidence-based treatment plans, and provide trauma-informed care. Trainings will also include mental health providers and school professionals to encourage communication and coordination between important systems in children’s lives.

“At CHOC, trauma-informed care is embedded into our treatment and interactions with our patients and families,” said Dr. Heather Huszti, CHOC’s chief psychologist. “The COVID-19 emergency underscores the critical need of using trauma-informed care to treat the whole child. We are so grateful to have received this funding to help teach providers throughout Orange County about the importance and practice of trauma-informed care.”s

CHOC was among 100 organizations throughout the state to receive a total of $14.3 million to extend the reach and impact of the ACEs Aware initiative. These grants will provide funding to organizations to design and implement training, provider engagement, and education activities for providers and organizations that serve Medi-Cal beneficiaries.

“We are looking forward to working in partnership with this amazing group of community leaders to further our efforts to help health care providers become ACEs Aware,” said California Surgeon General Dr. Nadine Burke Harris. “This work is critical, now more than ever, given the stress so many Californians are experiencing as a result of COVID-19 and the role of racial injustice as a risk factor for toxic stress. A trauma-informed health care workforce is vital for helping our state heal.”

The grant funding will provide critical support to community organizations serving Medi-Cal providers and beneficiaries, which have been experiencing increased stress during the COVID-19 emergency. Grant activities will augment California’s efforts, underway since the summer of 2019, to develop provider training and engage providers, including the promotion of payments to Medi-Cal providers for screening their patients for ACEs.

Added Dr. Karen Mark, DHCS medical director: “DHCS is committed to preserving and improving the overall health and well-being of all Californians. The ACEs Aware initiative is a vital part of the Medi-Cal program’s response to the COVID-19 emergency. These grants will help us reach Medi-Cal providers who serve diverse and often at-risk populations throughout the state, and will help to ensure that Medi-Cal members receive the high-quality, integrated care that every Californian deserves.”

Funding for the ACEs Aware grants was previously authorized in the 2019-20 budget using Proposition 56 funds for provider training on how to conduct ACE screening in the Medi-Cal population. In light of the COVID-19 emergency, the grant funding will provide critical support to the community organizations serving Medi-Cal providers and beneficiaries.

View the full list of ACEs Aware grantees.