• Addressing the Social Determinants of Health
• Improving Care for Marginalized Groups
• Engaging Patients and Community Members
• Improving Interprofessional Primary Care

There is a very strong link between toxic stress in childhood and a higher burden of disease later in life. This has been scientifically proven, and 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. 

At our Community Health Centre, Boyle McCauley Health Centre (BMHC), 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 felt strongly that we need to start looking at Adverse Childhood Experiences (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.

In 2015, we began participating in the Change in Mind inititiative, a three-year partnership led by the Robert Wood Johnson Foundation and the Palix Foundation’s Alberta Family Wellness Initiative, whose purpose is to demonstrate the larger impactful role of the nonprofit sector as educator, convener, advocate, and true influencer of getting appropriate systems aligned to the brain science of human development. Along with 15 organizations in the U.S., we are one of five non-profit organiaztions participating from Alberta, Canada (one other -- CUPS Calgary -- is also a CHC).

Through the initiative we implemented an organization-wide ACEs approach, training staff on use of the ACEs survey with clients.

We first asked each team and program at 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 team at our CHC to ask what went well, and what didn’t.

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. Based on feedback we began to develop a training and orientation approach for all staff of our CHC. We enlisted staff to develop training for other staff.  We played the Brain Architecture Game, watched videos, and shared insights and resources to support this process. Staff training and orientation on ACEs and resilience is now available to staff and volunteers at our CHC.

We have 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 have started feeling more confident about trying to do ACEs surveys with select clients.

Another positive outcome of our ACEs work is the development of improved relationships with clients. For example, one of our family physicians, 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 our clinic.

We studied the distribution of over 130 patient ACE scores at our CHC and have compared them to the general population’s ACE scores in Alberta (the province where we are located). The bulk of the general population has scores of 3 and under. The bulk of our patients have scores of 4 and up, with many having scores significantly higher than 4. When we display this in a chart, people are often astonished at the sight of two completely opposite bar graphs.

This compairson has enabled us to give people a deeper understanding of the degree of health disparity our patients’ usually experience. Looking at our data set in depth and teasing out the health problems of our clients with the highest ACEs has 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.

Successfully administering ACEs surveys has 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.”

Since we started this journey at our CHC, 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.