1. Daniel J. Harkness, PhD, LMFT Stacey K. Neu, MD
Teaching Trauma-Informed Care: Responding to Adverse Childhood Experiences (ACEs) in a Residency Setting
Daniel J. Harkness, PhD, LMFT
Stacey K. Neu, MD

2. Disclosures
We have no disclosures to report.

3. Who We Are

4. ACE Study Kaiser Permanente Drs. Felliti (Kaiser) and Anda (CDC)
More than 17,000 participants completed a standardized physical examination.
General Findings: Childhood experiences are powerful determinants of who we become as adults.
Showed a linear correlation between ACEs and chronic disease states

5. Disease, Disability, & Social Problems
Early
Death
Disease, Disability, & Social Problems
Adoption of Health-Risk Behaviors
Social, Emotional, & Cognitive Impairment
Disrupted Neurodevelopment
Adverse Childhood Experience

7. ACEs Questionnaire Physical abuse Emotional abuse Sexual abuse
An alcohol and/or drug abuser in the household
An incarcerated household member
Someone who is chronically depressed, mentally ill, institutionalized, or suicidal
Mother is treated violently
One or no parents
Emotional or physical neglect
The ACE Study used a simple scoring method to determine the extent of each study participant's exposure to childhood trauma.  Exposure to one category (not #s of incidents) of ACE, qualifies as one point.  When the points are added up, the ACE Score is achieved.  
An ACE Score of 0 (zero) would mean that the person reported no exposure to any of the categories of trauma listed as ACEs above.  An ACE Score of 9 would mean that the person reported exposure to all of the categories of trauma listed above.  The
ACE Score is referred to throughout all of the peer-reviewed publications about the ACE Study findings.
Important to acknowledge other forms of trauma or adverse experiences that are not listed in this study – historical trauma, combat experiences, bullying, racism…

8. 3 E’s of Trauma (SAMHSA)
Event
Experience
Effects

9. Trauma Informed Care
What’s wrong with you?
What happened to you?

10. Models of Trauma Informed Care
4 Tenets (NIH)
SAFETY
Emotional management
Loss
Future
“Three Pillars”
(H. Bath)
SAFETY
Making connections
Managing emotions
SAMHSA’S Principles
SAFETY
Trustworthiness & transparency
Peer support
Collaboration
Empowerment
Cultural, historical, and gender issues
RESILIENCE

11. 4 Rs of Trauma Informed Care (ie., What we are trying to do!)
Realize
Recognize
Respond (Policies, Procedures & Practices)
Resist Re-traumatization

12. Exposure to a traumatic event can cause _______ problems.

13. Being exposed to trauma as a child can cause later physical/medical problems:

14. How much do you think the health care team considers a person’s trauma history in their care/treatment?

15. Progression of Project
Late Fall, 2014 – Summer, 2015
Outline of prospective education
Completed pre-survey (a lot of info was not new to them because of ACEs)
Survey results informed content for education sessions
Created 6 brief sessions; taught at monthly staff meetings (next slide)
Reflected back to staff what was helpful
Late Fall, Current
November: 2nd set of sessions began by reviewing previous topics
December: Intro to ACEs & impact on health, economy and workforce
January: Review TIC models; Queried staff on what they still needed.
February: Clinic-based “self-assessment”
March: Spring Break
April: Resilience and plan from book “Childhood Disrupted”
May: R3 presents on attachment disorders r/t trauma

16. Monthly Curriculum (beg. 2014)
Introduction and defining trauma
ACEs & the relationship to high-risk behaviors and chronic disease development
Reviewing models of Trauma Informed Care (with a focus on a safe environment)
Taking their own ACE questionnaire and offering EAP services
Scenarios of traumatized individuals in a clinic setting
Hope and resilience

17. Staff at all levels of the clinic receive training and education on:
Most Positive
Least Positive

18. Case Example
A long-time EDM patient calls in to the clinic asking to talk to a doctor or nurse immediately. This patient is well-known to providers and nurses as a high utilizer of healthcare services. His family members have been EDM patients for decades so you know his history. He starts demanding his refills because they are due today but his physician is not in clinic today or the rest of the week. He sounds as if he is slurring his speech and you can hear his girlfriend yelling at him in the background. He says that if he cannot get his refill order, he will kill himself.

19. Trauma-Sensitive Practice
Respect
Taking time
Rapport
Sharing information
Sharing control
Respecting boundaries
Fostering mutual learning
Understanding “non-linear” healing
Demonstrating awareness and knowledge of trauma

20. Limitations EPIC implemented May, 2015
Didn’t finish 6th educational session until August, 2015
Significant staff turnover limited survey results and follow-up

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