California’s Surgeon General Readies Statewide Screening for Child Trauma

Pediatrician and best-selling author Nadine Burke Harris, left, was named California’s first-ever surgeon general in January. Now she is helping implement an ambitious trauma-screening effort across the state. Photo: Howard Pasamanick for First 5 LA.

Soon after being appointed California’s first-ever surgeon general, Nadine Burke Harris took off on a barnstorming tour across the state to talk about adverse childhood experiences and toxic stress, an issue she calls “the biggest public health crisis facing California today.”

Before the pediatrician was appointed to her position in January by Gov. Gavin Newsom (D), Harris had founded and led the Center for Youth Wellness, organization focused on addressing toxic stress and the study of adverse childhood experiences, or ACEs. Over the past decade, she has become a leading voice on the subject of ACEs, the scientifically proven idea that multiple incidents of childhood trauma can place people at risk of a lifetime’s worth of health issues. That role has carried her across the country, from helping nurture ACEs advocacy work in California to national meetings of the American Academy of Pediatrics and even the White House.

Newsom approved a budget in June that will help California move toward universal ACEs screening, a goal that Harris has long supported. The state is setting aside about $45 million next year to reimburse Medicaid providers in the state for trauma screenings of adults and children, and another $50 million to train primary care providers on how to administer these screenings.

As she prepares to put California’s ACEs screening process in motion, Harris talked with The Imprint about Newsom’s agenda, plans for a statewide screening process, and how doctor shortages are affecting children’s health.

I hear that you emailed then-candidate Gavin Newsom on the campaign trail to bring up childhood trauma. What made you do that and what did you say to him?

What made me do that was frankly I had just finished a wonderful exchange with Tonette Walker, who is the former first lady of Wisconsin. First Lady Walker had led a big ACEs initiative in Wisconsin. Then she convened 11 Republican first spouses on the issue of ACEs and toxic stress. To see so many other states that were beginning to have this conversation, I reached out to Newsom on the campaign trail and said “Hey, where is California on this issue?”

I will say, don’t raise something with Gavin Newsom unless you are prepared for him to do something about it because he responded in fine form and California is now leading the nation in our response to ACEs.

The governor just approved a hefty chunk of money for trauma screening in this year’s budget. What does it mean for California as a state to have regular screening for a children’s Medi-Cal population?

He has really put this money where his mouth is and what putting these dollars behind screening says is that California is serious about this. This is not some unfunded mandate but that we are truly investing in routine screening, early detection and early intervention. We’re not asking doctors to do this on their own time and not be reimbursed for it. We’re valuing their time.

My job is to help to implement training our 88,000 primary-care providers on how to screen and how to respond with trauma-informed care. That’s phenomenal. The thing that’s even more critical is that one of the things we’ve recognized is that it doesn’t begin and end with screenings … the move toward universal screenings for ACEs for our Medicaid population, that is simply a lever by which we can engage and organize all our program activities.

The governor has not just invested the dollars to reimburse providers for screenings, he’s also invested $50 million in after school education and safety programs, additional dollars to increase state preschool, early learning and childcare and workforce issues. All of these are connected. It’s not just the screenings, it’s the investments across the landscape.

What are a couple things you learned about training doctors on screening during your time with Center for Youth Wellness? 

Nadine Burke Harris. Photo courtesy of Winokur Photography

Many people would guess that the most important thing about training doctors to do ACEs screening in primary care is how to do the actual screen. Actually, the most important thing is what to do when you have a positive screen, making sure you have a critical protocol in place just like you would if you had a patient with a positive test for pneumonia. What are your next steps, how to follow up and ensure the patient gets the care they need?

Physicians are often worried about not having resources for their patients. No one went into medicine to not to have resources for their patients…I think that there’s the presumption that every patient who scores positive for ACEs needs mental health services. You know what? Not every patient does. In fact, most patients don’t. One of the most important things a primary care physician can learn is how to guide patients around which symptoms may be related to history of adversity and what are the tools that they can use to manage and improve their outcomes. Tools like sleep, exercise, nutrition, mindfulness, mental health and healthy relationships. For some folks, there’s a fear that every person is going to require a ton of resources that we don’t have. In practice, in the places that have piloted this and those that have done it at scale, it turns out that’s actually not the case.

The one other thing I would also add is that one of the exciting pieces is that, for a lot of this stuff, we have a lot of resources in place already but it’s about coordination and alignment of these resources. It’s not about re-inventing the wheel, it’s not about going out and requiring a ton of brand new resources or new money. It’s about how do we do a better job of early detection, early intervention and implementing the interventions that we know improve outcomes. All the research shows that early detection and early intervention work. How do we align that with the existing resources that are out there? A lot of it is coordination of what already exists.

On your state listening tour, you said that an issue that came up several times was primary-care shortages across the state. How big of an issue is this for California?

I think I was aware of it before, but it was something else entirely to see it up close and see how many of our communities, particularly in rural Northern California or in the Inland Empire, are really struggling for resources.

Right now, we’re looking at how do we provide access to services? A great example of a potential solution is at UCSF [University of California, San Francisco], which has a psychiatry consultation telemedicine service that they launched in several rural counties. Any primary care clinician who wants to do a consultation with their patients can call a hotline and get information from a trained psychiatrist to say, “Hey, what’s the right next step in my patient’s management?”

Thinking about how do we provide that full spectrum of care using innovations and current, existing programs, how do we deploy these resources differently and what are the opportunities for us to improve some of the services and improve the access for families. It’s definitely something that I’ll be weighing in on.

This interview has been lightly edited for length and clarity.

Don’t miss the Breaking Barriers Symposium, a working conference that focuses on providing practical ideas to help break the barriers to care for California’s youth and their families. The fourth annual Breaking Barriers Symposium will be held November 20-21, 2019, in Sacramento. You can register here.

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