A NEW UNDERSTANDING OF CHILDHOOD TRAUMA Zea Malawa, MD, MPH San Francisco Department of Public Health

The Bayview Child Health Center

Demographics of Bayview

Bayview/Hunters Point  

Health Disparities in the Bayview Among our Patients There Were Higher Rates of Obesity Infant Death School Problems Asthma ER Visits Low Birth Weight Babies Poorly Controlled Diabetes So hard to take care of these vulnerable, fragile children Infant Death is among the highest in CA. School Problems are both academic and behavioral.

Bayview Child Health Center ACEs ≥ 1 67.2% ACEs ≥ 4 12% ACEs ≥ 4 and BMI ≥ 85% OR: 2.0 p< .02 ACEs ≥ 4 and learning and/or behavior problems OR: 32.6 p< .001 N.J. Burke et al/ Child Abuse and Neglect 35(2011) 408-413

Model of Care at BCHC Holistic Approach Integrated Mental Health Routine ACEs Screening Holistic Approach Integrated Mental Health

Model of Care at BCHC Routine ACE Screening at Well Child Visits First Iteration: Physician interviews the patient face-to-face Second Iteration: Paper survey in which patients indicated which ACEs had occurred Third Iteration: Paper survey given in which patients would just indicate the total number of ACEs that had occurred

Model of Care at BCHC Multidisciplinary Disciplinary Rounds The Team Included: Pediatrician Mental Health Provider Case Manager Psychiatrist (when we were lucky) The Work Included: Presenting new cases and developing a holistic treatment plan Updating and problem solving for existing patients Reflection space for medical providers

Model of Care at BCHC Mental Health Integrated into Primary Care MD could leverage rapport with patient to introduce mental health intervention By housing mental health services within the clinic space, we could reduce stigma associated with receiving mental health treatment There was constant communication between mental health providers and medical providers about the patient’s progress and how we could support one another.

Challenges with our model Very expensive - dependant on donor funds Addressing ACEs and associated symptoms lowered productivity Incomplete buy-in from the community Precipitated CPS calls Black and Samoan patients much less likely to engage in individual therapy service Too few mental health providers of color Vicarious trauma on the medical side (MDs, MAs, Front-desk staff)

Challenges with our model Model did not address the structural inequities that created the traumatic environment in the first place

Many ACEs in Communities of Color Are a Result of Racism

Household Member Incarcerated Non-white people are significantly more likely to be arrested and convicted

Household Member Incarcerated Non-white people are significantly more likely to be arrested and convicted

Death of a Caregiver Health disparities disproportionately impact families of color

Childhood Neglect When parents of color earn lower wages, they have less time and fewer resources available for their children Source: US Census

Household Dysfunction Low access to financial resources makes it difficult for people of color to leave a home where there is domestic violence, substance abuse or other dysfunction. Median Wealth of White Families $116,000 $1,700 $2,000

Beyond ACEs Complex Trauma Describes children’s exposure to multiple or ongoing traumatic events Describes the long-term and pervasive impact of this exposure The impact of trauma is cumulative

Poverty and Racism Can Cause Complex Trauma Crowded Living Conditions Financial Worry Neighborhood Violence Lack of Adequate Child Care Substandard Housing

Poverty and Racism Can Cause Complex Trauma Frequent dehumanizing interactions (usually unacknowledged) Witnessing police violence –in person or on screen Family separation caused by deportation or displacement Racial bias in CPS interventions  

UNARMED BLACK MAN SHOT BY POLICE Community Trauma UNARMED BLACK MAN SHOT BY POLICE

Understanding the Connection Between Racism and Trauma ACEs Trauma

The Gardeners Tale Jones, C. P. (2000). Levels of racism: a theoretic framework and a gardeners tale. American Journal of Public Health, 90(8)

The Gardeners Tale Jones, C. P. (2000). Levels of racism: a theoretic framework and a gardeners tale. American Journal of Public Health, 90(8)

Unemployment in California

Poverty in California

African Americans and Hiring

Median Income in California

Incarceration in California (per 100,000)

Student Achievement in California Source: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, National Assessment of Educational Progress (NAEP), Reading Assessment.

How would our practices change if we viewed trauma in communities of color within the context of racism?

What kind of gardeners do we want to be? Are we focused on the flowers? Or the Soil?

What Can Public Health Leverage to Protect Kids from the Trauma of Racism?