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

2. The Bayview Child Health Center

3. Demographics of Bayview

4. Bayview/Hunters Point

5. 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.

6. 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)

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

8. 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

9. 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

10. 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.

11. 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)

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

13. Many ACEs in Communities of Color Are a Result of Racism

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

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

16. Death of a Caregiver
Health disparities disproportionately impact families of color

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

18. 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

19. 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

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

21. 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  

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

23. Understanding the Connection Between Racism and Trauma
ACEs
Trauma

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

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

26. Unemployment in California

27. Poverty in California

28. African Americans and Hiring

29. Median Income in California

30. Incarceration in California (per 100,000)

31. 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.

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

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

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