A December 2020 report, Roadmap for Resilience: The California Surgeon General’s Report on Adverse Childhood Experiences, Toxic Stress, and Health, detailed how Adverse Childhood Experiences (ACEs) and toxic stress can impact learning and school success. Toxic stress can impede learning and affect relationships and other aspects of functioning in school by impairing the areas of the brain responsible for learning, memory, threat detection, emotional regulation, impulse control and executive functioning.

More than 20 ACEs Aware grantees were awarded funding to develop practice papers highlighting promising strategies and lessons learned, as well as new research around ACE screening and trauma-informed systems of care. The practice papers cover a broad range of topics, some of which apply to local educational agencies and the organizations they partner with.

Developed by Training and Research Associates and the California School-Based Health Alliance, this paper (bit.ly/3rCoRO9) highlights emerging best practices and barriers to implementing trauma-informed care, ACE screenings and care coordination for the prevention and treatment of toxic stress in school-based health centers (SBHCs). SBHCs are well-positioned to coordinate care for some of the most medically underserved youth.

Ideally, SBHCs should employ multidisciplinary health and mental health professionals such as nurses, psychologists and social workers who consult regularly with school- and community-based supports on behalf of students to help identify and obtain the services they need. Additionally, SBHCs should be convenient, culturally responsive and eliminate structural barriers to service, including transportation, cost, language barriers, available hours and lack of confidential services for adolescents. SBHCs should also have a schedule that allows for ample time with patients and provides easy access to follow-up care.

SBHCs have been shown to increase school attendance, improve academic scores, decrease school dropout rates and provide high-quality care, according to the paper. Practices are often determined by the lead agency sponsoring the SBHC — be it a community health center, school district, county health department, hospital/medical center, nonprofit community-based organization or private physician group — and these lead agencies may adhere to different values and priorities, governing laws and policies, and billing mechanisms than a local educational agency. Reimbursement mechanisms and ongoing training for leadership, providers and staff at all levels of the clinic can also be challenging, and only a small percentage of SBHCs were early adopters of ACE screening.

In light of the barriers and best practices outlined in the report, researchers call on the state to continue to fund and sustain an infrastructure to provide ongoing training and capacity building for trauma-informed systems and networks of care; increase funding and sustainability of mental health providers in SBHCs to advance the goal of ACEs Aware to both prevent and address the impact of ACEs and toxic stress; and expand telehealth resources and training for rural settings.

These may include systems that support families by improving economic opportunities (primary prevention), early screening (secondary intervention) and integrating systems beyond the clinic setting to help mitigate the harmful effects of ACEs (tertiary).

Though no single example has been recognized as best practice, authors of the report note that integration is critical to ensuring more holistic support. Several core characteristics emerged from interviews that could inform the development of such models moving forward:

• Building appropriate infrastructure with consideration of the broader needs and context of the wider community
• Comprehensive screening at the beginning of the school year using the Pediatric ACEs and Related Life-events Screener (PEARLS) to establish a baseline among the student population
• Streamlined communication protocols to prevent any confusion or miscommunication
• Opportunities for equal access to screening and services for students
• Continuity of care by employing a case management approach to ensure follow-through on a student’s treatment program
• Program evaluation to track and monitor student progress and outcomes, provide information to school administration, and identify needed improvements to school-based integrated systems of care.