2 - Clinician Perspectives on Addressing Adverse Childhood Experiences in School-Based Health Centers: A Qualitative Study

Publication Number: 3001.2

Rebecca K.. Tsevat, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, CA, United States; Rosina Franco, Los Angeles Unified School District, Los Angeles, CA, United States; Roberta L.. Villanueva, Los Angeles Unified School District, Los Angeles, CA, United States; Kate Diaz Roldan, University of California, Los Angeles David Geffen School of Medicine, Covina, CA, United States; Gery Ryan, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States; Shannon M. Thyne, Olive View-UCLA Medical Center, Sylmar, CA, United States; Bahareh Gordon, UCLA Mattel Childrens Hospital, Sylmar, CA, United States; Ron Tanimura, Los Angeles Unified School District, Los Angeles, CA, United States; Shirley A. Russ, UCLA, Los Angeles, CA, United States; Rebecca N. Dudovitz, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, CA, United States

Background: Adverse childhood experiences (ACEs) are common and have been associated with poor health and educational outcomes throughout the lifespan. Early detection and mitigation of these adverse outcomes have been recognized as priorities by various medical societies, but most research on addressing ACEs has centered on primary care settings. School-based health centers (SBHCs) may be uniquely positioned to support youth with ACEs, but little is known about providers' experiences with ACEs screening and response in that setting.

Objective: This community-partnered, qualitative study sought to characterize facilitators and barriers to addressing ACEs in SBHCs from the perspectives of SBHC clinicians.

Design/Methods: We conducted semi-structured interviews with physicians and nurse practitioners (hereafter, clinicians) working in SBHCs in a large public school district in Southern California that implemented ACEs screening one year before the start of the study. The research question and design were co-developed by the district and academic partners. Interviews explored attitudes toward and experiences with ACEs screening in SBHCs, as well as perceived differences between screening in SBHCs and other settings. Interviews were audio recorded, transcribed, and independently coded by two members of the research team; discrepancies were resolved through consensus. We used an inductive thematic analysis approach, continuing until thematic saturation was reached.

Results: The sample included 10 clinicians, who collectively worked at 9 SBHCs in the district. Six major themes emerged, and within each theme, sub-themes were identified. Three themes were considered facilitators: 1) SBHCs serve as a bridge to care and resources for youth with ACEs, 2) SBHC clinicians are versatile in their approach to addressing ACEs, and 3) structural elements of SBHCs facilitate ACEs screening and response. The remaining three themes were considered barriers: 1) SBHCs have limited capacity for follow-up of youth with ACEs, 2) providers experience challenges with obtaining accurate ACEs screening results, and 3) responding to screening results is the most complex component of the screening process.

Conclusion(s): This is the first known study to provide insight from SBHC clinicians into the facilitators and barriers to addressing ACEs in SBHCs. The findings suggest that SBHCs have the potential to serve as a bridge to needed resources for students with ACEs, though challenges remain. Policy and practice recommendations may consider how SBHCs can be leveraged as a unique context to support vulnerable populations at risk of toxic stress.

Table 1: Sample Characteristics


Table 2: Facilitators and Barriers to Addressing ACEs in SBHCs


Figure 1
School-based health centers (SBHCs) function as a bridge for youth with ACEs. The pillars represent the structural components of SBHCs that facilitate ACEs screening and response: they allow for adolescents to be seen alone, are often co-located with schools, and have more flexible time for patient encounters. In turn, they can connect patients with medical care, social and community resources, and educational supports.