In a public health push, since 2020 California’s ACEs Aware Initiative has screened over 500,000 children for Adverse Childhood Experiences (ACEs). ACEs include experiences like witnessing intimate partner violence, physical neglect, having a parent with a substance use disorder or parental divorce. The massive public health program is a $141.5 million 2-year commitment to screen for ACEs using simple questionnaires. But why is California making such an investment?
The Costs of Trauma
The financial costs of ACEs are enormous. The CDC estimates that in 2015 child maltreatment cost the United States $428 billion in costs from illness and lost life-years. An estimated 2 out of 3 Americans experiences at least one ACE, and 1 out of 6 experienced four or more. Abuse, neglect, and trauma are all known to have negative impacts on a young person’s psyche, but what is less apparent are the long-term visceral impacts. The health impact of ACEs include an increased risk of heart disease, cancer, mental health struggles, drug use, and violence. Childhood adversity can be transmitted from one generation to the next, due in part by an increased stress response in parents who themselves experienced childhood trauma. The clear health and financial consequences of untreated ACEs for both individuals and society warrants this massive investment. Health policy to effectively screen for ACEs and address structural factors underlying them should be a key social justice priority.
Funding early screening programs like ACEs Aware is one way to identify young people at risk for ACEs, and ultimately lead to appropriate interventions. The PEARLS Screening tools used in California asks adults and children questions ranging from violence in neighborhood, homelessness, immigration policies/family separation, food insecurity, and discrimination. Screenings performed at UCLA led to immediate distribution of resources like baby food and diapers, as well as referrals to housing services. Programs like FIND (Family Information and Navigation Desk) at UCSF are used to connect families with local resources like counseling, food-stamps, and housing. A greater understanding of ACEs related needs can enhance the effective development of these programs. Doctors in the ACEs Aware Initiative also provide education on mindfulness techniques like meditation and yoga, and wellness strategies like exercise and nutrition. It may seem disingenuous to claim something as small as yoga and exercise can undo major life stressors like abuse, but studies have shown their effectiveness at reducing depression and anxiety and reversing the effects of ACEs.
Moving Beyond Clinics
As we uncover more about ACEs, we see that the clinic isn’t the only setting worth including. Interventions should focus on spaces where resiliency can thrive. Schools play a central role in many children’s lives and with the proper resourcing can strengthen young folks. Students have a significant decline in success in grade school with the more ACEs they experience including higher dropout rates, greater absenteeism, and decreased homework participation, an effect that was decreased by protective factors. Concurrently, worse school performance can lead to risk-taking behavior and further ACEs. Expanded ACEs screenings can presage policy change in classrooms, such as supporting the exchange of school-based policing programs for mental health counselors, and ending zero-tolerance policies that lead to suspensions or expulsions or even arrests like in one 2016 Tennessee case where 11 kids, the youngest of whom was 8, were arrested and jailed for not stopping a school fight. Rather we must place trauma-informed approaches and mental health at the forefront of teacher training. Practices like restorative justice and de-escalation are detailed in the Substance Use and Mental Health Services Administration (SAMHSA) guide for trauma-informed practices that can be adapted to suit the needs of any educational institution. ACEs-informed schoolscan focus on providing free or reduced-price meals, and helping students build relationships through extracurriculars or after/before school programs that involve them in things like art, music and sports. Schools that have adopted nutritious free lunch programs have seen improved wellbeing and educational outcomes, indicating the importance of providing social support to reduce the harm caused by ACEs. Screening allows administrators to better understand the ACEs impacting their population, and curate resources best suited for these community needs.
ACEs screening: Worth the Investment
Critics argue that screening in resource-strapped schools is impractical. However, California already has several required screenings in schools for other health indicators, such as vision, hearing and scoliosis. Others claim that this questionnaire can be ineffective or even harmful in addressing ACEs, if it retraumatizes children. While these fears are important, there has been no evidence of serious distress in responding to ACEs questions. Contrarily, ACEs screening increases patient-clinician trust and patient satisfaction.
There is still much to understand about the role of ACEs in our lives. What we know is that early interventions seem to work. We need to prioritize screening in intimate healthcare settings like primary care clinics and places that play a major role in children’s lives like schools. Innovative programs like ACEs Aware that combine physician training on ACEs and Medi-Cal reimbursement for screening patients with ACEs should be utilized and expanded as a powerful public health measure. States that want to decrease the societal and financial impact of illness, should address this hidden epidemic by implementing similar programs to actualize major benefits to health and society and significantly reduce health care cost.
Wasan Kumar earned his BS in Neuroscience and Public Policy at the University of Illinois at Chicago. He is a current medical student at Stanford University School of Medicine.