On 1 January, California became the first U.S. state to screen for adverse childhood experiences (ACEs)—early life hardships such as abuse, neglect, and poverty, which can have devastating health consequences in later life. The project is not just a public health initiative, but a vast experiment. State officials aim to cut the health impacts of early life adversity by as much as half within a generation. But critics say the health benefits of screening are unproven, and it could create demand for services the state cannot provide.
The $160 million initiative applies to 7 million children on Medi-Cal, California’s insurance for low-income people. Health care providers who complete 2 hours of online training are encouraged to screen children up to age 18 for ACEs. The questionnaire, filled out by children’s caregivers or teenagers themselves, includes 10 categories of ACEs, such as domestic violence, neglect, and substance abuse, with questions such as “Has your child ever seen or heard a parent/caregiver being screamed at, sworn at, insulted or humiliated by another adult?” and “Have you ever felt unsupported, unloved and/or unprotected?”
If a child has a worrying score, the provider is instructed to give information about helpful resources such as food stamps or housing assistance, discuss how trauma and stress affect the developing body and brain, and, if necessary, make referrals to specialists, such as psychologists.
“The overwhelming body of data … tells us that early detection and early intervention improves outcomes” for children with high ACEs scores, says California Surgeon General Nadine Burke Harris, who is leading the initiative. “We have the science to act.”
Burke Harris notes that toxic stress can set a child on a lifelong trajectory of ill health. A 1998 study by researchers at Kaiser Permanente, for example, found that of 9500 adults, those who remembered high numbers of ACEs had a four- to 12-fold increased risk of alcoholism, drug abuse, depression, and suicide attempts. A follow-up study of more than 17,000 people found that those who recalled six or more ACEs died 20 years earlier than people who reported none. To try to stem the toll, Medi-Cal also pays for adults to be screened for ACEs, so that doctors can recommend treatments for stress-related conditions such as addiction and depression.
The evidence that ACEs affect health in adulthood is “pretty indisputable,” says Aric Prather, a psychologist at the University of California, San Francisco (UCSF). But some researchers caution that the California screen could have unintended consequences. Because state law requires providers to report child abuse and neglect, David Finkelhor, director of the Crimes against Children Research Center at the University of New Hampshire, Durham, worries that screening could “tremendously increase the number of minor or unnecessary referrals to the child protection system.” Burke Harris says that pilot studies haven’t shown a significant uptick in such reports, but the state is monitoring for that. “We take those concerns seriously.”
Finkelhor points out that many ambitious screening projects have failed to show benefit, and some actually caused harm. Universal domestic violence screenings for women, for example, haven’t been shown to improve health or quality of life, he says—perhaps because providers don’t know how to help those who report abuse. The evidence about what to do for a child with many ACEs is also quite scant, Finkelhor says—especially if the trauma was not recent and the child shows no symptoms. “It’s not clear to me that [we should treat] a kid who was abused 5 or 6 years ago but doesn’t have symptoms or problems.”
To test the screen and find out what interventions work, pediatrician Dayna Long of UCSF is running a clinical trial of the new screen with 550 families. Researchers know that those with a stable, supportive caregiver are more resistant to the negative health effects of ACEs, so supporting caregivers is a top priority, she says. And other pilot studies suggest basic services such as food and shelter, counseling, and instruction in techniques such as meditation can also help children overcome trauma.
Yet California may not be capable of providing such wraparound services to all who need them. If doctors start to refer all Medi-Cal enrollees with a history of ACEs to specialists, it could “open a flood-gate,” Prather says. On the other hand, he says, the program could underscore the need “to ensure the safety of our youngest and most vulnerable” and prompt California to develop new services.
For researchers, Prather says, the screening program offers a chance to study why some people are more resilient to ACEs, and how different adverse experiences affect the brain and body. The state plans to fund studies with $9 million from the private-public California Initiative to Advance Precision Medicine. “My hope is that as we start to generate data as a state, there’s an investment in both the quality and rigor of science so that we can continue to drive policy,” Long says. “Ultimately, we want to be able to look across the generations and ask, ‘How did we do?’”
How will Burke Harris know whether her state’s ambitious plan to reduce childhood trauma has worked? One measure is money, she says. In 2013, for example, ACEs cost Californians $10.5 billion in personal health care costs, she and her colleagues report this week in PLOS ONE. If spending on ACEs-related conditions such as asthma, depression, and heart disease falls in coming years, she says, she will count the effort as a success.
*Clarification, 7 February, 2:10 p.m.: This story was updated to clarify that the $10.5 billion cost of ACEs in California came in the form of personal health care spending.