California’s well-meaning program to treat adverse childhood experiences relies on a system that requires doctors to report them, even if it doesn’t amount to abuse. The result could cause even greater harm to children.
Two years ago, Dr. Robert Anda, one of the authors of the original study of Adverse Childhood Experiences, cautioned that the scores from questionnaires to screen children for ACEs could be “misappropriated” as a diagnostic tool. California does not appear to have listened.
“Inferences about an individual’s risk for health or social problems should not be made based upon an ACE score, and no arbitrary ACE score, or range of scores, should be designated as a cut point for decision making or used to infer knowledge about individual risk for health outcomes,” Anda wrote in 2020.
Yet more than two years into a massive science-be-damned, ethically-questionable and albeit well-meaning experiment on overwhelmingly poor, nonwhite Californians, the only concern officials seem to have is that doctors haven’t done enough to surveil their parents and report on them to a state agency.
In 2020, the state began offering doctors $29 each time they administer ACE questionnaires to parents of children on Medi-Cal. Four or more ACEs is enough to diagnose trauma and refer the family for “services” – exactly the kind of arbitrary “cut point” Anda warned about.
No wonder he specifically singled out the California program for criticism.
The heart of the problem is something Finkelhor noted: Doctors are “mandated reporters” of child abuse and neglect. That supersedes doctor-patient confidentiality. Even if they don’t think the questionnaire results amount to abuse or neglect, doctors may be afraid of what would happen to them if they don’t make a report.
So instead of getting help, the children may experience more trauma. They could be subjected to the emotional turmoil of a child abuse investigation as caseworkers ask them questions about the most intimate aspects of their lives and, often, strip search them looking for bruises. A 2017 study found that more than half of all Black children are put through an investigation before they turn 18.
The trauma is, of course, compounded if the child is consigned to foster care. The California questionnaire that could lead to foster care lists even foster care itself as an adverse childhood experience.
The flawed questionnaire score-inspired reports further overload caseworkers, leaving them with even less time to find children in real danger. That’s why mandatory reporting itself has backfired.
The questionnaire also can magnify the racial and class biases that permeate child welfare, particularly the danger of conflating poverty with “neglect.” Questions include: “Have you experienced discrimination?” “Have you ever had problems with housing?” “Have you ever worried that you did not have enough food to eat or that food would run out before you or your parent/caregiver could buy more?”
There is no mention anywhere of informed consent. Doctors are not required to remind those filling out the forms that they are mandated reporters. Among parents who already know, the prospect of confiding in a mandated reporter may deter them from seeking help. That’s what UC Irvine professor Kelley Fong found when she interviewed poor families in the New England area. One mother, who regularly received similar questionnaires from her children’s school, called them “a trap” because teachers are mandatory reporters, too.
Dr. Leigh Kimberg, a UCSF clinician and scholar, has argued that questionnaires could be useful if patients were specifically warned that doctors are mandated reporters, but “through the racism that’s built into the child welfare system, Black, Indigenous and children of color have been removed from their families at markedly disproportionate rates. So these fears are justified.”
Yet now, apparently, state officials want doctors to follow-up and see if their patients took their advice and pursued their referrals. And if they didn’t, then what happens to them?
The creator of the California questionnaire, former state Surgeon General Dr. Nadine Burke Harris, defended her program by claiming that no one has anything better – but we do. A stunning number of studies find that even small amounts of cash significantly reduce what child welfare agencies call “neglect.” So California could “treat” far more ACEs far more effectively if it simply took the nearly $300 million it’s spending on this initiative and used it for cash assistance, childcare or housing vouchers.
You can’t fight trauma with trauma.