California program screening for adverse childhood experiences is imperfect but important

Re: “Why is California fighting adverse childhood experiences with more trauma?“

A recent commentary published by CalMatters raised a concern that screening for Adverse Childhood Experiences, or ACEs, may lead to unwarranted reports of suspected child abuse or neglect to Child Protective Services.

There is no evidence supporting the claim that ACE screening leads to unwarranted referrals to CPS. Rather, evidence collected as part of a seven-region statewide learning collaborative of 48 frontline clinics shows that both patients and providers find ACE screening to be acceptable and beneficial.

California’s groundbreaking ACEs Aware initiative emerged from the recognition that experiences of significant adversity as a child can negatively impact the developing brain and body, creating toxic stress. A large body of evidence now shows unaddressed ACEs and toxic stress are the root cause of many of the most common childhood and adult physical and emotional illnesses and disparities in health, especially for people in marginalized communities.

As a pediatrician caring for youth from vulnerable backgrounds, I believe the true problem is that our health care system and our society have failed to adequately prevent, identify and respond to the pervasive impacts of ACEs and toxic stress. ACEs Aware exists to address this very real problem and catalyze a more systematic and robust response to preventing ACEs and treating toxic stress. It reduces the negative health impacts and health disparities caused by unaddressed trauma.

Re: “Why is California fighting adverse childhood experiences with more trauma?“

As a family doctor and member of California’s Citizen Review Panel on critical incidents (child homicides due to abuse and neglect), I read Richard Wexler’s commentary with dismay. He expresses misperceptions about the utility of ACE screening and California’s ACEs Aware program.

The ACE screen is a risk screen, not a diagnostic instrument. It is similar to asking if a patient smokes – not a healthy habit, but not indicating a diagnosis of emphysema or lung cancer. ACE may result in trauma or toxic stress, which produce mental and physical disease, as has been well documented by the Centers for Disease Control and Prevention. The ACE screen may uncover current abuse or thoughts of suicide. From a medical point of view, it is preventive medicine, not “surveillance.”

Neither ACEs Aware, nor any clinician or agency, considers the answers to an ACE screen to be a stigma or a diagnosis, therefore they are definitely not “misappropriated” and not causing harm to children. The ACE screen is not unethical, and it should be as much a part of pediatric care as a growth chart.

The ACE screen has been proven to be transformative due to the insights provided to epidemiologic and clinical understanding of childhood family and environmental adversities, breaking through the barriers of cultural shame and avoidance which diverted medical and societal attention away from these issues. The ACEs Aware program was a major policy innovation, documenting the extent of exposure to the risk of possible harms and potentially identifying impacts among our poor, as well as investing in educating many naïve medical providers in the significance of ACE and the associated “trauma informed care” model which goes far towards humanizing the clinic.

I agree with Mr. Wexler that provision of concrete and economic supports to poor, stressed families is very effective in mitigating abuse and neglect. But so far no government agency has offered to put dollar bills in my pharmacy along with the medications.