Screening for ACEs has Improved Outcomes and Wellbeing

California is leading the way – again.

Mental health and substance use treatment organizations and primary care clinics throughout the nation are quickly learning the value of screening to understand the scope and impact of Adverse Childhood Experiences (ACEs).

We can trace the widespread adoption of screening back to 2019, when Dr. Nadine Burke Harris was appointed California Surgeon General.

Because of her leadership, California trains and provides payment to Medi-Cal providers for ACEs screenings. Those dramatic changes already have significantly improved the health and wellbeing of people – particularly youth – across the state.

Although youth-serving providers are screening more clients than ever, we must further expand screening and trauma-informed primary care.

Understanding ACEs and Toxic Stress

ACEs describe 10 categories of adversities in three domains – abuse, neglect and household challenges – experienced by the time a person reaches 18 years old.

Barely two years since the launch of the ACEs Aware grant, the initiative Dr. Burke Harris started, we know more than ever about the impact of ACEs and toxic stress on young people.

We know, for instance, that ACEs and toxic stress can change the way the brain develops and functions, contributing to increased risk of chronic diseases – including diabetes, cancer and stroke – as well as substance use, suicide and other injury and violence-related outcomes. If medical professionals are unable to diagnose and treat conditions that surface at an early age, children are likely to suffer from them throughout their lives. We know that in addition to the medical and social consequences, those failures have profound economic consequences.

We know that it is important to consider additional risk factors for toxic stress, like racism and discrimination. We know how important it is for clinicians to identify and treat ACEs and toxic stress as early as possible because ACEs can present life-long implications for health and wellbeing. We also know that it’s important to continue efforts to promote screening for ACEs, and that no one sector can do it alone.

We’ve learned that it requires collaboration across health care, public health, early education, education, justice and social service sectors to ensure that consistent trauma-informed approaches align to best serve our communities in need.

The Value of Trauma-informed Care

Trauma-informed care represents the health care community’s most thorough, effective approach to integrated care because it recognizes and responds to the signs, symptoms and risks of trauma to better support patients who have experienced ACEs and toxic stress. It is built upon a foundation of safety, trust and recognition that’s centered on the patient.

Trauma-informed primary care has its roots in a collaboration that began in 1995 between Kaiser Permanente and the U.S. Centers for Disease Control and Prevention (CDC). Researchers assessed more than 17,000 individuals to determine the psychological impact of adverse childhood experiences during the first 18 years of life.

Major findings from that initial study showed a strong correlation between ACEs early in one’s life and illness later in life.

People who experienced a combination of four types of ACEs had a 240% greater risk of hepatitis, were 250% more likely to have a sexually transmitted disease and were 390% more likely to have pulmonary disease.

There was also a link between ACEs and risky behaviors leading to diminished health. People who experienced an adverse childhood event were twice as likely to use tobacco products, seven times more likely to misuse alcohol, 10 times more likely to have injected street drugs and 12 times more likely to have attempted suicide.

Research efforts since that initial landmark study simply confirm the significant need for trauma-informed care.

Collaboration and Integration Play Vital Roles

Screening for ACEs is neither difficult nor demanding. Resources exist to help guide organizations through the protocols.

Roadmap for Resilience: The California Surgeon General’s Report on Adverse Childhood Experiences, Toxic Stress and Health urges communities to improve the health of young people by engaging numerous resources in a community – health care, public health, social services, early childhood education, education and justice.

That cross collaborative approach is vital to the success of trauma-informed care programs because it creates a process for achieving a warm handoff between health care providers and community resources, considers social risk factors across multiple sectors that impact whole person health, offers opportunities to learn and benefit from multi-agency perspectives for diagnosis and treatment and broadens awareness of ACEs and toxic stress mitigation to remove stigma and burden of proof from individuals.

Integration is also vital. Mental wellbeing is as important as physical health, which is why we must integrate mental health and substance use treatment with primary care.

Like Dr. Burke Harris, the National Council for Mental Wellbeing has long supported adoption of trauma-informed primary care.

Our change package, Fostering Resilience and Recovery: A Change Package for Advancing Trauma-informed Primary Care, offers guidance on screening for trauma and suggests trauma services. It also offers steps for the organizational changes that are necessary as practitioners embrace this shift in integrated care. We developed the package with the financial support of Kaiser Permanente.

We already knew how important trauma-informed care was, and it became even more relevant once the pandemic struck.

The pandemic has had a devastating effect on the health and wellbeing of so many people – it seems no one is immune from the fear, isolation or economic anxiety caused by this historic public health crisis.

The mental health of young people is of particular concern: In a recent CDC survey, 63% of 18- to-24-year-olds reported symptoms of anxiety or depression, with 25% reporting increased substance use to cope with that stress and 25% saying they had seriously considered suicide.

Screening for ACEs is no longer just something to consider. It is something youth-serving providers must do if we hope to make a difference in people’s lives.


Charles Ingoglia, MSW
(he/him/his) President and CEO
National Council for Mental Wellbeing
See bio