498 31 JANUARY 2020 • VOL 367 ISSUE 6477 sciencemag.org SCIENCEPHOTO: ISTOCK.COM/CRAIGRJDO
n 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 devastat-
ing health consequences in later life.
The project is not just a public health initia-
tive, but a vast experiment. State officials aim
to cut the health impacts of early life ad-
versity by as much as half within a genera-
tion. 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 com-
plete 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 do-
mestic violence, neglect, and sub-
stance 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 re-
sources such as food stamps or
housing assistance, discuss how
trauma and stress affect the developing
body and brain, and, if necessary, make re-
ferrals to specialists, such as psychologists.
“The overwhelming body of data ... tells
us that early detection and early interven-
tion improves outcomes” for children with
high ACEs scores, says California Surgeon
General Nadine Burke Harris, who is lead-
ing 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 Kai-
ser 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 re-
ported 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 Univer-
sity 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 Crimesagainst Children Research Center at the
University of New Hampshire, Durham,
worries that screening could “tremendously
increase the number of minor or unneces-
sary referrals to the child protection sys-
tem.” 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 ambi-
tious 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 withmany ACEs is also quite scant, Finkelhor
says—especially if the trauma was not re-
cent 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 in-
terventions 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 nega-
tive 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 medita-
tion can also help children over-
come trauma.
Yet California may not be capa-
ble 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 mil-
lion from the private-public California Ini-
tiative 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. “Ulti-
mately, 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 child-
hood trauma has worked? One measure is
money, she says. In 2013, for example, ACEs
cost Californians $10.5 billion, she and her
colleagues report this week in PLOS ONE.
If spending on ACEs-related conditions
such as asthma, depression, and heart dis-
ease falls in coming years, she says, she
will count the effort as a success. jBy Emily UnderwoodPUBLIC HEALTHScreen for childhood trauma triggers debate
Testing across California could have unexpected downsides, critics say
California aims to reduce childhood trauma’s harmful health effects.NEWS | IN DEPTHPublished by AAAS