In a recent article in The Imprint, Karen de Sá and Nadra Nittle reviewed arguments for and against universal pediatric screening for adverse childhood experiences, or ACEs, in California. They noted that California Surgeon General Nadine Burke Harris, who has led the push for this plan, recognizes the serious concerns of critics but does not hear alternative proposals from them that might achieve her important goal of reducing toxic stress among children.
But there are more effective options than requiring ACE screening that public health leaders can employ in the fight to diminish the effects of toxic stress on developing brains and bodies. I will discuss three that could help get California where it wants to go.
These resonate with my experience as a volunteer with the United Way of Mid Coast Maine working on early childhood interventions to diminish toxic stress. They follow directly from my research and writing about early childhood adversity, toxic stress and intergenerational poverty. As a sociologist collaborating with a neuroscientist, I saw the clear research evidence about the profound ways that adverse social environments affect child development but also the powerful counterforce that, for example, a well-designed preschool can have on life trajectories.
If California wants to make any pediatric screening exam universal, it should be developmental screening, which can identify health and behavioral issues related to toxic stress in individuals. The Ages and Stages Questionnaires, for example, probe gross and fine motor skills, executive functioning, adaptive functioning, problem-solving and social relationships among other factors. The most recent National Survey of Children’s Health reveals only about a quarter of California parents reported a developmental screening, below the national average of 33% and neighboring Oregon’s rate of 56%. The American Association of Pediatrics (AAP) recommends universal developmental screening, and the U.S. Department of Health and Human Services has catalogued validated developmental screening tools.
Pediatric nurses and doctors should also examine the social needs of the households of their patients, as recommended by the American Association of Pediatrics. Unlike the original ACE survey, which focuses entirely on the household environment, a social determinants of health screening uncovers the social and economic circumstances of families which themselves may induce toxic stress. Appropriate referrals to social services agencies could improve those circumstances by deploying community resources in support of patients and their families.
Outside of pediatric practice, state public health leaders should employ ACE science to support advocacy for creating or expanding those community resources that improve the lives of families and children. As the original ACE study co-author Dr. Robert Anda argues, the appropriate use of ACE data is not for screening individuals but rather for identifying populations at risk. ACE data and science thus can buttress support for social policies that will diminish the likelihood of adversity – universal child care, higher minimum wage and affordable housing, to name a few – and thus reduce the social determinants of toxic stress. Investment in developing community resilience promises to improve adverse environments that contribute significantly to toxic stress.
ACEs research has highlighted the significant public health challenges that childhood adversity and toxic stress create. Surgeon General Harris is right to give priority to addressing those challenges, but public health officials have better alternatives than universal ACE screening to respond to them.