Childhood adversity screenings are just one part of an effective policy response to childhood trauma

Amid increasing public awareness and concern about the harmful consequences of early adversity, policymakers in a number of states are calling for routine screening of individual children—in pediatric care, home visiting programs, early care and education, schools, and other child and family service settings—using the short list of adversities included in the original Adverse Childhood Experiences (ACEs) study.[6] As this movement gains traction, it is essential for policymakers to understand the limitations of this approach, as well as its potential for unintended consequences. These include:

• The potential for re-traumatizing children and families
• Contributing to stigma and a deficits focus
• The lack of age- and culture-sensitive screening tools
• A misleadingly narrow conception of adversity

Policy recommendations

Given the limitations of a screening-only approach, we recommend that policymakers instead adopt the following strategies for addressing childhood adversity:

Train service providers across child and family service systems in trauma-informed care (TIC).[7] TIC includes a wide range of approaches to identifying and addressing childhood adversity and lays a critical foundation for comprehensive screening and follow-up. Training in TIC has been shown to increase trauma knowledge and skills among service providers, family members, and foster parents, and to promote positive behaviors and mental health outcomes among children with symptoms of posttraumatic stress (e.g., problem behaviors, problems forming healthy attachments).[8],[9],[10],[11]

Promote adversity screening only as one component of a comprehensive, trauma-informed, strengths-based approach to addressing childhood adversity. Essential elements of this approach include the following:

• Service providers who are trained to sensitively conduct screening for adversity, without traumatizing or re-traumatizing the child and family, and without drawing faulty assumptions about a child’s future prospects
• High-quality screening tools shown to be valid for the child’s age and culture, and which account for social inequities (e.g., poverty, homelessness, discrimination, community violence, adversity related to immigration)
• Screening that assesses not only a child’s exposure to adversity (i.e., the types of adversity a child has experienced), but also a child’s reactions (i.e., trauma symptoms and related behaviors), which vary widely and require different types of intervention—or no intervention at all
• Service systems that can facilitate a family’s access to evidence-based treatment and supports, when needed
• Screening that is accompanied by comprehensive assessment across multiple domains of development (e.g., social-emotional, cognitive, language, physical development); such assessments can identify delays and other potential barriers to children’s healthy development, as well as promotive and protective factors in the household and community that can prevent or mitigate the harmful effects of early adversity

Support research to develop more sensitive tools for assessing adversity exposure in young children. Children’s reactions to adversity vary widely. Personal characteristics such as age and developmental stage, along with family and environmental stressors and supports, shape each child’s adjustment following exposure. Few screening tools are appropriate for infants and toddlers, despite the fact that their risk of exposure to many types of adversity (e.g., child abuse and neglect, domestic violence, unintentional injuries) is greater than for older children, and that they are especially vulnerable to the negative effects of trauma.[12],[13],[14]

Increase the availability and accessibility of evidence-based therapies. There are a number of effective treatments for childhood trauma following adversity (e.g., Child-Parent Psychotherapy,[15] Parent-Child Interaction Therapy,[16] Trauma-Focused Cognitive Behavioral Therapy[17]). Yet current demand far exceeds capacity, and children—particularly infants and toddlers—often face lengthy waits before they can access treatment because few trained providers are available in their community. Increasing the number of professionals trained to deliver evidence-based treatment—in addition to increasing families’ access to such professionals—is essential for children whose well-being may be compromised in the absence of such support.

Implement preventive strategies that reduce the likelihood of early adversity and its harmful effects on children and promote resilience in development. Prevention and early intervention are the most effective strategies for avoiding the negative effects of childhood adversity on children, families, and society. Making economic opportunity more inclusive, particularly for population groups who experience multiple disadvantages, should be part of this agenda; it is especially important to reduce poverty among children. Reducing children’s exposure to violence; and supporting safe, stable, nurturing relationships in families, schools, and other settings also represent essential overarching strategies.

Conclusions

We view growing public recognition of the importance of childhood adversity as a monumental development in the promotion of child well-being. However, it is also critical to guide policymakers toward the most effective, evidence-based strategies. Policymakers should not presume that screening as a standalone strategy is an adequate response to addressing the needs of children and their families. Thus, we join a number of experts[18],[19] cautioning against oversimplified adversity screening strategies, particularly those that employ tools such as the ACEs study index.[20] Rather, we need more comprehensive, trauma-informed[21] approaches that account for social-structural adversity and are aligned with current science on recognizing, understanding, responding effectively to—and preventing—childhood adversity.

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Glossary

Adverse childhood experience (ACE) – A term introduced by the Adverse Childhood Experiences (ACE) study (Centers for Disease Control and Prevention, and Kaiser Permanente, 1995-1997) to refer to the specific types of household challenges assessed in that study, occurring prior to an individual’s reaching age 18.

ACE study index – The measure used in the ACE study to assess childhood exposure to the following adversities: physical, emotional, and sexual abuse; parental mental illness; substance abuse in the household; incarceration of a household member; and witnessing violence against a mother. Two additional adversities—child neglect (emotional or physical) and parental separation or divorce—were added to the study in follow-up investigations.

Childhood adversity – One or more events or circumstances (including, but not limited to, those used in the ACE study) that can be harmful to a child’s short- and long-term physical and psychological health.

Trauma – An individual’s experience of one or more events or circumstances as psychologically and/or physically harmful or life-threatening.

Toxic stress – A over-activation of the body’s stress response system, accompanying trauma, which can lead to lasting impairments in physical and mental health, brain development, and genetic structure.

Trauma-informed care – A service system, program, or intervention in which all participations, practices, and policies reflect an understanding of the far-reaching impact of trauma, identify its signs and symptoms in individuals, provide pathways for recovery, and avoid re-traumatizing the individuals affected.

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Endnotes

[1] Benjet, C., Bromet, E., Karam, E. G., & Kessler, R. C., McLaughlin, K. A., Ruscio, A. M., …Koenen, K. C. (2016). The epidemiology of traumatic event exposure worldwide: Results from the World Mental Health Survey Consortium. Psychological Medicine, 46(2), 327-343.

[2] Fantuzzo, J., & Fusco, R. (2007). Children’s direct exposure to types of domestic violence crime: A population-based investigation. Journal of Family Violence, 22(7), 543-552.

[3] Grossman, G. (2000). The history of injury control and the epidemiology of child and adolescent injuries. The Future of Children, 10(1), 23-52.

[4] U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2019). Child maltreatment 2017. Retrieved March 8, 2019 from https://www.acf.hhs.gov/cb/resource/child-maltreatment-2017

[5] SAMHSA-HRSA Center for Integrated Health Solutions. (2018). Trauma. Rockville, MD: Author. Retrieved February 22, 2019 from https://www.samhsa.gov/capt/practicing-effective-prevention/prevention-behavioral-health/adverse-childhood-experiences

[6] Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., … Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245-258.

[7] Substance Abuse and Mental Health Services Administration. (2014). Substance Abuse and Mental Health Services Administration. (2014). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Author.

[8]Bartlett, J. D., & Steber, K., (2019, May). How to implement trauma-informed care to build resilience to childhood trauma. Bethesda, MD: Child Trends. Retrieved May 17, 2019 from https://www.childtrends.org/publications/how-to-implement-trauma-informed-care-to-build-resilience-to-childhood-trauma

[9] Barto, B., Bartlett, J. D., Bodian, R., Noroña, C.R., Spinazzola, J., Griffin, J. L., Goldman-Fraser, J., Montagna, C., & Todd, M. (2018). The impact of a statewide trauma-informed child welfare initiative on children’s permanency and maltreatment outcomes. Children & Youth Services Review, 81, 149-160.

[10] Redd, Z., Malm, K., Moore, K., Murphey, K., & Beltz, M. (2017). KVC’s Bridging the Way Home: An innovative approach to the application of Trauma Systems Therapy in child welfare. Children & Youth Services Review, 76, 170-180.

[11] Murphy, K., Moore, K. A., Redd, Z., & Malm, K. (2017). Trauma-informed child welfare systems and children’s well-being: A longitudinal evaluation of KVC’s bridging the way home initiative. Children & Youth Services Review, 75, 22-34.

[12] Fantuzzo, J., & Fusco, R. (2007). Children’s direct exposure to types of domestic violence crime: A population-based investigation. Journal of Family Violence, 22(7), 543-552.

[13] Grossman, D. C. (2000). The history of injury control and the epidemiology of child and adolescent injuries. The Future of Children, 10(1), 23-52.

[14] U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2019). Child maltreatment 2017. Retrieved February 3, 2019 from https://www.acf.hhs.gov/sites/default/files/cb/cm2017.pdf

[15] Lieberman, A., & Van Horn, P. (2004/2016). Don’t hit my mommy: A manual for Child-Parent Psychotherapy with young witnesses of family violence.  Washington, DC: Zero to Three Press.

[16] Eyberg, S. M., Boggs, S., & Algina, J. (1995). Parent–Child Interaction Therapy: A psychosocial model for the treatment of young children with conduct problem behavior and their families. Psychopharmacology Bulletin, 31, 83–91.

[17] Cohen, J. C., Mannarino, A. P., & Deblinger, E. (2006). Treating trauma and traumatic grief in children and adolescents. New York: Guilford.

[18] Finkelhor, D. (2018). Screening for adverse childhood experiences (ACEs): Cautions and suggestions. Child Abuse & Neglect, 85, 174-179.

[19] McEwen, C., & Gregerson, S. F. 2019). A critical assessment of the Adverse Childhood Experiences Study at 20 Years. American Journal of Preventive Medicine, 56(6), 790-794.

[20] Felitti  et al. (1998).

[21] Substance Abuse and Mental Health Services Administration. (2014).