Think of the Children: We Need National ACEs Screenings

February 25, 2021

There are 74.1 million children currently living in the United States. Roughly ten million of these children have three times the risk of developing heart disease and lung cancer, in addition to a 20-year difference in life expectancy. The cause? It’s not bacteria or a carcinogen or some up-and-coming infectious disease. The answer is stress.

Adverse childhood experiences, otherwise known as ACEs, are traumatic events that occur before age 18. The original ACEs study was conducted through a collaboration between Kaiser and the CDC between 1995 and 1997. The study identified ten adverse childhood experiences, including emotional, physical, and sexual abuse; neglect; and household challenges such as parental separation, substance abuse, incarceration, violence, and mental illness. ACEs are actually quite common: the study found that two-thirds of participants had experienced at least one ACE category. In 2019, the CDC found that, from data collected from 144,000 adults in 25 states, 61 percent of participants experienced at least one ACE and nearly 16 percent have experienced four or more ACEs.

Why does this all matter? The prevalence of ACEs is linked to adverse health outcomes: adults who experienced four or more ACEs had higher risk for negative physical and mental health outcomes. The original ACEs study and subsequent research have linked ACEs to increased risk of developing chronic diseases and behavioral challenges, including obesity, autoimmune diseases, depression, and alcoholism. The greater the number of ACEs, the greater the risk for negative outcomes. In 2019, the CDC found that at least five of the top 10 leading causes of death—including respiratory and heart disease, cancer, and suicide—are associated with ACEs.

ACEs are pervasive but largely unaddressed across all populations, making them one of the greatest public health crises facing the nation.

Perhaps the most surprising detail from the original ACEs study is that these adverse health outcomes are not the result of poverty or a lack of healthcare, as might be commonly assumed: the study examined a population that was 70 percent college-educated and all insured through private health insurance. This is not to say that the rates of ACEs are equally distributed; on the contrary, 61 percent of Black children experience at least one ACE compared to 40 percent of white children who experience at least one ACE. However, the takeaway is that ACEs are pervasive but largely unaddressed across all populations, making them one of the greatest public health crises facing the nation.

California is presently leading the way for state-wide ACEs screening under the guidance of California’s first surgeon general, Dr. Nadine Harris Burke. Her ambitious goal of reducing the prevalence of ACEs by half within one generation is not only praiseworthy but actually in progress. The California Department of Health Care Services has recently approved the use of the screening tool PEARLS, or Pediatric ACEs and Related Life-Events Screener, for Medi-Cal patients and offers reimbursement for providers.

But California alone cannot solve the burden of ACEs. Currently, 30 states across the United States have adopted some measure of legislation regarding ACEs, spanning from the minimal effort to raise awareness about ACEs to the efforts to implement statewide ACEs screening a la California. This is not good enough. By 2030, the federal government and all 50 states must move towards implementing mandatory ACEs screening for all minors.

As with any new screening tool implemented on a national scale, the most common pushback is that of cost; such concerns are, in fact, warranted. Take, for example, California’s PEARLS screening program, which cost $45 million to implement during the 2019-2020 fiscal year. But then consider the fiscal burden of ACEs on state budgets: in California alone, ACEs are estimated to cost $113 billion per year as they increase nine out of the ten leading causes of death in the United States; over the next decade, the cost is estimated to sum to a whopping trillion dollars.

When examining the U.S. as a whole, half of the original ten ACEs are estimated to cost approximately $401 billion in economic burden for employers and health care, education, child welfare, and corrections systems costs for states. Using California as a case study, it is apparent that the initial cost of implementation is a small price to pay in comparison to the estimated economic burden plaguing states annually. From the economic lens alone, reducing the prevalence of ACEs in adolescents is a fiscally responsible initiative.

Let’s be clear: screening is only the first step in tackling a much larger issue, one that spans across generations, races, and state lines. But it is still a vital step in paving the way for understanding the magnitude of ACEs and the accompanying health burden. It also is a call to action for researchers, policymakers, and community health workers: what are the next actionable steps in reducing the health impacts of ACEs efficiently and effectively? Think of the children: their health depends on it.

Claire Bang is an MPH student in the Department of Epidemiology.