Renee Gross, JD Renee Gross, JD

Over the past few months, the COVID-19 pandemic has caused everyone to grapple with uncertainty and manage new stressors at home, at work, and in our communities.

A recent Kaiser Family Foundation poll indicated that 45% of Americans report that the current crisis is harming their mental health. We are facing unprecedented disruption in our daily lives and navigating a world of school and business closures, job losses, social distancing, food access and housing constraints, and other types of economic hardship.

While these circumstances are challenging for adults, they can be especially difficult for children, who may not understand why their lives have changed so dramatically. Older youth may feel a sense of loss or unfairness about not being able to attend school, see their friends, or experience key events in their passage to adulthood.

This pandemic has brought to the forefront a conversation about the lasting effects of trauma during childhood. Trauma has long been a societal problem with profound effects on people’s physical and mental well-being throughout life.

Prior to the current crisis, many efforts were underway to prevent or mitigate the effects of childhood trauma. Kaiser Permanente is committed to being a leader of this work in the communities we serve in partnership with community agencies, schools, and other health systems. This includes supporting a variety of policy approaches that governments at all levels can take to address trauma. We hope that these policies can serve as a guide for policymakers and advocates looking for new ways to support children in the months ahead.

What is childhood trauma?

Trauma occurs when people experience a negative event that threatens their sense of safety and overwhelms their ability to cope. It can also occur when people witness these events inflicted on a family member, friend, or peer. Trauma is pervasive; an estimated 70% of U.S. adults have experienced a traumatic event at least once in their lives.

Traumatic events that occur early in life, such as abuse, neglect, or household dysfunction, are called adverse childhood experiences, or ACEs. In 2016, nearly half of U.S. children — 34 million — had at least one ACE and more than 20% experienced 2 or more. From mid-March 2020 to early April 2020, the National Domestic Violence Hotline received 2,345 calls in which COVID-19 was cited as a condition of the victim’s experience, and calls to the Substance Abuse and Mental Health Services Administration’s disaster distress help line increased by over 800% in April compared with the same time in 2019. These statistics suggest that the pandemic may be increasing the risk for more ACEs.

Kaiser Permanente’s leadership on childhood trauma research began with a seminal study of more than 17,000 participants conducted from 1995 to 1997 through a partnership with the Centers for Disease Control and Prevention. That study found certain experiences in childhood — and the number of those experiences — were strongly associated with the leading causes of illness and death as well as poor quality of life. Additional research expanded on these findings, demonstrating that ACEs can impact adult outcomes of disease, quality of life, care utilization, and mortality. Imelda Dacones, MD, president and CEO of Northwest Permanente, highlights the importance of addressing ACEs early in life. As an internist, she cares for older adults with multiple chronic conditions and complex needs. Dr. Dacones underscores the importance of acting now, “given what we know about ACEs, this is a tremendous opportunity to look upstream — much earlier in people’s lives, as children — where we can intervene and prevent chronic illness.”

State actions that address ACEs

Many states recognize the impact of ACEs on child development and lifelong health. Kaiser Permanente’s Institute for Health Policy has hosted policy forums on childhood resilience and trauma in school-aged children to provide a platform for state leaders and agencies to share some of these efforts.

Amid this pandemic, state action to support children is especially important. To date, states have enacted more than 60 statutes aimed at preventing or mitigating the effect of ACEs. Policies that provide support for tools, resources, and funding to prevent or mitigate ACEs will prove invaluable in the months ahead as a framework to learn from and expand upon.

A state leader paves the way

Wisconsin is considered the first “trauma-informed state” due to its comprehensive approach to addressing trauma. The state’s approach is spearheaded by Fostering Futures, a public-private partnership designed to boost trauma-informed care and raise awareness about trauma. Fostering Futures has trained more than 10,000 people on these practices, including the governor’s office staff. Additionally, Wisconsin’s efforts resulted in change at the federal level through passage of resolutions in the U.S. House and Senate that recognize the importance and effectiveness of trauma-informed care.

A state tool that screens for ACEs

One new approach to identifying ACEs early in life is to have providers screen children for ACEs during routine care visits. In 2019, California launched ACEs Aware, an initiative supported by policy and led by the Office of the Surgeon General and the California Department of Health Care Services to give Medi-Cal providers training, clinical protocols, and payment for screening children and adults for ACEs. Providers are not mandated to conduct screening, but in an effort to increase participation, California allocated more than $105 million to promote ACEs screening. Funding is set aside to train doctors to provide screening ($50 million) and to reimburse doctors in the state’s Medi-Cal program ($45 million total, $29 per screening). Additional screening will provide the state with data about the prevalence of ACEs and areas that require additional resources and support.

As with any innovative practice, the long-term outcomes remain to be seen. California’s screening initiative raises the following considerations among public health advocates and providers:

  • Screening design and intention: The ACEs screening tool was originally intended for a large population of patients. If used on individuals, the severity of the stressor is lost (for example, whether someone is abused daily versus one time). This can result in misleading data.
  • Resources post-screening: Additional screening will likely expose new trauma and require funding to address those needs. Governments and the health care systems must be prepared to provide the support needed by vulnerable children.
  • Screening tool limitations: The screening tool does not account for other factors in a child’s life (such as having a positive role model) that could buffer against trauma and build resilience. Accurate assessment will be challenging without also collecting this information.

States building and sustaining a trauma-informed workforce

Several states understand the importance of educating and training their workforce on ACEs and trauma-informed practices. To address trauma across a variety of settings and populations, the Washington State Health Care Authority applies a trauma-informed model for change that promotes resilience in patients and staff. The state awarded $1.4 million in grants to organizations across the state to expand existing trauma-informed work. This effort is augmented by online training, toolkits, and federal block grants.

In the school setting, Washington and Colorado use state and federal funding to implement a trauma-informed approach to education. For example, Washington directs school personnel to act as a protective factor in the lives of students, beginning the journey to health, building resilience, and supporting student success. Colorado sustains a trauma-informed approach by blending state and federal funding, a practice highlighted at the Institute’s recent forum, Building Resilience: Addressing Trauma From Birth to Graduation. For example, Colorado recently received 5-year funding from the Substance Abuse and Mental Health Services Administration, for state education agencies to build infrastructure and capacity for schools to meet student mental health needs with a focus on a strong referral system for care coordination.

Federal funding and awareness-building can augment state actions

Supporting child welfare through guidance and data, and reducing the effects of trauma is the work of federal agencies such as the CDC, SAMHSA, and the Administration for Children and Families within the Department of Health and Human Services. To implement the guidance provided by these agencies, it is critical that Congress continue to fund programs that support families and mitigate childhood trauma. Federal policies, such as recent economic relief policies related to COVID-19, can help mitigate the causes of trauma and ACEs by preventing domestic violence, alleviating financial pressures related to housing and food access, and reducing other types of hardship.

Looking ahead for solutions

Children and youth are especially vulnerable to their experiences during natural disasters and crises. Emotional reactions vary based on individual characteristics such as age, family member support, and previous physical and mental health experiences. In examining history, we know that this pandemic will impact children’s mental health and well-being. Together we can mitigate the impact of associated trauma by evaluating and expanding upon supportive policies and interventions and maximizing existing resources.

During the current crisis, our societal mindset must shift. Our state and federal leaders all need more mainstream education, training, and awareness of ACEs. Much can be learned from states that are taking action to support children’s health during this difficult time. Addressing ACEs on a population basis requires a systems approach, and collaboration and coordination across organizations, policies, and lawmakers. Kaiser Permanente is committed to continuing to lead this work in the communities we serve in partnership with community agencies, schools, and other health systems.