California Gears Up for Universal Trauma Screening

Expert pediatrician shares model for states across the country

child and mother at pediatricianAccording to a recent federal report, at least five of the top ten leading causes of death are associated with early childhood trauma. Reducing exposure to trauma during childhood, then, is a vital upstream strategy for improving lifelong health outcomes for children across the country.

Adverse childhood experiences (ACEs) are potentially traumatic events that can include violence, abuse,  neglect and household disfunction. Studies show that nearly half of American children have had one or more ACEs. And the more ACEs children have, the higher their risk for physical health problems, like asthma and obesity, and behavioral and mental health issues, which ultimately reduce their overall life expectancy and quality of life.

Recognizing the need for upstream solutions, California recently passed legislation incentivizing pediatric practices to screen for early childhood trauma. This move reflects the vital need to incorporate trauma screenings into pediatric care, so that children at risk can connect with supportive resources and preventive interventions.

“ACEs have a dose-dependent relationship on health outcomes,” explains Dayna A. Long, MD, director for the Center for Child and Community Health at the University of California San Francisco (UCSF) Benioff Children’s Hospital in Oakland. “As your exposure to trauma increases, so too does the intensity and severity of your symptoms. If our goal as pediatricians is to advocate for children and to improve wellness, then we need to do whatever we can to reduce their exposure to trauma, and that starts with screening. With early universal screening, we can proactively connect children with the resources, referrals and interventions that correspond with the level of trauma they’ve experienced.”

Trauma’s Troubling Effect on Health Disparities
Non-Hispanic Black children and children living in poverty disproportionately experience adverse childhood experiences, making trauma screening and prevention an important lever for promoting equity.

Long is a faculty expert on Pediatrics Supporting Parents, a NICHQ-led quality improvement initiative seeking to better utilize the well-child visit to encourage positive parent-child interactions that promote healthy social emotional development. Strong parent-child relationships during those early years not only foster healthy brain development, but they also protect the brain against the harmful effects of toxic stress that ACEs can cause. 

Through her work at UCSF, Long has developed a cohesive system that supports trauma screening and referrals in pediatric care. Here, she shares four important steps pediatric and early childhood care providers can use in their work. For additional resources, be sure to check out

Screen for ACEs and risk factors for toxic stress

The sooner you identify children at risk for trauma, the sooner they can receive support. That’s why Long recommends universal screening in all primary care clinics, as well as Early Head Start and other early education programs.

The American Academy of Pediatrics provides multiple ACEs assessment tools. California also recently released the Pediatric ACEs and Related Life-event Screener (PEARLS), which incorporates ACEs (e.g., abuse) as well as life events that may increase a child’s risk for toxic stress and negative health outcomes (e.g., bullying or food or housing insecurity).

Talking to parents about early childhood trauma’s impact on lifelong health is a vital part of the screening process, says Long. “We need to provide parents and communities with education and guidance about how common ACEs are and how they affect children’s behavioral and physical health, so there’s an understanding of what is happening to the child as opposed to this notion of what's wrong with the child.”

Provide appropriate and timely referrals

After reviewing a child’s screening result, providers should be prepared to connect families with appropriate resources and referrals to interventions. Depending on a child’s score on the screener, this may mean referring families to community resources that can help lower the risk of ACEs, such as play groups, public parks and foodbanks; or families may need additional support through interventions that target trauma symptoms, such as individual or group therapy. And regardless of a child’s score, providers should always provide anticipatory guidance on ACEs, toxic stress and resiliency.

Helping families connect with referral agencies and community partners is just as important as providing the referral, says Long. She recommends developing relationships with a broad array of partners, so that providers can easily refer families to relevant resources in their community and track the success of those referrals. Long also emphasizes the importance of a standardized process for follow-up, where timing depends on how urgent the family’s need (e.g., providing a quicker follow up for a family without a home). To optimize the referral process, Long’s team has developed a technology system with a shared database that helps community partners and providers collaborate on case management, track and manage referrals, and standardize follow-up with families (see an example here).

Build the capacity of clinics

Adding trauma screenings to well-child visits may overwhelm pediatric practices. That’s why Long recommends promoting a team-based model of care where all partners—nurses, pediatricians, administrative staff, community health workers, referral agencies, and families—work together toward the common goal of universal screening and case management. With this model, no one person shoulders all of the responsibility; instead everyone understands their specific roles and responsibilities and work together as cohesive system. Technology systems, like the one Long describes, encourage team-based care because they provide a digital space to manage and track roles and responsibilities.  

Provide trauma-informed care

Asking families to share personal hardships and traumatic experiences requires an approach to care that recognizes trauma’s pervasive consequences, is sensitive to the many ways re-traumatizing can occur, and provides a compassionate environment for healing conversations.

“Our providers are working on how to be able to ask hard questions while sitting in a space with someone who may come from a very different place than them,” says Long. “We need to be able to sit in that space with empathy, instead of feeling like we constantly have to fix the problem. Because so much of this work around trauma and ACEs is being able to connect with families and build trusting relationships, knowing that we can't make all the bad things go away, but we can listen.”

Trauma-informed care has multiple components, including practicing cultural humility, developing a diverse workforce that mirrors the family, and recognizing how the dynamics of power and privilege play out in the workforce. Trauma Transformed provides ten principles of trauma-informed care that can help all pediatric practices and early childhood care providers approach these conversations.

“The more we learn about early childhood trauma’s effect on lifelong health, the more urgent the need for preventive strategies,” says Long. “With this new legislation, California is leading the way in trauma prevention and support for children. We’re thrilled to highlight our work because we hope it will provide models for other states, encouraging them to replicate relevant strategies and even use our legislation as a template in their state.”

Looking to learn more? We’re planning to follow up with California later this year and share their lessons-learned from promoting universal screenings across the state. Sign up for NICHQ News to stay informed.