Has your child ever lived with a parent or caregiver who had mental health issues, such as depression?
Witnessed a parent or caregiver being screamed at, insulted or humiliated by another adult?
Been separated from their parent or caregiver due to foster care or immigration?
Those are some of the questions on a survey that California pediatricians will use to screen millions of children for traumatic experiences beginning Jan. 1, 2020. Many more of these screenings are expected, after the 2019-20 budget just approved by the state Legislature allocated $45 million to reimburse doctors for screening MediCal patients for trauma, and $50 million to train doctors on how to conduct trauma screenings. The funding is in addition to funding for screenings for developmental and other disabilities.
The new screenings are part of a push by Gov. Gavin Newsom to focus on adverse childhood experiences, underscored by his appointment of Dr. Nadine Burke Harris as California’s first surgeon general earlier this year. Burke Harris is recognized as a pioneer in the study of how these experiences can affect children’s developing brains and cause a number of lifelong health and mental health problems. Research has shown that experiencing a large number of traumatic events in childhood can increase the risk of cancer, heart disease, diabetes and depression, among other chronic illnesses.
The nonprofit organization Burke Harris founded in San Francisco, Center for Youth Wellness, has screened children for traumatic experiences for years and helped develop the survey for children, known as the PEdiatric ACEs and Related Life-events Screener (PEARLS). The survey was chosen by a statewide task force to be used for the new screenings. The results help doctors determine whether children or adults need mental health counseling or other preventative treatments to help them avoid some of the long-term effects caused by the trauma they have experienced.
The new funding is significant, said Dr. Jonathan Goldfinger, chief medical officer and vice president of innovation for the Center for Youth Wellness.
“As far as understanding the causes and determinants of health, it’s one of the most momentous changes in health care policy out there,” Goldfinger said.
The screening will not be required, but having the list of questions to ask and reimbursements available is expected to encourage more doctors to screen their patients for trauma. The goal is to get more doctors to screen children for traumatic experiences so they will be able to treat them earlier.
Goldfinger said in addition to mental health counseling, there are also ways that doctors themselves can change the way they treat patients for asthma or other chronic disease, based on their patients’ trauma score.
“What we’ve learned and what we’ve been able to teach providers is that that number may actually relate to additional risk for disease,” Goldfinger said. “There are things the pediatrician can actually do differently, based on that score.”
Doctors routinely conduct screenings for developmental challenges. Some doctors also currently screen children and adults for trauma, but they have to bill MediCal and other insurance companies for it as a standard preventive screening.
With the new funding, the California Department of Health Care Services will pay MediCal providers $29 extra for each trauma screening. There are about 5.5 million children enrolled in MediCal. Under the new reimbursement program, MediCal would cover screening of children every 1 to 3 years for children. Adults can be screened once about the events they experienced as children.
The questions on the children’s survey focus on experiences that range from sexual and physical abuse to parents separating or getting a divorce. Goldfinger said parents often don’t realize that some of these experiences could cause lasting harm.
“More risk than smoking comes from adversity,” Goldfinger said.
Department of Health Care Services Director Jennifer Kent said the department is currently translating the surveys into 13 languages. After the budget is signed, Kent said department staff will be working closer with Burke Harris and other experts to develop guidelines for doctors on how to treat patients with high levels of trauma.
“A lot of providers don’t know what to do,” Kent said. “Her goal is making sure that we create a set of clinical guidelines.”
Advocates for children’s health welcomed the prospect of new trauma screenings.
“We’re really excited that that’s called out specifically,” said Molly Pilloton, project director for the California School-Based Health Alliance, which represents school health centers. Pilloton helps train teachers and school staff on how to help students who have experienced trauma.
“We see that there is difficulty paying attention in class, remaining focused,” Pilloton said. “Especially if they are activated by some kind of trauma cue in class, they immediately go into survival mode, fight, flight, freeze. Teachers might think the student is acting out, or the student is not listening.”
Pilloton said it’s important for school staff to not only screen for traumatic experiences but to receive training to provide counseling or support for children and adults to heal.
“You don’t want to screen a giant school and find you have a really high percentage of trauma experiences, symptoms and then not have the capacity to serve those students,” Pilloton said.
Erin Gabel, deputy director of external and governmental affairs for First 5 California, a commission focused on children newborn to 5 years old, said trauma screenings are especially powerful when coupled with the budget’s expanded funding for screening infants and toddlers for developmental delays.
“We see those things together and are incredibly excited about the power of prevention and how that may lead to truly addressing the achievement gap,” Gabel said. She said 70 percent of developmental delays are not identified before kindergarten. “By the time children have entered kindergarten, we’ve lost a peak era of brain development for them. Ninety percent of brain development is happening before the age of 5.”