States’ Efforts to Address Adverse Childhood Experiences Are Critical during COVID-19
Adverse childhood experiences (ACEs), such as poverty, food and/or housing insecurity, child abuse, neglect, and mental illness, contribute to poor health outcomes, and the pandemic’s health and economic impacts exacerbate the risk of ACEs. States are continuing to implement strategies to identify and measure ACEs and connect children to appropriate services that can mitigate potential negative health outcomes.
These state investments are particularly important during the pandemic, because COVID-19 has disproportionately affected low-income individuals and communities of color, which are already at an increased risk of ACEs due to historic racism.
The first step states are taking to reduce negative health outcomes from ACEs and trauma is identification through screenings. The ability to identify and measure ACE data can help shape state strategy to ensure children’s well-being. According to the Behavioral Risk Factor Surveillance System (BRFSS), since 2009, 48 states and Washington, DC have included at least one question about ACEs on its survey.
The California Department of Health Care Services (DHCS), in partnership with the California Office of the Surgeon General, created a statewide effort to screen for ACEs, with a goal of reducing ACEs by half in one generation. Detecting ACEs early and referring children with ACEs, and their families, to appropriate resources or necessary interventions, including care coordination, educational materials, or community health workers, is another key step to promote healthy development.
As part of North Carolina’s comprehensive 2030 strategy, the state added a health indicator measuring ACEs to improve child well-being. North Carolina’s goal is to reduce the number of children with two or more ACEs 25 percent by 2030. The levers for change North Carolina identified to reach this accomplishment include:
- Increasing minimum wage and employment opportunities;
- Increasing opportunities for trauma-informed parenting support;
- Expanding community and domestic violence prevention initiatives;
- Increasing access to behavioral health treatment; and
- Increasing access to parenting programs and home visiting programs.
The Oregon Health Authority (OHA) 2020-2024 State Health Improvement Plan (SHIP) has tasked a subcommittee to address adversity, trauma and toxic stress, acknowledging that factors including abuse, neglect, living in poverty, incarceration, family separation, and exposure to racism, have a lifelong impact on physical and mental health. The subcommittee has created a framework to improve children and family’s well-being, categorizing the strategies across the following areas: healthy families, health students, equity and justice, workforce development, technology and innovation, housing and food, and behavioral health.
One result of the COVID-19 pandemic, however, is that fewer children are receiving well-child visits, which means a subsequent reduced opportunity for children to be screened for ACEs. And, because of COVID-19, young children and their parents are experiencing increased mental health stress and trauma, all of which is exacerbated by financial strains. With limited interactions and uncertainty of what school will look like in the future, children and families are increasingly isolated and may be at particular risk for depression and anxiety. Parents and caretakers, especially those who are frontline and essential workers – who are also disproportionately Black and Latinx – may experience mental health concerns as well, which can affect their children. States are recognizing the importance of supporting children and caregivers to address ACEs and trauma during the pandemic.
- California: As part of California’s approach to responding to COVID-19, the Office of the California Surgeon General released a playbook to help support children and their caregivers’ mental and physical health, considering that those with a history of ACEs are especially vulnerable to the stressors of COVID-19.
- North Carolina: During the COVID-19 pandemic, North Carolina Medicaid has temporarily allowed for virtual well-child visits for children under the age of 21 using telemedicine. During those virtual visits, providers may also conduct maternal depression screenings for mothers of children up to age 24 months.
- Tennessee: The Tennessee Department of Education’s COVID-19 Well-being Task Force released its initial COVID-19 Impact Report, examining how the pandemic and school closures impact children’s overall health, with early data suggesting that children and families’ conditions have been exacerbated. The report suggests this an opportunity to create infrastructure in Tennessee to ensure consistent access to services, even after COVID-19 has been contained.
Though the COVID-19 pandemic continues to create uncertainty, states are continuing work to increase child well-being and screening is an important baseline step to identifying ACEs. States are also notably working to move past identification by reducing potential exposure to trauma and ACEs, and connecting children and families to needed health, social, and other supports.
The National Academy for State Health Policy (NASHP) will continue to track state progress on reducing ACEs and share state and national tools related to promoting healthy child development policies and practices.
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
