ACE Detection and Treatment: A Holistic Approach for Foster Youth

As explained in my previous posts, adverse childhood experiences (ACEs) are detrimental to juvenile development and have lasting affects that shape adult behavior. Therefore, the subsection of youth in the foster care system is vulnerable to the detrimental affects of ACEs and should be afforded additional care and services.

But since ACEs seem to be fairly pervasive, how do we determine who has ACEs and how many they have?

Implementation of a Universal Form of ACE Testing:

The 1998 Kaiser-CDC study that introduced ACEs found that 52% of participants reported at least 1 ACE, and 25% of participants had more than 2 ACEs. It is unlikely that the Kaiser-CDC ACE findings have decreased given that the United States has the highest incarceration rate in the world, greatly surpassing our neighbors abroad.  In the US, almost 1 in 28 children have a parent who is incarcerated. For that reason, it is important that a standardized ACE test is implemented as a base determination of child trauma and as a mechanism to assess what services may be beneficial to youth who are entering the dependency system.

In 2016, the national Commission to Eliminate Child Abuse and Neglect Facilities (CECANF) issued a report on the current status of child abuse in America. In addition to data and trends, the report issued a series of recommendations for governmental agencies. Recommendation 7.2d supports the use of universal ACE screening by the Centers for Disease Control (CDC) and Health Resources and Services Administration (HRSA). It states:

Ensure that HRSA and CDC expand the rollout of evidence-based screening tools for Adverse Childhood Experiences (ACEs) and parental risk. The tools should be nonproprietary to ensure expanded access. Screenings must be supported with access to effective, high-quality treatment services to address the identified needs of both parent and child.

The CECANF recommendation is in line with the current push for trauma-informed care. In September 2018, the California Legislature passed AB-2083. AB-2083 adds to existing law, the Continuing Care Reform (CCR), by requiring county agencies to develop and implement memorandums of understanding (MOUs) that set forth the roles and responsibilities of agencies that serve children and youth in foster care “who have experienced severe trauma.” The purpose of mandating MOUs is to provide better placement and services for traumatized youth in foster care.

As noted by one of my peers, California has been attempting to make strides in trauma-informed care through legislative means. AB-2083 states: “a county is responsible for. . . ensuring that a resource family applicant completes specified training that includes certain courses, including one regarding the effects of trauma and child abuse and neglect on child development and behavior, and methods to behaviorally support children impacted by that trauma or child abuse and neglect.” AB-2083 is a step in the right direction as it demonstrates that even the legislature understands the effects of trauma on children.

CECANF and AB-2083 both highlight the importance of trauma identification and treatment. In keeping with the spirit of AB-2083 and the explicit recommendation of CECANF, California should screen all at-risk youth for ACEs, starting with those in the foster care system. Foster youth experience ACEs at rates that greatly surpass their peers. Looking at the ACE of parental incarceration alone, 40% of children in the foster care system have experienced the ACE of parental incarceration . Additionally, when viewing ACEs through the subset of foster youth who have an ACE of parental incarceration,  90.6% of those children had additional ACE scores. Realizing the high number of ACEs that foster youth experience, it is no longer shocking that American foster care children are twice as likely to experience Post-Traumatic Stress Disorder (PTSD) as veterans. Therefore, if the California Legislature and CECANF would like to reach their goal by targeting a group of children heavily affected by trauma, they should address foster youth by implementing ACE testing.

Difficulties in Administering ACE Tests:

It should be noted that a variety of the ACE questions do have the possibility of triggering mandated reporting and criminal liability. For example, if a child answers “yes” to illicit drug and alcohol abuse in the home, would an ACE test administrator have to report that information to law enforcement? For the purposes of providing tailored services to the child’s individual needs, I believe that subjecting ACE testing to criminal liability would directly oppose that interest. I think that it is in the best interest of the child that no criminal implications attach to ACE screenings. If those who are screened, or their parents, became criminally liable for answers given during the screening, it would discourage full disclosure of ACEs which would harm the ACE treatment process. When ACE participants bury traumatic experiences and fail to disclose them during an ACE test, their subsequent treatment is impaired. Since certain ACEs indicate necessary treatment, if the ACE is never flagged, then the underlying trauma will be left untreated. Therefore, in order to encourage full disclosure and effective treatment, ACE testing should be left as a diagnostic procedure and not be allowed for use in criminal investigations or proceedings.

Another difficulty in administering ACE tests, and receiving accurate responses, is the fallibility of the human memory. For example, when interviewing Mario, I administered an ACE test before and after discussing his childhood. After his recollection was refreshed as to his childhood experiences, his ACE score went from one to three. This same phenomenon occurred when I administered an ACE test to my father and grandfather. Both of their primary examination scores nearly doubled after discussing their childhoods. Whether the cause is lapses in memory or the desire to “forget” or repress certain memories, inaccurate ACE scores impair participants’ opportunities to receive tailored treatment. In order to receive accurate scores, I recommend that a single ACE test, by itself, is not used as the basis for ACE treatment. An ACE examination should be administered at least twice, hopefully after the participant is able to briefly talk about their childhood, before the score is used for treatment.

Implementation of Standardized ACE Testing into CPS Intake Procedures:

In its 2016 national report, CECANF illustrated one of the problems that youth face when being assessed by Child Protective Services (CPS). The report stated that CPS agency staff tend to be trained as generalists. It is of critical importance that we focus on strengthening CPS procedures for screening and investigations.  

CPS identifies familial problems and needs through the intake meeting’s interview process. The CPS Guide for Caseworkers provides examples of information that CPS workers should gather from each source. (Child Protective Services’ 2018 Guide for Caseworkers, pages 69-74). Only one subtopic within the CPS Guide for Caseworkers recommends the CPS agent ask the caregiver about their “[h]istory as a child (positive and negative memories), educational and employment history, any criminal activity, or history of physical or mental health problems.” Although there has been a push for a trauma-informed response, with heightened awareness of ACEs and their effects, the CPS guide has failed to incorporate any procedure that directly utilizes ACE findings. A comparison of the 2018 Child Protective Service Guide reveals that it has the same interview topics for children and caregivers that was provided to CPS caseworkers in the 2003 Child Protective Services Guide for Caseworkers (pages 52-57). The rest of the questions look at immediate harms but fail to address the root of the parental mistreatment, which is likely maladaptive behaviors that were acquired as a coping mechanism caused by untreated ACEs.

CPS is missing an opportunity to assess and provide services for youth (and their families) affected by ACEs when it fails to perform a standardized ACE test. Generalized topics leave too much discretion to the individual caseworker and increase the chances that useful information, provided by an ACE test, will be omitted. Implementing the standardized, 10-question ACE test into CPS intake interviews can help CPS match children and parents into better services, helping parents with difficulties keep their children out of foster care and helping youth in foster care gain access to the services they need based on their trauma. In addition, if CPS were to introduce a perfunctory ACE test into foster youth intake, it could save time and resources by diverting funds to preventative treatment rather than punishment and placement issues. Furthermore, it would create a rich resource of numerical data that could be tracked by time, geographic location, and ethnicities to track patterns in ACEs. Again, tracking patterns in ACEs could be used as a preventative method to help foster youth avoid high-risk coping mechanisms. In turn, they will be able to receive more emotionally stable placements and be less likely to enter the criminal justice system.

(Take your own interactive ACE test, here.)

Currently, we are failing to treat the ACEs of parents and children when CPS does not administer a diagnostic ACE test. Our current form of treatment for ACEs is a form of suppression. Children are put in services, school, and extracurriculars to keep them “busy” and out of trouble, but we fail to reach the underlying trauma that places those children at a greater risk of impulsive, maladaptive, often criminal, behavior in adulthood.

It is a waste of time and resources to use a “shot-gun blast” approach to assigning services to youth. As resources for foster youth are limited, (see Washington Foster Youth Sent to Hotels More Than 1,000 Times Last Year, Why Adoption Centers and Foster Homes Are So Full, and State: California Will Lose $320 Million in Child Welfare Funding If Waiver Ends ) we need to act strategically when helping youth and their parents with services by choosing targeted care that will be most effective to their underlying trauma. By implementing a standardized ACE score, mental healthcare professionals can determine what categories of trauma the child/parent has experienced and what type of services is appropriate. Additionally, by using a standardized, 10-question ACE test, the results can be easily shared between agencies, like CPS, who will be able to easily interpret the findings.

Matching Foster Youth with High ACE Scores To Therapeutic Foster Care Placements:

Youth with high ACE scores benefit from therapeutic foster care (TFC) placements, a clinical form of treatment for youth in foster care with severe mental, emotional, or behavioral health needs. TFC specially trains foster parents to be able to provide therapeutic treatment for youth in an in-home setting, keeping them out of group homes and mental institutions. In order for a child to be placed in a TFC home, medical treatments must be authorized by public state agencies in order to be reimbursed. Since resources are so thin, youth must generally be approved by the appropriate public state agency (child welfare or Medicaid) in order to qualify for TFC status.

Previously, counties in California were unable to seek reimbursement for TFC services. However, pursuant to California State Plan Amendment (SPA) 09-004, the Centers for Medicare and Medicaid services approved a plan that allows the Department of Health Care Services to offer TFC as an allowable expense under Medicaid. All California counties are now able to offer TFC through Medicaid services

The expansion of TFC placements is important because it means that there is treatment for foster care children who suffer from high ACE scores. ACE testing should not be avoided because of the possibility that it will create an untreatable group of youth. On the contrary, today, there are more means than ever that focus on trauma-informed care of foster youth. (For more information on the legislative history of trauma informed care in California, view my peer’s post explaining the current state of the law and her recommendations for better social services here.)  TFC placements are another service and resource that California has added to help foster youth suffering from ACEs.

Pursuing Policy that Prevents ACEs:

While we should treat ACEs, it is more cost effective and more humane to help people avoid ACEs in the first place. Policy measures surrounding society’s youth should be forward-focused and concerned with reduction of traumatic experiences. As I mentioned in my first post, the ACE of parental incarceration is alarmingly prevalent for today’s youth, and it is an indicator that a child has additional ACEs. As explained by one of my peers, the criminal justice system has a great potential to positively affect children by reducing the ACE of parental incarceration. The District Attorney has the discretion to choose which crimes will be charged and to request alternative sentences in lieu of formal incarceration.

In Tennessee, the state legislature recently passed a bill that gives non-violent offenders, who are primary caregivers, community-based alternatives instead of incarceration. SB 0985, also known as the Primary Caregiver Bill, requires a sentencing court to determine (1) if the offense was violent or non-violent, and (2) if the convicted person is a “primary caretaker of a dependent child.” If both are answered affirmatively, the court may impose an “individually assessed sentence, without imprisonment, based on community rehabilitation, with a focus on parent-child unity and support.” The legislation was created by incarcerated, and formerly incarcerated, mothers who experienced the harm of incarceration and witnessed the detrimental effects on their own children.

Although judges traditionally have some discretion during sentencing, the Primary Caregiver Bill requires that judges consider alternatives to formal incarceration. Not only does this immediately impact sentencing decisions by requiring that judges consider alternatives, but it will likely impact future decisions for defendants with children, as the court is now more educated about the detrimental effects of parental incarceration and removal from the home. This is creating a shift from traditional ideas of “punishment” by viewing the defendant more holistically, requiring that the defendant’s children be considered if the defendant is a primary caregiver. This forward-looking approach will help reduce ACEs by allowing some parents involved in the criminal justice system to keep custody of their children. In turn, this will reduce the number of children left without caregivers, also reducing the number of youth placed into the foster care system.

Conclusion:

Awareness, education, and legislation are three ways to reduce ACEs. With over half of the population having at least one ACE, it is fair to say that their prevalence cannot be understated. However, ACEs can only be identified once they are understood and internalized by the participant. In order for the participant to be in the best position to recall traumatic childhood experiences, they should be educated on ACEs and given the opportunity to openly discuss their youth prior to administration of a formal exam. Additionally, ACE education within our legislative and judicial ranks will shape future policies. By raising awareness, legislation can change to include measures that help adults suffering from ACEs and to implement safeguards that reduce future ACEs in youth. ACEs must be reduced or eliminated in order to break the generational cycle. Tennessee’s Primary Care Bill is a step in the right direction; hopefully it creates a ripple effect that encourages other states to implement policies that preserve the parent-child bond and divert children from the foster care system.