Adverse Childhood Experiences (ACEs) and toxic stress represent an urgent public health crisis that demand a public health solution. Two-thirds of Americans have experienced at least one ACE, and one in five of us have experienced four or more. These experiences - like abuse, neglect, or growing up in a household with substance dependence or mental health challenges - are associated with increased risk of more than 40 health conditions, including nine of the 10 leading causes of death in the U.S.  The consequences are not just for the individual, they ripple outward - affecting entire families, communities, and our society as a whole, with an estimated 28.4% of current Medicaid expenditures attributable as excess expenditures due to ACEs.

Thanks to advances in science, we now understand how ACEs lead to long-term health and social risks. The prolonged activation of the biological stress response during the critical and sensitive developmental periods of childhood, can lead to long-term changes in our neurologic, endocrine, immune, and genetic regulatory systems, a process now known as the toxic stress response. The good news is that there’s a consensus of medical and scientific evidence demonstrating that early detection and intervention can improve outcomes and improve medical, mental and behavioral health outcomes across the lifespan. Yet our systems are currently structured to do exactly the opposite. Across our nation, most children experiencing ACEs do not have access to evidence-based interventions until they have developed mental health diagnoses, which are the downstream outcomes of the toxic stress response and are far more difficult and expensive to treat. Meanwhile, the medical, non-mental health impacts of toxic stress frequently go unrecognized. Help is coming too late. It is time to transform our systems to reflect the science by enabling early detection and access to interventions based on risk rather than harm.

Despite increased awareness and champions across philanthropic, healthcare, policy, and non-profit sectors, there are continued barriers within the U.S. healthcare system to routine assessment, early identification, and evidence-based intervention for ACEs and toxic stress risk. We have an opportunity to provide meaningful support to countless healthcare professionals, community organizations, policymakers and families facing adversity across the country, and to create a durable and sustainable system of prevention, early intervention and treatment of toxic stress.

In January of 2020, California launched a research-backed strategy to address ACEs and the toxic stress response on an unprecedented, public health scale known as the ACEs Aware Initiative. ACEs Aware was created in recognition that early detection of toxic stress risk is a critical enabling function that has been missing from the field. Since 2020, California has:

• Trained 46,270 individuals on ACE screening to assess toxic stress risk and evidence-based strategies to mitigate the toxic stress response, leading to improved access and improved health outcomes for patients.

• Screened more than 2 million individuals, including over one-third of all California children on Medicaid.

• Created clinical and community networks of care to support prevention and evidence-based treatment of the toxic stress response.

The ACEs Aware model, developed by California’s inaugural Surgeon General, Dr. Nadine Burke Harris, provides an important example of how to create a public health approach to the prevention, early detection, and treatment of toxic stress. Subsequently, several states, including Wyoming, New York, and North Carolina, have initiated portions of the ACEs Aware model, such as reimbursement for screening or eligibility for services based on the result of the screen. Advocates in many other states have proposed policies to address ACEs and toxic stress.