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As California Moves to Screen Children for Childhood Trauma, Poverty Has To Be Part of the Equation


“The most important single issue facing our country’s disadvantaged populations [may be] the prevalence of childhood trauma.”

— J.D. Vance, author of
Hillbilly Elegy

In the mid-nineties, I was travelling around the country as part of the Clinton Administration’s task force on welfare reform, investigating barriers to family stability and independence. What we found was unsettling.

Of the people receiving welfare, we found many problems we expected to see, such as interruptions in healthcare, transportation, education, and child care that kept people out of the workforce. But at least a third were suffering from a problem we didn’t have a name for at the time — something we suspected had to do with a deeper issue.

At around the same time, in San Diego, Drs. Vincent Felitti and Robert Anda were working with Kaiser Permanente and the CDC on a landmark study of abuse, neglect, and other Adverse Childhood Experiences (ACEs). Their research, known as the ACE study, involved 17,000 people and found that the more ACEs people had, the greater their chance of developing life-threatening physical and mental illnesses down the road.

When the ACE study was made public in 1998, I realized we finally had a name for the deeper issue afflicting the high-risk people we talked with: Adverse Childhood Experiences (ACEs).

Without buffering from a loving parent or caregiver, ACEs can lead to stress that is severe, prolonged, and hazardous. This condition, which doctors call toxic stress, floods the body with stress hormones that can undermine different body systems and even change the way our DNA is read and transcribed.

Since the original ACE study, some researchers have added “poverty” and other social inequities such as homelessness to the list of ACEs that can result in lifelong harm to health.

And just this month it really hit home: A remarkable new study from Northwestern University showed poverty actually leaves a mark on our genes, something that validated what I’ve seen in my work and what I saw play out in underserved neighborhoods from coast to coast. It suggests why generation after generation may be affected by the shadow of poverty.

In this study, researchers linked lower socioeconomic status to something called DNA methylation — an epigenetics signaling tool. This occurs when a methyl group gets added to the DNA molecule and turns certain genes on or off. Researchers found that poverty left a mark on 10 percent of the genome. They’re now looking at whether this can explain how our bodies ‘remember’ the experience of poverty.

So although we think about poverty as a social issue whose impact may fade if you can leave it behind, the effect may linger on even after you’re no longer poor. Poverty, it seems, can get under our skin and change us — literally.

In California, we are coming full circle in recognizing the connection between poverty and health. As interim CEO for the Center for Youth Wellness, an organization that promotes ACEs screening and treatment, I’m proud to be part of this movement.

I applaud Gov. Gavin Newsom of California for proposing a budget that includes funds for universal ACEs screening for all children and adults receiving Medi-Cal. He also recently appointed our founder, Dr. Nadine Burke Harris, a pediatrician and international expert in child trauma, to be the state’s first Surgeon General — an important validation of the need to recognize and combat toxic stress.

Our California Campaign to Counter Childhood Adversity (4CA) played a critical role in the state’s adoption of universal screening for ACEs — bill AB 340. The ACEs screening tool that CYW helped develop in partnership with UCSF — known as PEARLS — builds upon the original ACEs screen by including questions about social inequities. Now that research suggests poverty can change our genes as well, expanding the tool to include questions about poverty is still more important.

Imagine what we can learn from that. Imagine having more data to better understand and help undo the harm caused by childhood poverty, which affects more than 2 million children in California and about 15 million in the United States. As the momentum builds for ACEs screening and treatment, let’s make sure the relationship of toxic stress to poverty and social inequity is part of it.

— Jim Hickman is the interim CEO of the Center for Youth Wellness, based in the Bayview district of San Francisco. Previously, he has served as CEO of Sutter Health’s Better Health East Bay; he also worked for HHS Assistant Secretary for Planning and Evaluation David Ellwood as a staff member of President Clinton’s welfare reform task force. Jim is a member of the Advisory Committee for the Camden Coalition of Healthcare Providers’ National Center for Complex Health and Social Needs.

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David Dooley posted:
There's so much effort going into helping hurting people and so little effort into the primary prevention of adverse childhood experiences.  I am discouraged.

I agree. I am not entirely sure that we need *more* data to prove that growing up in poverty can have long lasting harmful effects? There are already so many studies finding this. Why not focus our prevention efforts on alleviating poverty and other forms of social injustice and inequity families face that contribute to trauma and toxic stress? How much data is needed before there is political will to act?

I’ve seen this in suicide prevention with a million studies and more every day that “prove” that depression is a major factor contributing to suicide. But little to no effort is put into alleviating the conditions that contribute to depression and suicide. Even though this course of action has been specifically recommended by the CDC. 

Last edited by Leah Harris

I liked this post.  I agree that poverty must be part of the story when screening children for trauma.  I understand how it can leave a permanent injury on one’s DNA.

I grew up on Welfare.  I had a Medi-Cal card for doctor visits.  We often did not have enough money for basic needs.  We did not have a car, and either walked or took public transportation.

I recall how ashamed I felt at my family being on welfare, and how I did not want my friends to find out that my family was receiving public assistance. 

Besides the physical limitations of poverty—lack of transportation, lack of medical care (or lack of a medical home), and food insecurity--the struggle of poverty also affects one’s mental health.  For those in poverty, there is a lack of the kind of social supports that come with being able to afford extracurricular activities or to participate in community happenings.  Poverty is isolating, and isolation puts children at further risk--when there is little contact with others who might be able to intervene in neglect or abuse, or who can model what mental healthiness looks like.

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