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Disappointing perspective and advice.


First, here is an opinion published in CALMATTERS by Richard Wexler who is Executive Director of NCCPR.  His interest in child welfare grew out of 19 years of work as a reporter for newspapers, public radio and public television, often doing  stories about child abuse and foster care.   He is the author of Wounded Innocents: The Real Victims of the War Against Child Abuse (Prometheus Books: 1990, 1995). Wexler is a graduate of Richmond College of the City University of New York and the Columbia University Graduate School of Journalism.

While he gets many systemic issues right, his perspective on the ACE screen, Dr. Burke-Harris, the California ACES AWARE program and the appropriate approach to the clinical care of individual abused people is concerning, insensitive and bordering on the paranoid. First we have his essay, followed by my response:

"Two years ago, Dr. Robert Anda, one of the authors of the original study of Adverse Childhood Experiences, cautioned that the scores from questionnaires to screen children for ACEs could be “misappropriated” as a diagnostic tool. California does not appear to have listened. “Inferences about an individual’s risk for health or social problems should not be made based upon an ACE score, and no arbitrary ACE score, or range of scores, should be designated as a cut point for decision making or used to infer knowledge about individual risk for health outcomes,” Anda wrote in 2020. Other experts on childhood trauma, such as renowned researcher Dr. Bruce Perry and University of New Hampshire professor David Finkelhor, agreed.

Yet more than two years into a massive science-be-damned, ethically-questionable and albeit well-meaning experiment on overwhelmingly poor, nonwhite Californians, the only concern officials seem to have is that doctors haven’t done enough to surveil their parents and report on them to a state agency. In 2020, the state began offering doctors $29 each time they administer ACE questionnaires to parents of children on Medi-Cal. Four or more ACEs is enough to diagnose trauma and refer the family for “services” – exactly the kind of arbitrary “cut point” Anda warned about. No wonder he specifically singled out the California program for criticism. The heart of the problem is something Finkelhor noted: Doctors are “mandated reporters” of child abuse and neglect. That supersedes doctor-patient confidentiality. Even if they don’t think the questionnaire results amount to abuse or neglect, doctors may be afraid of what would happen to them if they don’t make a report. So instead of getting help, the children may experience more trauma. They could be subjected to the emotional turmoil of a child abuse investigation as caseworkers ask them questions about the most intimate aspects of their lives and, often, strip search them looking for bruises. A 2017 study found that more than half of all Black children are put through an investigation before they turn 18.The trauma is, of course, compounded if the child is consigned to foster care. The California questionnaire that could lead to foster care lists even foster care itself as an adverse childhood experience. The flawed questionnaire score-inspired reports further overload caseworkers, leaving them with even less time to find children in real danger. That’s why mandatory reporting itself has backfired. The questionnaire also can magnify the racial and class biases that permeate child welfare, particularly the danger of conflating poverty with “neglect.” Questions include: “Have you experienced discrimination?” “Have you ever had problems with housing?” “Have you ever worried that you did not have enough food to eat or that food would run out before you or your parent/caregiver could buy more?”

There is no mention anywhere of informed consent. Doctors are not required to remind those filling out the forms that they are mandated reporters. Among parents who already know, the prospect of confiding in a mandated reporter may deter them from seeking help. That’s what UC Irvine professor Kelley Fong found when she interviewed poor families in the New England area. One mother, who regularly received similar questionnaires from her children’s school, called them “a trap” because teachers are mandatory reporters, too.

Dr. Leigh Kimberg, a UCSF clinician and scholar, has argued that questionnaires could be useful if patients were specifically warned that doctors are mandated reporters, but “through the racism that’s built into the child welfare system, Black, Indigenous and children of color have been removed from their families at markedly disproportionate rates. So these fears are justified.” Yet now, apparently, state officials want doctors to follow-up and see if their patients took their advice and pursued their referrals. And if they didn’t, then what happens to them?

The creator of the California questionnaire, former state Surgeon General Dr. Nadine Burke Harris, defended her program by claiming that no one has anything better – but we do. A stunning number of studies find that even small amounts of cash significantly reduce what child welfare agencies call “neglect.” So California could “treat” far more ACEs far more effectively if it simply took the nearly $300 million it’s spending on this initiative and used it for cash assistance, childcare or housing vouchers.

You can’t fight trauma with trauma."

My evaluation and response:

Fighting for Children and Adults who Experienced Adverse Childhood
Experiences (ACEs)
Jeoffry B. Gordon, MD, MPH, December 19, 2022

"As an advocate for children and adults who have been traumatized or experienced toxic stress from their adverse childhood experiences (ACEs) I read Richard Wexler’s CALMATTERS’ commentary, “Why is California fighting adverse childhood experiences with more trauma?” on December 9, with great interest and enthusiasm and some dismay. I greatly appreciate the salutary insights and accomplishments of Mr. Wexler and the National Coalition for Child Protection Reform. I share his passion and anger that we have not been able to do better for our kids. From my years of experience as a family doctor and advocating for child protection I agree with his evidence backed findings that many systems, institutions and agencies set up for “child protection” are inept and undependable at best, and harmful at worst. I also agree that sophisticated
reform of official agencies, some “well-meaning,” is long overdue. Nonetheless, as a clinician, I find that he shares common misperceptions with other
critics of the value and utility of ACE screening and California’s ACES AWARE program.

The original ACE screen evolved pragmatically in a clinical setting (a Kaiser health maintenance clinic - in an employed population without racial or class selection bias). It was not intended to be comprehensive nor scientifically balanced and valid. Most important of all, it was intended to be a risk screen, not a diagnostic instrument. It is similar to asking if a patient smokes - not a healthy habit, but not indicating a diagnosis of emphysema or lung cancer. The possible resultant diseases from experiencing ACEs are the trauma or toxic stress which disorders bodily genetics, neuroanatomy,endocrinology, and immune response, as well as behavior. The CDC has clearly documented that having more than 4 or more of the 10 ACEs is highly correlated with adverse physical, mental, and social outcomes. These are strong associations, but clear
causal pathways have yet to be established. In 30 years of extensive international use, the ACE screen has been proven to be heuristic, catalytic and transformative due to the insights it has provided to understanding childhood experiences and the harmful effects of family and environmental adversities, breaking through the barriers of cultural shame and avoidance which turned medical and societal attention away from these issues. On an epidemiological basis it has helped generate a quantum improvement and appreciation
of the components of child well-being (health and resilience) and the diagnostic
specification of harmful occurrences. This is an ongoing process.

As a current member of California’s Citizen Review Panel on Critical Incidents (child homicides due to abuse and neglect), I can attest that in California official attention to these tragedies and their prevention is wholly inadequate. There is not even a reliable count of how many child murders occurred in any given year, never mind any coordinated preventive policies or programs. The ACES AWARE program was, at minimum, a quantum policy innovation at the epidemiology level, documenting the extent of exposure to the risk of possible
harms and potentially identifying the resultant impact on disease among the poor in California. Additionally, ACES AWARE was successful in educating a large number of naive medical providers in the significance of childhood adversities and maltreatment and how to best approach their management.
Most importantly, the ACE screen has been a valuable, quick, practical addition to clinical medical practice. In the first place, concurrent child abuse, which may berevealed by an ACE screen in children and youth, is a red flag event indicating possible risks of harm, including suicide and requiring immediate intervention. Being a mandated reporter from a medical point of view is preventive medicine, not “surveillance.”

As far as adults go, a recent study of over 80,000 adults abused as Boy Scouts documented the average age of first disclosure of abuse was 42 years of age. Recognizing thatabuse is a risk for illness, not a diagnosis, this is good documentation that ACE screening is worthwhile throughout the life span. Ignorance of the impact of childhood trauma on adult disease is very common among physicians, including psychiatrists, who treat adults. The promotion of the ACE screen as in ACES AWARE has been very valuable in educating medical professionals about the significance of this dynamic. ACES AWARE invested in required education for participating physicians to learn appropriate interpretation and management of patients with high ACE scores who may have suffered ill effects from childhood trauma. Furthermore, neither my clinical colleagues nor ACES AWARE report instances of patient harms or complaints associated with the routine use of the ACE questions. Indeed, there are many anecdotal reports from adult physicians who find that asking the ACE questions enhances the caring aspects of the doctor-patient relationship and increases intimacy and empathy. Closely associated with learning the use of ACE screen, is learning about the associated “trauma informed care” model which goes far towards humanizing the clinic.

Neither ACES AWARE nor any medical clinician I know, considers the answers to an ACE screen to be a stigma or a diagnosis, therefore they are definitely not
“misappropriated” and not causing harm to children. Using the billing codes ACES AWARE inexpensively and efficiently collected epidemiologic data on the prevalence of high scores for future policy and care planning. This is not unethical as it should be as much a part of pediatric care as a growth chart. It is not appropriate for Mr. Wexler to ascribe detrimental “surveillance” to medical care. Paying attention to children who may be in harm’s way is no different than our long time responsibilities to report STDs, food poisonings, gun shot wounds, and impaired drivers. To my knowledge the main problem with ACES AWARE and its cooperating MediCal doctors was that they had to depend
upon the underfunded, understaffed, generally under-trained, and essentially
overwhelmed MediCal mental health system to care for those whose ACE’s trauma has been found to impact their lives and health. Evidence based treatments have to be personalized, trauma informed, time consuming, have continuity and be sophisticated to be effective. This is an impossible task for the underfunded, atrophied and stressed services of the MediCal mental health system.

I agree with Mr. Wexler’s long time criticism of the dysfunction of many child welfare agencies, foster care, and the current imposing, disruptive, punitive and unsuccessful authoritarian approach to family dysfunction, but this should not impair the opportunity and obligation of the medical profession to identify children in need. I also strongly agree with Mr. Wexler that there is strong evidence that provision of concrete and economic supports to poor, stressed
families is very efficient and effective in mitigating abuse and neglect (ACEs). However, so far no government agency has offered to put dollar bills in my pharmacy along with the various vitamins and other medications."

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Comments (3)

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@Former Member posted:

It isn’t a racial issue either. There are plenty of Rural kids coming from Middle Class families that drop into poverty because they grew up w/ Character Disordered Parenting and because of it, they grew up character disordered.

I’ve seen so many white Parents who sell their own kids’ bodies for Drugs - Methamphetamine, Oxycontin and now Heroine.  Or the mothers, so desperate to be loved by anyone take in Character Disordered Men who are only interested in sexually abusing her child.   No Amount of Money is going to end this dysfunctional, circular pattern.  

Again you are quite right. It is a racial AND... a neoliberal corporatist exploitive issue. In my lifetime (81) years I have seen the "characteristic" dysfunctions of the (Black) ghetto - then fueled by the racialized neglect of the then consolidated white society - spread into blue collar, rural, and the middle American white neighborhoods with the same dysfunctions of drugs, teen pregnancies, un- or underemployment, depression and anxiety. To put it bluntly, there is a core of dysfunctional parents and parenting swimming in a sea of a dysfunctional, exploitative, uncaring society built to preserve the sad comfort of the ultra wealthy in their gated communities.

@Former Member posted:

You can give some poor families a million dollar house and 20,000 dollars a month and it won’t make a dent in child abuse because as the ACE Study shows, we are dealing with character disordered Parents - Addicts, Alcoholics, Mentally Ill, Violent, Criminal, Deadbeats who abandon their own kids.

It looks like one group wants a UBI with CBDC hooked to AI Algorithms with a Social Credit Score to direct behavior and the other wants to get an ACEScore.

Who focuses on Healthy Attachment, Infant Mental Health, Improving the Character of Dysfunctional Parents —> aka Turning these people away from Self Centered, Self Serving Child Abusers into Protective Parents?

The entire problem is Dysfunctional and Abusive Parenting.   And it’s Parenting, a learned behavior that is transmitted from Generation to Generation creating the Intergenerational Cycle of dysfunction, misery and human suffering.

To a great extent I agree with you. There are many "disordered parents," some mentally ill, some using drugs, some having learned abusive parenting habits and so on. When child maltreatment occurs in middle or upper class families - and it does - these factors are certainly more significant.  I believe there is a larger group, especially if living in poverty, if given concrete, economic, and community support could be relieved of the existential stress so that they could blossom as good parents. The interesting fact is that I am not aware of any study or data that actually studied families of maltreated children to document the relative prevalence of these factors. Our racialized health and social work systems just tend to tarnish all of them as incompetent parents. Of course there are many individual stories of loving parents who have a lot of love and care to potentially offer their child, being overwhelmed of the circumstances of poverty (for example working 2 jobs, or being homeless) who are separated from their children by the child welfare system - but this does not clarify the situation.

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