What is Trauma-informed Care?

Trauma-informed care recognizes and responds to the signs and potential consequences of trauma to better support the health needs of patients who have experienced ACEs and toxic stress. Trauma-informed care is a framework that involves:

  • Understanding the prevalence of trauma and adversity and their impacts on health and behavior.
  • Recognizing the effects of trauma and adversity on health and behavior.
  • Training leadership, providers, and staff on responding to patients with best practices for trauma-informed care.
  • Integrating knowledge about trauma and adversity into policies, procedures, practices and treatment planning.
  • Resisting re-traumatization by approaching patients who have experienced ACEs or other adversities with non-judgmental support.

Click here to read an article by Dr. Marie-Mitchell on “Adverse childhood experiences: Can government policy reduce trauma?

What is the ACEs Aware Initiative?

The ACEs Aware initiative seeks to change and save lives by helping Medi-Cal providers understand the importance of screening for Adverse Childhood Experiences (ACEs) and training them to respond with trauma-informed care.
ACEs Aware offers Medi-Cal providers training, screening tools, clinical protocols, and payment for screening children and adults for ACEs. Screening for ACEs, assessing for toxic stress, and responding with evidence-based interventions can significantly improve the health and well-being of individuals and families. The ACEs Aware initiative is part of a statewide effort, led by the Office of the California Surgeon General and Department of Health Care Services (DHCS), to cut ACEs and toxic stress in half in one generation.

For more information about ACEs Aware, visit


Why is the state addressing this issue?

ACEs and toxic stress represent a public health crisis that has been, until recently, largely unrecognized by our health care system and our society. By screening for ACEs and responding with evidence-based interventions and implementing trauma-informed care, we can significantly improve the health and well-being of individuals and families.

What is a toxic stress response?

Repeated or prolonged activation of a child’s stress response, without the buffering of trusted, nurturing caregivers and safe, stable environments, leads to long-term changes in the structure and functioning of the developing brain, metabolic, immune, and neuroendocrine responses, and even the way DNA is read and transcribed. Development of the toxic stress response is influenced by a combination of cumulative adversity, buffering or protective factors, and predisposing vulnerability.

How can toxic stress impact child and adolescent health?

Children are uniquely vulnerable to the effects of an overactive stress response due to ACEs because their brains and bodies are still developing. The effects of toxic stress are detectable as early as infancy and, without buffering supports, may lead to ACE-Associated Health Conditions. In babies, high doses of adversity are associated with failure to thrive, growth delay, sleep disruption, and developmental delay. School-aged children may have increased risk of viral infections, pneumonia, asthma, and other atopic diseases, as well as difficulties with learning and behavior.

How can providers participate in the ACEs Aware Initiative?

Providers should follow these steps to be able to receive Medi-Cal payment for ACE screening:

Step 1: Get trained now. Providers can take a free two-hour, online training to learn about ACEs and toxic stress, ACE screening tools, evidence-based interventions, and trauma-informed care.
Step 2: Screen for ACEs, assess risk for toxic stress, respond with evidence-based interventions, and implement trauma-informed care.
Step 3: Receive Medi-Cal payment. Beginning July 1, 2020, Medi-Cal providers must have self-attested to completing certified ACE screening to continue receiving payment for ACE screenings.

What are ACEs?

The term Adverse Childhood Experiences (ACEs) comes from the landmark 1998 study by the CDC and Kaiser Permanente. It describes 10 categories of adversities in three domains experienced by age 18 : abuse, neglect, and/or household dysfunction.

A consensus of scientific research demonstrates that cumulative adversity, especially when experienced during critical and sensitive periods of development, is a root cause to some of the most harmful, persistent, and expensive health challenges facing the state of California and the nation.

What are ACE - Associated Health Conditions?

ACEs are strongly associated, with some of the most common and serious health conditions facing our society, including at least nine of the 10 leading causes of death in the United States.

People with four or more ACEs are:

  • 37.5 times as likely to attempt suicide.
  • 11.2 times as likely to have Alzheimer’s or dementia.
  • 3.1 times as likely to have chronic lower respiratory disease.
  • 2 – 2.3 times as likely to have a stroke, cancer, or heart disease.
  • 1.4 times as likely to have diabetes.
How can toxic stress impact adult health?

ACEs are strongly associated, with some of the most common and serious health conditions, including at least nine of the 10 leading causes of death in the U.S. These ACE-Associated Health Conditions include cardiovascular disease, diabetes, chronic obstructive pulmonary disease, Alzheimer’s or dementia, and depression. The life expectancy of individuals with six or more ACEs is 19 years shorter than that of individuals with none.

What is the clinical response to ACEs and toxic stress?

Based on a patient’s toxic stress risk assessment, ACE-Associated Health Conditions, and buffering factors, providers offer evidence-based interventions and develop a treatment plan with the patient.


To learn more about ACEs Aware Initiative visit:

All information on this web page was obtained from this document.