The California Surgeon General's Report on Adverse Childhood Experiences, Toxic Stress, and Health
Explore the ScienceImagine your body's stress response system as a highly sensitive alarm system. In normal circumstances, it sounds briefly when faced with immediate danger, then quietly resets. Now imagine that alarm stuck in the "on" position, blaring constantly for months or years during childhood.
This biological phenomenon—known as toxic stress—represents what California's Surgeon General, Dr. Nadine Burke Harris, has identified as one of the most significant public health threats of our time 1 4 .
Adverse Childhood Experiences (ACEs) are potentially traumatic events occurring before age 18 that disrupt a child's sense of safety and stability 2 5 .
Toxic stress occurs when there is "excessive or prolonged activation of stress response systems in the brain and body" 1 .
This sustained activation can disrupt the development of:
Over 17,000 participants from Kaiser Permanente's San Diego population 2
Physical examinations, confidential surveys, and long-term follow-up 2
The study demonstrated that childhood trauma wasn't just a social issue—it was a biological issue with profound implications for physical health. Participants with four or more ACEs faced dramatically increased risks for conditions ranging from heart disease and cancer to depression and substance abuse 2 5 9 .
In January 2020, California launched the first statewide effort to systematically address ACEs and toxic stress through its ACEs Aware initiative 6 .
For ACEs in primary care settings
On trauma-informed care
For providers conducting screenings
ACE screens conducted by Medi-Cal providers 6
Individuals trained in ACE screening 6
Paid to providers for conducting screenings 6
| Outcome Measure | Impact of ACE Screening Implementation |
|---|---|
| Healthcare Access | Improved access to social work, community health worker, and non-specialty mental health services |
| Primary Care Quality | Significantly improved compliance with quality metrics for vaccines, well child and adolescent care, and preventive health counseling |
| Clinical Outcomes | Reduction in physical symptoms, depression scores, and anxiety scores |
| Identification of At-Risk Children | 2x increase in identification of children eligible for Enhanced Care Management |
Source: ACEs Aware Progress Report 6
While the science of ACEs and toxic stress might seem dire, research consistently points to a powerful mitigating factor: responsive relationships with caring adults 1 3 8 .
These supportive connections can help buffer a child's stress response, potentially preventing or even reversing the damaging effects of toxic stress.
A recent nationwide study found that the presence of just one supportive adult can make a profound difference in the lives of children who experience neglect. In fact, adults who experienced neglect but had a supportive adult in their lives reported less depression than those who did not experience neglect 3 .
California's roadmap extends beyond clinical screening to encompass broader policy initiatives:
The economic case for these investments is compelling. The estimated annual cost of ACEs to the state of California is approximately $1.5 trillion, including $24.6 billion in direct medical spending and $1.49 trillion in lost healthy life years 6 .
Recognizing ACEs and their impact
Building supportive relationships
Developing coping strategies
Thriving despite adversity
The roadmap for resilience emerging from California represents a paradigm shift in how we understand health and well-being.
By recognizing the profound connection between childhood experiences and adult health, we can begin to address some of our most intractable public health challenges at their roots.
The science is clear: ACEs and toxic stress create a biological pathway from early adversity to lifelong poor health.
Equally clear is the solution: buffering relationships, trauma-informed care, and supportive policies can change this trajectory.
As the research continues to evolve—exploring everything from the intergenerational transmission of trauma through epigenetic changes to the rising impact of new adversities like cyberbullying—our approach must continue to adapt 3 .
What remains constant is the fundamental understanding articulated in California's report: toxic stress is a health condition amenable to treatment 6 .
References would be listed here with full citations.