DECEMBER 09, 2020 Roadmap for Resilience The California Surgeon General’s Report on Adverse Childhood Experiences, Toxic Stress, and Health Roadmap for Resilience: The California Surgeon General’s Report on Adverse Childhood Experiences, Toxic Stress, and Health Suggested citation for the report: Bhushan D, Kotz K, McCall J, Wirtz S, Gilgoff R, Dube SR, Powers C, Olson-Morgan J, Galeste M, Patterson K, Harris L, Mills A, Bethell C, Burke Harris N, Office of the California Surgeon General. Roadmap for Resilience: The California Surgeon General’s Report on Adverse Childhood Experiences, Toxic Stress, and Health. Office of the California Surgeon General, 2020. DOI: 10.48019/PEAM8812. OFFICE OF THE GOVERNOR December 2, 2020 In one of my first acts as Governor, I established the role of California Surgeon General. Among all the myriad challenges facing our administration on the first day, addressing persistent challenges to the health and welfare of the people of our state—especially that of the youngest Californians—was an essential priority. We led with the overwhelming scientific consensus that upstream factors, including toxic stress and the social determinants of health, are the root causes of many of the most harmful and persistent health challenges, from heart disease to homelessness. An issue so critical to the health of 40 million Californians deserved nothing less than a world-renowned expert and advocate. Appointed in 2019 to be the first- ever California Surgeon General, Dr. Nadine Burke Harris brought groundbreaking research and expertise in childhood trauma and adversity to the State’s efforts. In this new role, Dr. Burke Harris set three key priorities – early childhood, health equity and Adverse Childhood Experiences (ACEs) and toxic stress – and is working across my administration to give voice to the science and evidence-based practices that are foundational to the success of our work as a state. The Office of the California Surgeon General has already established strong programs, including the first-in-the-nation ACEs Aware initiative, in partnership with the Department of Health Care Services (DHCS), taking a systematic and science-based approach by training healthcare providers to screen for ACEs and toxic stress in children and adults. We have also matched our resolve with funding. Through the California Initiative to Advance Precision Medicine, we have invested $9 million for research demonstration projects that address health impacts of ACEs using precision medicine approaches. California is leading the way on addressing ACEs and toxic stress as a public health crisis because it is one. This work is a key preventive measure to improve health and societal outcomes for our state’s residents for generations to come. GOVERNOR GAVIN NEWSOM • SACRAMENTO, CA 95814 • (916) 445-2841 Roadmap for Resilience i As e collectiely face an unrecedented confluence of challenges—the COVID-19 andemic, the ensuing economic recession our ongoing national reconing on racial inustice deastating ildfires eacerated by climate change—our state and communities are grateful for Dr. Burke Harris’ leadershi to resond to the aes of trauma and adversity that are upon us. It is our resonsiilit to meet the moment. This reort rovides a roadma for a sstemic and euitale ay forard ased on science and strong cross-sector artnershis. e must listen and e advised the eidence that clearl tells us that cumulatie adversit articularl hen eerienced early in life is a root cause of some of the most detrimental longest lasting and costl health challenges facing our state and nation. This reort highlights ho ACEs and toic stress if unaddressed, ill cost California over a trillion dollars in the net ears due to the costs of direct health care and years of life lost from oor health disailit or earl death. t is clear to me that imlementing the te of evidence-ased cross-sector resonses necessar to decrease the urden of CEs are not onl an ethical and moral imeratie ut critical to our economic italit. This first California Surgeon General’s Report offers not only critical insights for olicymaers scientists healthcare roviders, educators, and advocates ut also advances evidence-ased solutions and approaches to etter the health and safety of the Golden State’s residents no and in the future. Furthermore this ecetional luerint can trul set the stage for etter health, ell-eing and euit for countless communities here and elsehere in the nation and orld. incerel, avin esom overnor of alifornia Roadmap for Resilience ii GAVIN NEWSOM DR. NADINE BURKE HARRIS GOVERNOR SURGEON GENERAL In establishing the Office of the California Surgeon General, it was important to me to begin by visiting communities and listening. I wanted to more fully understand the complexities of our most pressing challenges, as well as the bright spots of innovation and the creative problem-solving that exist all over our great state. In the past year and a half, I have had the privilege to visit the places where Californians live, learn, work, play, and pray, as well as the opportunity to see up close what residents throughout our state are experiencing. Each community shared their unique challenges—such as homelessness, substance dependence, mental illness, and difficulty accessing healthcare—and successful approaches or proposed solutions. Over and over, I heard that communities identified trauma as a root cause of many of the challenges they are facing. Californians clearly recognize what the science has been revealing over the past several decades: that adversity, especially in the early years of life, can dramatically curtail health and life opportunities. In California, more than six out of 10 of us have experienced at least one Adverse Childhood Experience (ACE), such as having a caregiver with mental illness or witnessing domestic violence, and one in six of us have experienced four or more ACEs. The consequences for individuals and communities across our state are significant. An individual with four or more ACEs has a 70% higher risk of kidney disease, more than double the risk of heart disease, and triple the risk of chronic lung disease as someone without ACEs. He or she is also 4.7 times as likely to experience depression and 10.2 times as likely to become dependent on substances; experiencing any ACEs increases the risk of homelessness by two to four times. We now have the science to understand that the toxic stress response is a key biological mechanism by which ACEs lead to these downstream consequences. ACEs and toxic stress represent a public health crisis in California and across our nation. The good news is that ACEs are not destiny! Every day, we are learning more about how to effectively interrupt the progression from early adversity to disease and early death. These lessons are being applied to policy and practice in our clinics and hospitals, schools, workplaces, childcare centers, courtrooms, and elsewhere throughout our communities. Roadmap for Resilience iii What has surprised me most, and what fuels my optimism, is the broad range of steps already being taken by passionate healthcare providers, community leaders, government officials, advocates, educators, and others to advance innovative solutions. We have an army of people who have rolled up their sleeves and are willing and ready, or already hard at work on these issues. In my role as California Surgeon General, I am committed to empowering these medical and social innovations, and marshalling the energy and insights of our healthcare and community leaders to catalyze breakthrough solutions. This work could not be more timely. Today, in the midst of a global pandemic, record- setting wildfires, and historic civil unrest, many communities across California are experiencing greater adversities than ever before. The extraordinary disruptions and hardships brought on by these circumstances have impacted everyone, but particularly our most vulnerable neighbors. There has never been a more urgent time for trauma- informed care everywhere. This report is intended to act as a blueprint for primary, secondary, and tertiary prevention—that is, prevention, early detection, and cross-sector coordinated interventions to address ACEs and toxic stress in a systematic way. None of these strategies is sufficient alone, and each extends the reach of the others. As California Surgeon General, I have set a bold goal to cut ACEs and toxic stress in half in one generation. I believe that we can get there with shared vision, shared understanding, and clear roles and responsibilities to help align cross-sector efforts. This report is grounded in the most up-to-date science, and highlights evidence-based and promising practices that can be applied at the federal, state, county, and community levels within and across sectors. Together, we can break the intergenerational cycle of adversity. Most importantly, as we move forward in this work, I urge everyone to start by putting their own “oxygen masks” on. This is long and difficult work, and we need you in this fight. Self-care is not selfish—it is an essential first step in an individual, family, or community’s journey to healing. Please join me in enacting the solutions laid out in these pages to realize a more just and equitable reality where we can truly prevent and heal from childhood adversity. With gratitude, Nadine Burke Harris, MD, MPH California Surgeon General Roadmap for Resilience iv CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY Office of the Secretary Adverse Childhood Experiences (ACEs) and toxic stress comprise preventable root causes of some of the most intractable health and social challenges facing our state. Over the past few decades, a powerful body of evidence has emerged which demonstrates the extent to which our environments shape our health. While this science is important, it is most useful when put into practice in the service of improving the health and the lives of our communities.