Introduction 426 I. Adverse Childhood Experiences and Their Impact 428 A. The ACEs Studies 431 B. The Impact of ACEs on Children: Toxic Stress 440 C. The Significance of the ACE Study 445 II. High Rates of Trauma Among Delinquent and Criminal Justice Populations 448 A. Gender Differences 451 B. High Rates of Trauma in Early Childhood 451 C. ACEs Among the Juvenile Justice Population 452 D. Effect of Childhood Trauma on Mental Health Needs of Youth in the Juvenile Justice System 457 III. Solution: A Collaborative, Multi-Generational, Upstream Model 459 A. Need for Early Identification and Intervention 459 B. Early Identification of a Particular ACE in Albuquerque, New Mexico: Household Substance Abuse 462 C. The University of New Mexico Medical-Legal Alliance 470 1. Early Identification of Children Who Have Experienced ACEs and Multi-Disciplinary, Multi-Generational Healthcare and Early Intervention 473 a. Kinship Guardianship Advocacy 485 b. Educational Advocacy 487 Conclusion 489 INTRODUCTION
A groundbreaking public health study funded by the U.S. Centers for Disease Control and Prevention (CDC) and the Kaiser Foundation found astoundingly high rates of childhood trauma, including experiences like abuse, neglect, parental substance abuse, mental illness, and incarceration. (1) Hundreds of follow-up studies (2) have revealed that multiple traumatic adverse childhood experiences (or "ACEs") make it far more likely that a person will have poor mental health outcomes in adulthood, such as higher rates of depression, anxiety, suicide attempts, and substance abuse. (3) Interestingly, the original ACE Study examined a largely middle-class adult population living in San Diego, (4) but subsequent follow-up studies have examined the prevalence of ACEs and its impact on mental health in other populations, including among people involved in the juvenile and criminal justice systems. (5) Unsurprisingly, individuals entangled in those systems are more likely to have experienced higher numbers of these traumatic events, (6) despite a frequent lack of access to critical mental health treatment, including the treatment necessary to address past childhood trauma. (7) The ACEs framework for understanding health and mental health outcomes resulting from childhood trauma has received a high level of attention recently following an in-depth, multi-part series on these issues by National Public Radio (NPR) and other media. (8)
Because the ACEs public health research shows us that events in childhood can cause "toxic stress" (9) and have a lasting impact on the mental health of a child well into adulthood, this framework provides us with an opportunity to consider how to more effectively intervene to stop the pathway from ACEs to juvenile justice system involvement and address the related health, mental health, developmental, and legal needs of children and their families. Before a child becomes an adult facing a mental health crisis or incarceration, attorneys, doctors, and other professionals can collaborate to disrupt that fate. This Article argues for a more upstream approach to address mental health using a medical-legal collaboration, based on the experiences of the authors, a law professor and medical school professor who work together to try to improve outcomes for children who have experienced trauma and their families.
In Part I, we begin by examining the groundbreaking ACE studies, exploring the toxic stress and health and mental health outcomes that are associated with high rates of ACEs in childhood. (10) Next, in Part II, we analyze the research revealing high rates of trauma and ACEs among populations involved in the juvenile justice system. (11) Finally, we conclude in Part III by arguing for a more upstream public health and justice approach. (12) We examine a particular problem in the city of Albuquerque, the largest urban area in New Mexico: children who have a particular ACE right from birth in the form of substance abuse by a household member. (13) These infants are born with prenatal drug exposure and many experience symptoms of withdrawal in their first weeks of life, often quickly followed by an accumulation of additional forms of early childhood trauma. (14) We discuss an approach through which the authors work to address those issues and disrupt the path from that childhood trauma to poor outcomes and juvenile justice system involvement. This approach engages attorneys with doctors and other health and developmental professionals to address ACEs among young children ages zero to three and their siblings, parents, and other caregivers. (15) We advocate for an early, holistic, multi-generational, multi-disciplinary public health and justice approach to address ACEs early and improve the trajectory for children who have experienced childhood trauma. (16)
ADVERSE CHILDHOOD EXPERIENCES AND THEIR IMPACT
Loretta, a four-month-old infant, came to the University of New Mexico Health Sciences Family Options: Caring, Understanding Solutions, or FOCUS, Clinic for her first doctor's appointment following her discharge from the hospital at birth. (17) The FOCUS Program provides medical and home-based early intervention services to children who experienced prenatal drug exposure and their families. (18) Early intervention services are those developmental services provided under special education law to meet the needs of an infant or toddler with a disability in the areas of physical, cognitive, communication, social/emotional, and adaptive development, such as family training and counseling, occupational therapy, and psychological services. (19) The doctor's appointment had been scheduled with the FOCUS Clinic because baby Loretta and her mother Christi had urine drug screens completed at delivery that found the presence of methamphetamine and opiates in both of their systems. The discharging medical team at the hospital wanted Loretta to have follow-up with a team that had experience caring for infants and children with prenatal drug and alcohol exposure. Loretta's mother, Christi, grandmother, Rosa, and nine-year-old brother, Antonio, also crowded into the exam room. Rosa explained that Christi was recently released from jail for serious drug trafficking charges. Christi volunteered that she has "had a problem with methamphetamine and heroin" but after spending time in jail, plans to stay "clean." The father of Loretta and Antonio, Eddie, is not involved in the children's lives. He separated from Christi when Antonio was two years old, and briefly reunited with Christi the prior year, leading to the birth of Loretta.
While the doctor's appointment was for baby Loretta, Rosa and Christi wanted to talk about Antonio. They complained that Antonio "is nothing but trouble" and that he came with them to the doctor's office that day because he was home on his second out-of-school suspension since the school year began two months earlier. As Antonio dashed from one corner of the exam room to the other, jumping off and on the laps of the adults in the room, the medical team conducted a complete new patient visit, including review of the infant's hospital care, review of Christi's interrupted prenatal care due to her arrests, and a full physical exam of baby Loretta. The history and findings of potential developmental problems for Loretta supported referral for medically necessary early intervention services, a form of special education services provided by an early intervention specialist and other developmental specialists under the Individuals with Disabilities Education Act for young children ages zero to three, (20) coordinated with primary medical care in the FOCUS Clinic. The medical provider introduced an early intervention specialist to the family, and the family agreed to a home visit to start home-based early developmental intervention and family support.
At the subsequent FOCUS team meeting, the early intervention specialist discussed with the combined medical and early intervention team what she learned from the intake that the early intervention team completed with the family in Rosa's home. This intake involved a multi-disciplinary evaluation (21) regarding baby Loretta's developmental needs, as well as an Environmental Risk Assessment that evaluated factors in Loretta's life that put her at risk for developmental delays. (22) When the early intervention specialist went to the home, she met with Rosa alone because Christi had been arrested again. Rosa explained that Christi was addicted to methamphetamine and heroin starting at age 15. She had been in and out of jail and in and out of the children's lives. Antonio had been through a lot in his short life. His parents separated when he was two, and he had not seen his father since then. He had been emotionally and physically neglected, bounced among strangers, and often left to care for himself even as a young child. Rosa mentioned that Antonio learned at five years old how to make himself a sandwich and use the microwave; otherwise, he would have starved. Until recently, he did not know how to take a bath or shower. Both Antonio and Loretta were now in Rosa's care. Rosa felt relieved that she could have home-based support services for the baby and that the FOCUS Program would schedule Antonio for medical care to better understand his behavioral and school issues. However, Rosa expressed concern about the fact that Antonio's school told her she could not be the one to deal with the paperwork related to his suspensions and his educational needs more broadly because she did not have legal custody of him. She was also worried about whether, given baby Loretta's complex medical needs, some doctors might also refuse to work with Rosa since she was not the baby's biological mother and had no legal custody documentation.
The framework of "adverse childhood experiences," or ACEs, can help us understand Antonio's and Loretta's situations--and their...