Adverse childhood experiences (ACEs) are a well-established precipitant of negative lifelong physical and mental health outcomes.1 There is also growing evidence of transmission of these poor outcomes from parent to child. Recent studies have demonstrated the connection between parental ACEs and developmental outcomes,2,3 behavioral problems,4 and specific health outcomes such as poor overall health status and increased rates of asthma5 in their children. Current parental stressors are also known to unfavorably affect the quality of interactions between parents and their children. Disruptions in parent-child attachment due to past or current toxic stress is likely at the root of these disturbances in child development.
In 2011, the American Academy of Pediatrics (AAP) published the policy statement “Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician,”6 which amounted to a call to action for primary care pediatricians to address toxic stress in their practice. The policy's authors assert that addressing childhood trauma should become a focus for general pediatricians because pediatricians play a significant role in lifelong health and wellness through prevention and health promotion. Among the AAP's recommendations are screening for the precipitants of toxic stress and the provision of appropriate trauma-informed anticipatory guidance and positive parenting advice.6
Despite these recommendations, there has been limited uptake of asking about ACEs and toxic stress (in either patients or parents) among pediatricians. Part of this is due to a general lack of awareness of the original ACE study; a 2016 survey found that less than 11% of pediatricians reported being very or somewhat familiar with the ACE study,7 and only 4% of pediatricians asked about all ACEs. Almost two-thirds of pediatricians (61%) did not inquire about any parental ACEs.8
Multiple factors are implicated in pediatricians' hesitation toward assessing ACEs in practice;8 these include a lack of knowledge of available tools, concerns about time and feasibility of assessments, a lack of confidence or skills in managing conversations, a perception of parent or patient resistance to assessments, and concerns about mandatory reporting. Additionally, authors have cited concerns about assessing for ACEs in primary care given a lack of proven interventions once trauma has been disclosed or identified.9
This article focuses on what is currently known in the field of screening for ACEs and toxic stress in primary care practice. Common pitfalls to addressing toxic stress in practice are discussed, as well as the possibilities that can be achieved in implementing these assessment tools in practice. Although there is still much to be learned about practice-based assessments for toxic stress and the impacts of screening on health outcomes, a thoughtful approach to implementing these assessments in practice is feasible. Thoughtful implementation of assessment tools in practice represents an important step in family-centered care for primary care providers who care for children.
Choosing the Right Tool
The choice of assessment tools in practice requires weighing the goals of the screening program as well as recognizing the population being assessed by the tool. Some tools are more appropriate for universal screening, such as assessing parents' trauma histories or assessing how trauma affects a larger population; other tools are useful when clarifying a trauma history in the context of a specific clinical complaint. It is important to consider that the goals of universal screening of parents or caregivers are generally not to force a disclosure but to open a conversation about toxic stress as a way to offer education and referrals to necessary services. Unlike other screening tools, assessments for toxic stress are generally intended to identify risk rather than to provide a specific diagnosis for a patient or family.10
When screening parents or caregivers, the 10 ACEs described in the original work Felitti et al.1 are often used. Some centers use an aggregate format for these questions, which results in higher likelihood of disclosure of ACEs,11 presumably due to increased caregiver comfort in revealing the number of ACEs rather than the specific traumas experienced. Additional traumatic experiences are sometimes added to these original ACEs, such as exposure to community violence, extreme bullying, or racism and discrimination.12
When assessing children, many tools have been developed to explore the precipitants of trauma and child abuse, as a method for identifying risk and offering preventive services. Some tools, such as the Safe Environment for Every Kid, have been shown to reduce the incidence of child abuse in certain settings.13 This approach includes attention to broader social determinants of health and family stressors, rather than ACEs specifically, as a way of opening the door to further conversations about toxic stress and the impacts of trauma on health and development.
Targeted tools can also be employed in specific clinical scenarios, such as assessing mental health concerns, school problems, or somatic complaints. There are many tools that have been tested and validated for use in these settings, and they may be considered as an adjunct to clinical history when needed.14
Feasibility and Time
A common pitfall in assessing for ACEs or toxic stress in practice is the perceived lack of time within clinical visits to address these types of issues. Several feasibility studies have recently been conducted in different settings, including outpatient pediatric practice11 as well as family medicine15 and obstetric/gynecology practices;16 these authors found that time was not a significant barrier. In most cases, conversations about ACEs were able to be completed in less than 5 minutes. In family medicine practices, the disclosure of ACEs did not typically change the immediate follow-up steps for the visit.15 One study examined the predictive value of a shortened, two-question ACE assessment tool that may further help address time concerns.17
Conversations can be facilitated by developing trigger questions to use when trauma has been disclosed. For example, when assessing parental ACEs, one clinic uses three questions to navigate the subsequent conversation: (1) do any of these experiences still bother you now; (2) of those experiences that no longer bother you, how did you get to the point that they don't bother you; and (3) how do you think these experiences affect your parenting now?11 These questions assist providers in identifying further needs while keeping the conversation confined to a more manageable timeframe.
Parent and Caregiver Resistance
Another common concern with screening is the perception that parents and caregivers will resist conversations about trauma and toxic stress. However, when parents are asked about preferences and concerns related to these conversations, respondents are generally comfortable with being asked about trauma, and furthermore are comfortable having these conversations documented in their medical records.18 In a series in family medicine practice, no patient refused screening.15 At the same time, knowledge of a history of ACEs provided significant or important knowledge to the clinical visit. This knowledge can ultimately save clinicians time in the long run by allowing the conversation to focus on potential underlying causes as opposed to ill-defined or seemingly unrelated symptoms. Parents tend to view their pediatrician as a change agent and as a bridge to needed services.19 Parents and caregivers also express understanding of the intergenerational impact of ACEs and toxic stress, and express a desire to break the transmission of trauma between generations.
As previously stated, the goal of screening should not be to force a disclosure, but rather to create a culture in which the practice is a safe place to discuss any and all concerns and problems that may be facing a family. Careful explanation of the purpose of screening facilitates the conversations and reduces resistance; giving parents and caregivers the option to identify what resources would be most helpful to them may also help minimize discomfort in screening.
Navigating Difficult Conversations
A feared pitfall in assessing ACEs in primary care practice is the provider's own confidence in managing the subsequent conversation after a disclosure of trauma. The ability to develop and build relational trust, employ emotional regulation, and use reflective practice are necessary skills.20 Pre- and post-surveys of obstetricians/gynecologists embarking in ACE screening in practice found that confidence came with experience; the more time spent practicing these skills, the more confident the providers became.16
The interview approach when addressing toxic stress mirrors motivational interviewing (MI) skills, which are skills that can be adopted by any primary care provider.21 This includes the spirit of MI of “abandoning the righting reflex” (ie, the instinct to need to fix any and all problems faced by the provider). MI would suggest that the patient has ideas and suggestions for how to best address their own problems if given the opportunity to express these ideas. In a similar editorial, Earls22 discusses using the “common factors” approach as an effective communication tool when addressing trauma in practice. These common factors have been shown to be effective in increasing patient and family functioning across a wide range of mental health problems. The HELP mnemonic (Hope, Empathy, Language, Loyalty, Permission, Partnership, Plan) is a useful way of approaching these conversations in practice.
Mandatory reporting creates an additional barrier in navigating conversations about trauma. Pediatricians must, of course, report abuse when it is suspected or disclosed in the course of a clinical visit; however, the goal of the report, in addition to ensuring child safety, should be to facilitate needed support services for patients and families. This is the primary purpose of the differential or alternative response in child welfare. Rather than simply referring reported cases of abuse or neglect to a traditional investigative response (with a goal of determining whether or not abuse or neglect has occurred), the differential or alternative response explores the root causes of abuse or neglect by encouraging families to accept or use prevention services. Child welfare organizations that have implemented a differential response approach then attempt to address these root causes through provision of services such as stress management, parenting skill building, or resolution of social determinants such as food or housing insecurity. This type of partnership with child welfare agencies is a valuable asset to practicing clinicians.
Identifying Resources and Interventions
Some authors have stated that there is a paucity of evidence-based interventions for trauma and toxic stress, and this should preclude primary care providers from embarking on screening efforts.9 This assumes, however, that necessary interventions are all based within mental health services. When asked about needed or desired resources, parents identify parenting resources and support as their primary need. Information was the second most common self-identified need.11 This information mirrors the AAP's policy statement, which suggests that positive parenting resources and enhanced developmental promotion are desired outcomes of screening (Table 1).
ACEs, Positive Parenting, and Resilience Building Resources
The resource needs identified by parents also parallel evidence-based reviews of which primary care interventions are most likely to have an impact in practice. Traub and Boynton-Jarrett23 proposed five evidence-based modifiable resilience factors for primary care providers to address within practice. These include (1) enhancing trauma understanding, (2) positive appraisal style and executive function skills, (3) responsive/positive parenting skill building, (4) treating maternal mental health problems, and (5) self-care skills and routines. Dube echoed the importance of education as an intervention, citing public health principles that assert that “knowledge is important and powerful,” and that there may be a “moral obligation…to share what is known.” Trauma education, anticipatory guidance that focuses on positive parenting practices, and screening and referral for parental mental health problems are all well within a primary care provider's expertise.
Additionally, survivors of trauma often feel that one of the most important factors contributing to their healing is having been listened to with compassion and understanding. The Survivor Voices study24 found that patients who had experienced trauma, and later felt that they had been listened to with compassion, were almost 3 times more likely to report being almost or completely healed. Similarly, in an article by Pick,25 Felitti is quoted as saying that “asking and listening…was itself a very powerful form of doing.” The simple act of asking patients, parents, and caregivers about their experiences begins their healing process, even without more complex interventions.
This is not to say that mental health resources are unnecessary; these should be viewed as complementary to the primary care provider's role in addressing toxic stress within practice. Evidence-based therapies, such as trauma-focused cognitive-behavioral therapy or parent-child interaction therapy, may be accessed as needed based on the clinical scenario.
One of the greatest possibilities that comes from assessing ACEs in practice is the possibility of preventing ACEs from transmitting from one generation to the next. As stated previously, studies have shown that parental ACEs are correlated with negative developmental and behavioral outcomes for children.2–5 Although the mechanism for this correlation remains to be proven, the early identification of families at risk allows pediatricians to provide enhanced services to these families. If parents can be assisted in improving resilience, parenting skills, and attachment with their children, the intergenerational transmission of ACEs may be mitigated or even avoided.
Universal screening of children at a population level, therefore, functions as a potential outcome measure of interventions delivered in early childhood. If the ultimate goal is to prevent toxic stressors from affecting future generations of children, then assessing the pre- and postintervention incidence of ACEs is necessary to be able to prove that interventions have the desired effects.
Another goal of addressing ACEs and toxic stress in practice is to reduce the stigma attached to childhood trauma. The basis of trauma-informed care is to create a culture in which trauma is openly discussed in a safe and nonjudgmental atmosphere. This culture shift not only validates the importance of a trauma history but allows survivors to create a “trauma narrative,” which is an important step in healing. If parents and families feel safe discussing the relevance of their trauma history to their parenting experience and are able to openly ask questions and seek advice for challenges, it is a reasonable assumption they will become less likely to repeat the patterns of their past. A good screening tool in primary care includes an educational component; in the case of ACE and toxic stress, the tool is not just about discovering a trauma history but is also intended to open future conversations about ongoing toxic stress and other social determinants of health.
Continuing to address toxic stress in parents and in patients also allows for a collective research agenda by identifying and understanding parent and family needs, clarifying gaps in needed services, and studying potential interventions to improve outcomes for children. Our current understanding of the effects of toxic stress on health and wellness, including the effects of parental ACEs on child outcomes, necessitate a continued, careful entry into practice-based screening efforts.
There is still much to learn when it comes to screening for ACEs in primary care practice. However, as stated in a review by Dube,10 “we are now at a juncture to act cautiously and ethically.” Parents and caregivers view their pediatrician as a trusted source of knowledge and help, and many practitioners have found screening not only feasible but also valuable in the clinical care being delivered. The interventions most desired by parents and likely to be efficacious are well within the grasp of pediatricians; these include information, active listening, and anticipatory guidance focused on developmental promotion and positive parenting skills. Addressing trauma in primary care pediatrics has the potential to reduce or remove stigma around discussing trauma histories, connect patients and families with needed services, and most importantly may provide a mechanism for preventing the transmission of trauma from one generation to the next.
- Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. Am J Prev Med. 1998;14(4):245–258. doi:10.1016/S0749-3797(98)00017-8 [CrossRef]
- Folger AT, Eismann EA, Stephenson NB, et al. Parental adverse childhood experiences and offspring development at 2 years of age. Pediatrics. 2018;141(4). pii:e20172826. doi:. doi:10.1542/peds.2017-2826 [CrossRef]
- Sun J, Patel F, Rose-Jacobs R, Frank DA, Black MM, Chilton M. Mothers' adverse childhood experiences and their young children's development. Am J Prev Med. 2017;53(6):882–891. doi:. doi:10.1016/j.amepre.2017.07.015 [CrossRef]
- Schickedanz A, Halfon N, Sastry N, Chung PJ. Parents' adverse childhood experiences and their children's behavioral health problems. Pediatrics. 2018;142(2):e20180023. doi:. doi:10.1542/peds.2018-0023 [CrossRef]
- Le-Scherban F, Wang X, Boyle-Steed KH, Pachter LM. Intergenerational associations of parent adverse childhood experiences and child health outcomes. Pediatrics. 2018;141(6):e20174274. doi:. doi:10.1542/peds.2017-4274 [CrossRef]
- Garner AS, Shonkoff JP, Siegel BS, et al. Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health. Pediatrics. 2011;129(1):e224–e231. doi:10.1542/peds.2011-2662 [CrossRef].
- Kerker BD, Storfer-Isser A, Szilagyi M, et al. Do pediatricians ask about adverse childhood experiences in pediatric primary care?Acad Pediatr. 2016;16(2):154–160. doi:. doi:10.1016/j.acap.2015.08.002 [CrossRef]
- Szilagyi M, Kerker BD, Storfer-Isser A, et al. Factors associated with whether pediatricians inquire about parents' adverse childhood experiences. Acad Pediatr. 2016;16(7):668–675. doi:. doi:10.1016/j.acap.2016.04.013 [CrossRef]
- Finkelhor D. Screening for adverse childhood experiences (ACEs): cautions and suggestions. Child Abuse Negl. 2018;85:174–179. doi:. doi:10.1016/j.chiabu.2017.07.016 [CrossRef]
- Dube SR. Continuing conversations about adverse childhood experiences (ACEs) screening: a public health perspective. Child Abuse Negl. 2018;85:180–184. doi:. doi:10.1016/j.chiabu.2018.03.007 [CrossRef]
- Gillespie RJ, Folger AT. Feasibility of assessing parental ACEs in pediatric primary care: implications for practice-based implementation. J Child Adolesc Trauma. 2017;10(3):249–256. doi:. doi:10.1007/s40653-017-0138-z [CrossRef]
- Finkelhor D, Shattuck A, Turner H, Hamby S. Improving the adverse childhood experiences study scale. JAMA Pediatr. 2013;167(1):70–75. doi:. doi:10.1001/jamapediatrics.2013.420 [CrossRef]
- Dubowitz H, Feigelman S, Lane W, Kim J. Pediatric primary care to help prevent child maltreatment: the Safe Environment for Every Kid (SEEK) model. Pediatrics. 2009;123(3):858–864. doi:. doi:10.1542/peds.2008-1376 [CrossRef]
- Oh DL, Jerman P, Boparai SKP, et al. Review of tools for measuring exposure to adversity in children and adolescents. J Pediatr Health Care. 2018;32(6):564–583. doi:. doi:10.1016/j.pedhc.2018.04.021 [CrossRef]
- Glowa PT, Olson AL, Johnson DJ. Screening for adverse childhood experiences in a family medicine setting: a feasibility study. J Am Board Fam Med. 2016;29(3):303–307. doi:. doi:10.3122/jabfm.2016.03.150310 [CrossRef]
- Flanagan T, Alabaster A, McCaw B, Stoller N, Watson C, Young-Wolff KC. Feasibility and acceptability of screening for adverse childhood experiences in prenatal care. J Womens Health. 2018;27(7):903–911. doi:. doi:10.1089/jwh.2017.6649 [CrossRef]
- Wade R, Becker BD, Bevans KB, Ford DC, Forrest CB. Development and evaluation of a short adverse childhood experiences measure. Am J Prev Med. 2017;52(2):163–172. doi:. doi:10.1016/j.amepre.2016.09.033 [CrossRef]
- Goldstein E. Patient preferences for discussing childhood trauma in primary care. Perm J. 2017;21:16–055. doi:. doi:10.7812/TPP/16-055 [CrossRef]
- Conn A-M, Szilagyi MA, Jee SH, Manly JT, Briggs R, Szilagyi PG. Parental perspectives of screening for adverse childhood experiences in pediatric primary care. Fam Syst Health. 2018;36(1):62–72. doi:. doi:10.1037/fsh0000311 [CrossRef]
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- Rollnick S, Miller WR, Butler CC. Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York, NY: Guilford Press; 2008.
- Earls MF. Trauma-informed primary care: prevention, recognition, and promoting resilience. N C Med J. 2018;79(2):108–112. doi:10.18043/ncm.79.2.108 [CrossRef].
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- Cortez P, Dumas T, Joyce J, et al. Survivor voices: co-learning, re-connection, and healing through Community Action Research and Engagement (CARE). Prog Community Health Partnersh. 2011;5(2):133–142. doi:. doi:10.1353/cpr.2011.0020 [CrossRef]
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ACEs, Positive Parenting, and Resilience Building Resources
|News and information on ACEs and how to become more trauma-informed in practice: <ext-link ext-link-type="uri" xlink:href="https://www.acesconnection.com" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://www.acesconnection.com</ext-link>
|A network of providers across the country who are addressing ACEs in practice: <ext-link ext-link-type="uri" xlink:href="https://nppcaces.org" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://nppcaces.org</ext-link>
|Led by Nadine Burke-Harris, MD, Center for Youth Wellness is an international leader in addressing ACEs in practice: <ext-link ext-link-type="uri" xlink:href="https://centerforyouthwellness.org/" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://centerforyouthwellness.org/</ext-link>
|The Resilience Project from the AAP describes what providers can do in practice to address ACEs and toxic stress: <ext-link ext-link-type="uri" xlink:href="https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/resilience/Pages/Resilience-Project.aspx" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/resilience/Pages/Resilience-Project.aspx</ext-link>
|Helpful tip sheets for positive parenting at different ages: <ext-link ext-link-type="uri" xlink:href="https://www.cdc.gov/parents/index.html" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://www.cdc.gov/parents/index.html</ext-link>
|More tips on positive parenting: <ext-link ext-link-type="uri" xlink:href="https://www.zerotothree.org/parenting" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://www.zerotothree.org/parenting</ext-link>
|Free parenting webinars based on developmentally appropriate discipline: <ext-link ext-link-type="uri" xlink:href="https://parentingbeyondpunishment.com/pdep/" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://parentingbeyondpunishment.com/pdep/</ext-link>
|Guided meditations to teach mindfulness to children age 5 to 11 years: <ext-link ext-link-type="uri" xlink:href="https://www.mindyeti.com" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://www.mindyeti.com</ext-link>
|Information on practical steps for building resilience: <ext-link ext-link-type="uri" xlink:href="https://www.stresshealth.org" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://www.stresshealth.org</ext-link>
|AAP “Pediatrics for the 21st Century” presentation on screening parents for ACEs: <ext-link ext-link-type="uri" xlink:href="https://www.youtube.com/watch?v=Ai0YjNgUdZA" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://www.youtube.com/watch?v=Ai0YjNgUdZA</ext-link>
|Initiating the conversation with parents: <ext-link ext-link-type="uri" xlink:href="https://www.youtube.com/watch?v=qYvxptguhhY" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://www.youtube.com/watch?v=qYvxptguhhY</ext-link>
|The role of educating parents: <ext-link ext-link-type="uri" xlink:href="https://www.youtube.com/watch?v=V_R-mqYsyD8" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://www.youtube.com/watch?v=V_R-mqYsyD8</ext-link>