ARTICLE

Adverse Childhood
Experiences and Trauma-
Informed Care
Anna Goddard, PhD, APRN, CPNP-PC

Adverse childhood experiences (ACEs) refer to the abuse, neglect, ADVERSE CHILDHOOD EXPERIENCES AND
and traumatic experiences in childhood that directly affect long- TRAUMA-INFORMED CARE
term adolescent and adult health. Understanding the ACE Pyramid Adverse childhood experiences (ACEs) is the umbrella term
and the physiological stress response has guided research toward a to describe abuse, neglect, and traumatic experiences that
better understanding of the long-term mental and physical health
occur under the age of 18 years. Once considered a social or
consequences from psychological impacts early in life. Trauma-
mental health problem, the impact of ACEs on pediatric
informed care becomes critical for pediatric clinicians to operation-
alize in practice. The four R’s approach—realize, recognize, development and long-term adult health outcomes has since
respond, and resist re-traumatization—can be used by pediatric been recognized as a public health crisis (Anda, Butchart,
providers as guidance. The trauma-informed care approach Felitti, & Brown, 2010). As stated by Dr. Robert Block, the
includes the realization of how ACEs affect health, the recognition American Academy of Pediatrics (AAP) past president,
of pediatric clinical symptom presentation and screening protocols “Children’s exposure to adverse childhood experiences is
for ACEs, and the health care provider’s ability to respond and not the greatest unaddressed public health threat of our time”
re-traumatize patients when delivering evidence-based care. As (Kennedy et al., 2011). Severe and cumulative trauma is
recent events have triggered worldwide mental and emotional often misdiagnosed later in life as depression, anxiety, or
trauma in youth, clinicians must start operationalizing trauma- attention-deficit hyperactivity disorder (ADHD) and leads
informed care into practice, as future presentations of trauma are
to disease, disability, and early death (Briere, Elliott, Harris,
expected. J Pediatr Health Care. (2021) 35, 145−155
& Cotman, 1995; Felitti et al., 1998; Felitti, 2009; Felitti &
Anda, 2010).
KEY WORDS
Adverse childhood experiences, trauma-informed care, toxic stress,
Adverse Childhood Experiences
trauma-informed approach, Adverse Childhood Experiences Study
The original ACEs study was conducted from 1995 to 1997
in Southern California at Kaiser Permanente’s Health
Appraisal Clinic, where more than 17,000 health mainte-
Anna Goddard, Assistant Professor, Sacred Heart University, nance organization members completed a confidential sur-
Fairfield, CT; and Pediatric Nurse Practitioner, Child and Family
Agency of South Eastern Connecticut, New London, CT.
vey as part of an examination. The survey reviewed
childhood experiences and current health status and behav-
This manuscript or one that is similar is not under review for any
iors (Felitti et al., 1998). This landmark study became known
other journal or under consideration for publication elsewhere.
The work is original. as one of the largest investigations of childhood abuse,
neglect, and household challenges connecting later life health
Conflicts of interest: None to report.
and well-being in adulthood from trauma in childhood.
Correspondence: Anna Goddard, PhD, APRN, CPNP-PC, Sacred Researchers specifically focused on abuse (physical, emo-
Heart University, 5151 Park Ave., Fairfield, CT 06825; e-mails:
tional, sexual), neglect (physical, emotional), and household
goddarda@sacredheart.edu; goddarda@childandfamilyagency.
org dysfunction (mental illness, mother treated violently, divorce,
J Pediatr Health Care. (2021) 35, 145-155 an incarcerated relative, and substance abuse) (Felitti et al.,
0891-5245/$36.00
1998). Hallmark findings from the study included more than
two third of the participants reporting at least one ACE,
Copyright © 2020 by the National Association of Pediatric Nurse
with 1 in 5 reporting three or more ACEs. The analysis
Practitioners. Published by Elsevier Inc. All rights reserved.
showed a graded-dose relationship among adults with the
Published online October 28, 2020. highest levels of childhood traumas 5 times more likely to
https://doi.org/10.1016/j.pedhc.2020.09.001

www.jpedhc.org March/April 2021 145

FIGURE. Adverse Childhood Experiences Pyramid.
FROM “RELATIONSHIP OF CHILDHOOD ABUSE AND HOUSEHOLD DYSFUNCTION TO MANY OF THE
LEADING CAUSES OF DEATH IN ADULTS. THE ADVERSE CHILDHOOD EXPERIENCES (ACE) STUDY,” BY
V. J. FELITTI, ET AL., 1998, AMERICAN JOURNAL OF PREVENTIVE MEDICINE, 14, 245−258. REPRINTED
WITH PERMISSION. THIS FIGURE APPEARS IN COLOR ONLINE AT WWW.JPEDHC.ORG.

become an alcoholic, 9 times more likely to abuse illegal subsequent studies have found additional recognized ACEs,
drugs, 3 times more likely to have clinical depression, such as school and community violence, natural disasters,
17 times more likely to attempt suicide, 2 times more likely forced displacements, and war, terrorism, and political vio-
to develop heart disease, and 2 times more likely to be obese lence, with similar or compounded negative health outcomes
(American Academy of Pediatrics [AAP], 2014; in adulthood (Anda et al., 2010; Bruskas, 2008; Felitti &
Kennedy et al., 2011). Anda, 2010; See Box). Consequently, ACEs have both short-
The number of ACEs also predicted adult diseases, and long-term impacts on child development. The neurobio-
including heart disease, cancer, chronic lung, and liver logical effects of brain abnormalities and stress hormone
disease. In addition, this study created a better under- dysregulation coupled with psychological effects of poor
standing and subsequential development of the concep- attachment, poor socialization, and self-efficacy put com-
tual framework known as the ACE Pyramid to pounded risk on health risk behaviors (such as smoking,
understand ACEs in terms of the original causes of adult obesity, substance abuse, and promiscuity; Perry, 2009;
disease (see Figure). The ACE Pyramid is now used by Shonkoff, Garner, Committee on Psychosocial Aspects of
dozens of resiliency and ACE researchers over the last Child and Family Health, Committee on Early Childhood,
three decades to frame linkages between psychological Adoption, and Dependent Care, & Section on Developmen-
behaviors that become a long-term organic disease, tal and Behavioral Pediatrics, 2012). These impacts on child
bridging the need for physical and mental health integra- development subsequently lead to long-term consequences,
tion of care (Anda et al., 2010). which include disease and disability (major depression, sui-
Internationally recognized pediatrician Dr. Nadine Burke cide, posttraumatic stress disorder [PTSD], drug and alcohol
Harris brought renewed attention to how childhood trauma abuse, heart disease, cancer, chronic lung disease, sexually
affects health across the lifetime. Her message of a proac- transmitted diseases, intergenerational transmission of
tive, preventive approach to childhood trauma includes a abuse) and social problems (homelessness, prostitution,
call to action to pediatric clinicians to recognize the tangible criminal behavior, unemployment, parenting problems, high
effects on brain development across the lifetime (Har- use of health and social services, shortened life span;
ris, 2014). Anda et al., 2010; Garner, Shonkoff, Committee on Psycho-
social Aspects of Child and Family Health, Committee on
Significance Early Childhood, Adoption, and Dependent Care, & Section
Although the ACEs from the original study (Felitti et al., on Developmental and Behavioral Pediatrics, 2012;
1998) are among the most commonly reported traumas, Shonkoff et al., 2012).

146 Volume 35  Number 2 Journal of Pediatric Health CareÒ

BOX. Adverse Childhood Experiences in a widening in the smaller airways, which maximizes oxy-
gen intake. Epinephrine then triggers the body’s release of
Bereavement glucose and fat stores as an energy-reserve release. Activa-
Bullying tion of the HPA axis signals the hypothalamus to release cor-
Community violence ticotropin-releasing hormone, which signals
Domestic violence
Emotional abuse
adrenocorticotropic hormone to stimulate cortisol release
Food scarcity from the adrenal glands, ultimately putting the body in a
Forced displacement state of alert (Perry, 1994; Perry & Pollard, 1998; van der
Foster care system experiences Kolk, 2014).
Illness/medical trauma Under normal physiological conditions, when the stress
Interpersonal violence
Impaired caregiver
passes, cortisol levels decrease, and the parasympathetic ner-
Kidnaping vous system shuts down this process. However, under con-
Living in unsafe environments ditions of chronic or toxic stress, cortisol levels remain
Multiple deaths and traumatic loss elevated, and epinephrine is continually released into the
Natural disasters body (Grogan & Murphy, 2011). This long-term HPA-axis
Neglect
Peer rejection
activation can then cause damage to blood vessels and arter-
Physical abuse ies and increase blood pressure, resulting in a greater risk of
Physical assault heart attack and stroke (American Heart
Political violence Association [AHA], 2020; Anda et al., 2006). Persistent ele-
Poor academic performance vation in stress hormones also creates a physiological
Poverty
Racism over time
buildup of fat tissue, resulting in weight gain. In addition,
School violence elevated cortisol causes increased appetite and decreased
Serious injury/accident satiety, further contributing to long-term obesity owing to
Sexual abuse chronic stress (Binder, 2009; McGowan et al., 2009). Under-
Sexual assault/rape standing this pathophysiology becomes critical in under-
Terrorism
Traumatic loss
standing how ACEs fit into HPA-axis activation, as
War persistent, elevated stress hormones from toxic and chronic
stress directly lead to health outcomes of severe obesity, dia-
And betes, heart disease, cancer, stroke, and chronic obstructive
a et al. (2006); Anda et al. (2010); Briere et al. (1995); Brus- pulmonary disease (Garner et al., 2012; Grogan & Mur-
kas (2008); Bucci et al. (2016); Burke, Hellman, Scott, phy, 2011; Hornor, 2015; Johnson, Riley, Granger, & Riis,
Weems, and Carrion (2011); Cook et al. (2005); 2013; Shonkoff et al., 2012).
Felitti et al. (1998); Felitti (2009); Felitti and Anda (2010);
Dube et al. (2001); Grogan and Murphy (2011);
Hughes et al. (2017); Johnson et al. (2013); The brain’s response
O’Donnell, Creamer, and Pattison (2004); Perry (2002); Chronic and toxic stress can also lead to changes in brain
Schneider and Phares (2005); Simmel (2010). development and structure. Specifically, chronic stress
−induced HPA activation changes synapses, receptors, and
neurohormones in the brain; decreases dendrite complexity,
The stress response brain weight, and dendritic spines; and interferes with myeli-
Understanding how trauma specifically affects the body nation (Grogan & Murphy, 2011). High levels of circulating
aides in comprehending the subsequent physical manifesta- cortisol also results in auditory and visual delays and
tions and long-term chronic health conditions related to decreased hippocampus volume, which directly affects
ACEs. The normal neurobiological reaction to threat or memory storage and retrieval (Binder, 2009; Grogan & Mur-
stress includes activation of the hypothalamic-pituitary-adre- phy, 2011; Perry, 2009). This disruption in brain develop-
nal (HPA) axis (van der Kolk, 2014). When the brain and ment leads to learning difficulties (language, cognition,
body sense danger, the amygdala (emotional processing cen- socioemotional) and maladaptive behavioral responses
ter of images and sounds) sends a signal to the hypothala- (Shonkoff et al., 2012). Although these neurobiological and
mus. When the hypothalamus receives a distress signal, neuroendocrine systems are influenced by negative environ-
epinephrine is then released to signal the body’s nervous sys- mental experiences, the individual ability to overcome com-
tem to either fight or flee. Breathing, blood pressure, heart plexities from trauma includes a degree of repair through
rate, and blood vessel constriction occur, as the sympathetic protective factors that foster resilience through childhood
nervous system sends signals through the autonomic nerves (Anda et al., 2006; Hornor, 2015; Hughes et al., 2017).
to the adrenal glands, the adrenals then pump epinephrine
(adrenaline) into the bloodstream. As epinephrine circulates, Significance for the Pediatric Clinician
the heart beats faster, and blood rushes to the muscles, More than 10,000 studies have cited the original Kaiser Per-
heart, and vital organs. This response results in an increased manente ACE study, with bodies of research continuing to
heart rate and blood pressure. More rapid breathing results show the dose−response relationship between higher ACE

www.jpedhc.org March/April 2021 147

scores resulting in higher health outcome risks Harris, 2018; Hornor, 2015). The pediatric medical home
(Hughes et al., 2017). Over 40% of children and adolescents has long been recognized as the ideal location for addressing
experience four or more different types of trauma and trauma (AAP, 2014). However, school-based health centers,
adversity during childhood (Bucci, Marques, Oh, & Harris, the educational system, and specialty services are also key
2016). Identified long-term effects of trauma include gastro- sources of care and structure for children and youth and,
intestinal disorders, pelvic pain, headaches, anxiety, depres- therefore, must also be familiar with the associated chal-
sion, PTSD, attention-deficit disorder, eating disorders, lenges of approaching trauma.
alcohol and drug dependence, asthma, self-injury, and high- Different organizations and leaders in pediatric health
risk behaviors in adolescence and adulthood (Anda et al., care have proposed trauma-informed care for practice.
2010; Chapman et al., 2004). Emerging research on the Universally these components fall into the Substance
social determinants of health has found an increased vulner- Abuse and Mental Health Administration trauma-
ability and higher risk of experiencing ACEs related to social informed care approach of realize, recognize, respond, and
and economic conditions in which they live, learn, work, and resist re-traumatization (four R’s; Substance Abuse and
play (AAP, 2014; ACEs Aware, 2020; AHA, 2020). Among Mental Health Services Administration [SAMHSA],
the recent calls to action regarding the recognition of ACEs 2014; SAMHSA, 2018). A trauma-informed approach
and trauma in the pediatric population, social determinants includes being empathetic and supportive while recogniz-
of health have gained political and organizational priority for ing that sharing difficult information is hard for individu-
future research in the field of childhood trauma als. General principles include assessing for social
(AHA, 2020; Daniel, Bornstein, Kane, & Health and Public connectedness, support systems, and encouraging the use
Policy Committee of the American College of Physicians, of family, friends, religious, and community resources
2018; Hughes et al., 2017). (SAMHSA, 2014; SAMHSA, 2018). In addition, the
The AAP released a policy statement regarding ACEs, AAP (2014) has published a Trauma Toolbox for pediatric
early adversity, toxic stress, and the role of the pediatrician, providers to assist in understanding these principals
which included the need for pediatric clinicians to screen for through case studies and learning modules. See Table 1
ACEs routinely (Garner et al., 2012). The AAP has addition- for a summary of the four R’s of trauma-informed care.
ally charged all pediatric primary care providers to achieve
competence in pediatric behavioral health management in Realize
primary care, which includes an understanding of trauma, Realize refers to the provider’s understanding surrounding
depression, ADHD, and anxiety experienced in childhood the widespread impact of trauma. One of the first steps for
and how these relate to ACEs (AAP, 2019). In 2019, the all providers is to understand how ACEs affect pediatric
National Association of Pediatric Nurse Practitioners pub- development and the long-term effects into adulthood. The
lished a position statement around the importance of “build- profound neurological, physiological, biological, psychologi-
ing resilience in childhood and adolescence,” which included cal, and social effects of trauma on the individual across the
recognizing ACEs and adversity in early childhood, and the lifetime should be recognized, not only by the pediatric
long-term health outcomes on brain functioning and devel- health care system, but also those who treat the family sys-
opment. This position statement includes the need to tem and caregiver−child dyad, such as the educational sys-
decrease risk factors of ACEs and calls for pediatric pro- tem, allied health professionals, and early childhood
viders to assist in enhancing and increasing protective fac- providers (SAMHSA, 2018). This first step provides the
tors to build resiliency (National Association of Pediatric framework to reframe the previous perception from “what
Nurse Practitioners [NAPNAP] et al., 2019). With these is wrong with you?” to a trauma-informed approach of
standards and calls for action, pediatric clinical practices “what happened to you?” to inform the provider, caregiver,
have begun implementing screening and educating providers or system (Harris, 2014, 2018; Kennedy et al., 2011;
for ACEs as part of new evidence-based practice (Bryant & Perry, 2002).
VanGraafeiland, 2020).
Recognize
TRAUMA-INFORMED CARE Recognize refers to the different signs and symptoms of
Supportive, nurturing relationships are critical to healing. trauma in families and patients, as well as staff who are
Based on this premise, every person who has contact with a involved in the system of care delivery, to identify potential
patient can contribute to that healing process if that relation- re-traumatization situations. This process involves asking
ship is supportive. Hodas (2006) calls for a movement of open-ended questions such as “has your living situation
universal precautions in reference to trauma-informed care by changed in any way?” and “has anything stressful, sad, or
creating a system in which all patients served are presumed scary happened to you or your child?” Providers should fol-
to have a history of traumatic stress or experience. The low-up to all expressed concerns from the patient and their
premise of universal precautions and trauma-informed care family and let the parent or guardian know that sometimes
has since been put forth by many pediatric-based disciplines different behaviors seen in children can be related to ongo-
as a shift in mindset on how one approaches the patient ing stress. Trauma manifests in a variety of ways. Therefore,
−provider relationship (AAP, 2014; AHA, 2020; children who experience trauma may look and present

148 Volume 35  Number 2 Journal of Pediatric Health CareÒ

 TABLE 1. Substance Abuse and Mental Health Services Administration: Four R’s of trauma-informed
care
Realize refers to understanding the widespread impact of trauma
Understand how ACEs impact development and long-term effects into adulthood
ACEs have neurological, physiological, biological, psychological, and social effects
Shift perception from “what is wrong with you?” to “what happened to you?”
Recognize the signs and symptoms of trauma in patients and families
Open-ended questions “Has your living situation changed in any way?”
“Has anything stressful, sad, or scary happened to you or your child?”
Diagnosis Include comorbidities such as depression, anxiety, and substance abuse
Red-flag presentations Be aware of red-flag presentations of trauma such as suicidality, self-injurious behavior, or
presenting in psychosis
Assess for Disordered eating
Sleep disorders
Elimination concerns
Developmental delays
Respond to trauma by coordination with the health care system, community referrals, and education system to best support the child and
family
Screening ACE-Q
Pediatric ACEs screening and related life-events screener
Children’s stress disorders checklist (The National Child Traumatic Stress Network, 2020)
Anticipatory guidance Resiliency promotion
Consistent, developmentally appropriate parenting
Nonphysical discipline
ACEs education, to include possible symptom presentation
Sleep hygiene recommendations
Healthy eating recommendations based on symptoms
Healthy toileting and elimination support based on symptoms
Treatment referrals Community connections
After-school programs and activities
Spiritual and religious community connections
Parent support groups
Mentoring programs (e.g., Big Brothers)
IEP referral
SBHC
Behavioral health therapy (see Table 2)
CPS if indicated
Resist re-traumatization refers to rethinking the clinical approach to patient care, including support for those providing the care
Become a trauma- Review policies, protocols, and procedures for care with a trauma-based lens
informed organization Consider input from clients and providers (employees) who provide care
Approach all patients with a universal precautions mindset
Provide training for all staff, regardless of position, on ACEs and trauma-informed care

Note. ACEs, Adverse Childhood Experiences; ACE-Q, Adverse Childhood Experience-Questionnaire; IEP, Individualized Education Pro-
gram; SBHC, school-based health centers; CPS, Child Protective Services. Four R’s = realize, recognize, respond, resist re-traumatization.

differently across the developmental life span. This process Disordered eating
requires recognizing trauma as a potential differential with Disordered eating because of trauma is thought to be caused
disordered eating, sleep issues, and developmental concerns by an inhibition of the satiety center in the body, often as a
that present during wellness or acute visits. In addition, pro- result of anxiety (Binder, 2009; van der Kolk, 2014). Rapid
viders should pay special attention to the child who does not eating, lack of satiety, food hoarding, loss of appetite, and
want to hang out with friends, quits a team, or no longer other eating disorders have been noted as symptom presen-
wants to do things they used to enjoy. Although these signs tation in children with ACEs and resulting mental health
can be symptoms of depression, one must remember that comorbidities from trauma (AAP, 2014; SAMHSA, 2014).
trauma can also be triggered by different people, places, Baseline eating habits should be noted, especially when
signs, and smells that remind the individual of the trauma potentially prescribing psychopharmaceuticals when accom-
(AAP, 2014; The National Child Traumatic Stress Net- panying depression, anxiety, ADHD, or other mental health
work, 2011; SAMHSA, 2014). In addition, all pediatric pro- diagnoses that often require medications as part of the treat-
viders should also be familiar with red-flag presentations, ment plan (Riddle, Baum, Foy, & dosReis, 2018). Psycho-
including suicidality, self-injurious behavior, or presenting in pharmaceuticals used for treatment can additionally create
psychosis. side effects around disordered eating, sometimes further

www.jpedhc.org March/April 2021 149

compounding medical management (Riddle et al., 2018). For Behavioral responses
example, stimulants for ADHD can cause appetite loss, The impact of trauma on pediatric development is a little
whereas antipsychotics have been known to cause loss of more well-known, differing based on the developmental
satiety. Therefore, symptoms that accompany chronic stage of the patient (Perry, 2009; Perry, Pollard, Blakley,
trauma and ACEs add complexity around prescribing for Baker, & Vigilante, 1995). In infants, toddlers, and pre-
pediatric behavioral health disorders. Patients with ACEs are schoolers, trauma may present as difficulty acquiring mile-
also at an increased risk of diabetes and metabolic syn- stones, varying tantrums from mild to severe, and
drome. Medications used to treat accompanying mood or aggression with other children (Perry, 2002). Similarly, in
anxiety disorders can put them at additional risk factors for school-aged children, presenting features include difficulty
these outcomes (Riddle et al., 2018). The provider should with skill acquisition, loss of ability to remember details,
recognize these intricacies around disordered eating related fighting, and reports of classroom disruptions (Cook et al.,
to trauma and account for them when considering treatment 2005; Lawson & Quinn, 2013). Adolescents may additionally
options. present with a range of school-aged behavioral concerns as
well as difficulty in academic school work and organizational
Sleep difficulties skills. For example, they have difficulty with keeping home-,
Individuals who have encountered both acute and complex school-, and work-life straight. Trauma also manifests in
trauma report difficulty falling asleep and staying asleep as teens by risk-taking and law enforcement involvement
well as having nightmares and other sleep disturbances such (Cook et al., 2005). These behaviors are sometimes misdiag-
as insomnia and parasomnias (sleep terrors, nightmares, and nosed or misunderstood in the clinical setting. Recognize
rapid eye movement sleep behavioral disorder; AAP, 2014). symptomatology such as aggression, exaggerated responses,
Sleep disturbances in patients who present with trauma are hypervigilance and anxiety, detachment, and numbing as a
thought to be from an overstimulation of the reticular acti- possible response to trauma versus depression, ADHD,
vating system in the brain (AAP, 2014). Depression, anxiety, conduct disorder, bipolar disorder, and anger management
and impulsive behavior, all of which have been correlated difficulties misunderstood cause (AAP, 2014;
with ACEs, are also associated with shorter sleep cycles SAMHSA, 2018). Trauma impedes areas of brain develop-
(Carrion, Weems, Ray, & Reiss, 2002; Kovacky et al., 2013). ment that are responsible for executive functioning of inhibi-
Adverse associations between poor sleep with health include tory control, working memory, and cognitive flexibility
behavioral issues such as reduced emotional regulation, (AAP, 2014).
brain growth, quality of life, and cognitive ability; physical
health impairments of insulin sensitivity; increases in body Respond
weight; and hypertension (AAP, 2014; Kovacky et al., 2013). Responding involves knowing the health care and educational
Sleep loss results in slower reaction times (psychomotor vig- systems to refer and coordinate in regard to trauma-based
ilance), memory consolidation, attention difficulties, and care, including referral systems for the family’s needs
decreased creativity and academic performances—all vital (SAMHSA, 2014). Responding also incorporates trauma-
for the developing child and adolescent (AAP, 2014). informed care into pediatric health care provider practices,
Healthy sleep is also vital for reducing clinical symptoms of protocols, procedures, and policies. Practices and protocols
mental illness and the ability to participate in cognitive in the primary care setting should include screening, antici-
behavioral therapy and other mental health behavioral thera- patory guidance, and setting up referral sources for the child
pies needed for patients in treatment for trauma. Asking and family. Policies include both organizational systems
about sleep habits, including anticipatory guidance sur- incorporating trauma-informed care into an agency-based
rounding sleep hygiene, is imperative for pediatric providers. practice and the broader state and national policy response
needed for the health care system to recognize and support
Elimination concerns youth and families who have experienced trauma.
Toileting and elimination issues in children who have experi-
enced ACEs or trauma are thought to be caused by the Assessment and screening
increase in sympathetic tone and increased catecholamines Pediatric providers must explicitly assess for trauma expo-
from long-term stress response (AAP, 2014). Presentation sure. The AAP (2014) recommends universal assessment to
can include constipation, encopresis, enuresis, or accidents decrease stigma. This recommendation provides assurance
in a child who has already been toilet trained that every child and every family is screened at every visit
(American Psychiatric Association, 2013). Emphasis is and not singling out a specific individual or group. Annual
placed on assessment for elimination patterns in wellness risk assessments for depression, anxiety, and substance use
examinations with younger children (AAP, 2019). When chil- are incorporated into the annual well-child examination as
dren present specifically with elimination issues, after ruling defining quality metrics and standards as recommended by
out organic causes, consideration for trauma should be the AAP and Bright Futures (AAP, 2019; Bright Futures/
made and include asking if there has been a recent change in AAP, 2020). Although pediatric clinicians are more familiar
the home environment or a known stressful event in the with screening tools for depression and anxiety, screening
child’s life. specifically for ACEs has only recently emerged as equally

150 Volume 35  Number 2 Journal of Pediatric Health CareÒ

important in clinical practice (Bryant & VanGraafei- essential to thrive in these complex environments related to
land, 2020). However, research on universal screening with ACEs (NAPNAP et al., 2019; Hornor, 2017). Seminal
available ACE tools is still newer, with limited validity and research works related to strengthening resilience have con-
reliability studies to date. tinued to be substantiated in scientific research
The original ACE Questionnaire now has more than two (NAPNAP et al., 2019). The emphasis of consistency around
decades of research on childhood trauma as a primary cause caregiving, including attention and developmentally appropri-
of adult mental illness, addiction, and medical diseases ate expectations, should be conveyed. The importance of
(Zarse et al., 2019) and has been newly initiated as a clinical nonphysical discipline is critical. Education regarding ACEs
screener in a variety of settings (ACEs Aware, 2020). This and the short- and long-term impacts on pediatric develop-
one-page screener, available in 17 languages and free to pro- ment can also help caregivers understand the need to adapt
viders, reviews the original ACEs (10 items) plus an addi- resilience-based strategies into the environment. Finally, par-
tional 7−9 items where the parent or caregiver indicates the ent support groups can provide additional support, connec-
number of ACEs. The parent-completed 17-item child ver- tion, and self-efficacy for families experiencing ACEs.
sion (ages 0−12 years) and the 19-item teen self-report ver- Improving childhood resiliency factors through various posi-
sion (ages 13−19 years) are scored in the same way. Scores tive childhood experiences has shown to decrease the nega-
between 0 and 3 indicate primary care provider anticipatory tive effects of stress and trauma on the brain, including the
guidance, whereas a score of 1−3 with symptoms or a score neuroplasticity of earlier neurological insults
of 4 or above requires referral to treatment (Anda et al., (NAPNAP et al., 2019; van der Kolk, 2014). Table 2
2010; Zarse et al., 2019).
Dr. Nadine Burke Harris of The Deepest Well (Har-
ris, 2018) was recently appointed California’s first-ever Sur- TABLE 2. Recommendations to promote
geon General (2020) based on her mission to recognize resiliency
ACEs as a critical factor in pediatric and adult health out- Factor Anticipatory guidance
comes. In March 2020, Harris announced the ACEs Aware
Caregiving Importance of a caring family
initiative and development of the Bay Area Research Con- Sensitive caregiving (clear, consistent,
sortium on Toxic Stress and Health (BARC), created in part- compassionate)
nership between the University of California, San Francisco Assess parental stressors
and the University of California, San Francisco Children’s Provide support/referrals
Hospital with the Center for Youth Wellness. The ACEs Provide practical knowledge on pediatric
development
Aware initiative aims to provide system reform across the Advise on parenting skills related to the
California health care system, recognizing and responding to developmental stage
ACEs in the community, and provides resources for incor- Recommend a parent support group
porating ACE screening into patient care. The Pediatric Connection Importance of close relationships and
ACEs Screening and Related Life-events Screener and the emotional security
Instill a sense of belonging
ACE Questionnaire for Adults were developed through the Provide resources for community
Bay Area Research Consortium on Toxic Stress and Health, connections
with translation in 17 languages and freely available to pro- Recommend a parent support group
viders (ACEs Aware, 2020). Environment Importance of adaptation to new situations
Regardless of the organizational protocol implemented, Provide routines and rituals
Recommend school engagement activities
trauma screening should evaluate for (1) exposure to poten- Consider referral to ARC or CBITS
tially traumatic events and loss, and (2) traumatic stress Skill-building Importance of self-regulation and emo-
symptoms. Saxe (2001) provides a screening checklist for tional regulation
children at risk for trauma, measuring symptoms of acute Provide resources for skilled parenting
stress disorder and PTSD once trauma has been identified. training
Consider referral to MDFT
This checklist is free to providers, and recommendations Refer to other trauma-based therapy
include screening at initial and annual visits as well as for modalities (see Table 3)
any presenting symptoms (Hornor, 2015; Saxe, 2001). Intrinsic self- Importance of hope, faith, and optimism
work Build self-efficacy and identity
Anticipatory guidance Build self-confidence
Importance of meaning-making of events
Families who are experiencing ACEs should receive anticipa-
tory guidance around both the patient presentation (i.e., dis-
Note. ARC, attachment, self-regulation, and competency;
ordered eating) and promotion of resiliency protective CBITS, cognitive behavioral intervention for trauma in schools;
factors (Hornor, 2015; Hornor, 2017). Resilience is a multidi- MDFT, multidimensional family therapy.
mensional concept which, in simplest terms, is defined as Garner et al. (2012); Hornor (2015, 2017); Harris (2018);
positive adaptation and competence while facing adversity Johnson et al. (2013); NAPNAP et al. (2019); Masten (2001);
(Masten, 2001; Masten, 2018; Shonkoff et al., 2012). Facilitat- Masten (2018).
ing strategies related to building resiliency is, therefore,

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summarizes these recommendations. Furthermore, anticipa- (The National Child Traumatic Stress Network, 2008). A
tory guidance should be aimed around the presenting symp- variety of trauma-based therapy modalities are available.
toms or behaviors. Most of these modalities require specific training, experi-
ence, and even additional certifications. Clinical therapists
Disordered eating. Caregivers of youth with symptoms of trained and credentialed in trauma-informed therapy
disordered eating should be reminded of the importance of modalities include psychologists, social workers, marriage
a consistent eating schedule, with calm, pleasant, sit-down and family therapists, and licensed professional counse-
family meals as helpful in creating a routine and also protec- lors, to name a few. Examples of trauma-based include
tive resiliency building (Hornor, 2015). Multivitamins and trauma-focused cognitive behavioral therapy, multidimen-
supplementation may be needed, especially if underweight. sional family therapy, cognitive behavioral intervention
The importance of not reprimanding for refusing food and for trauma in schools, or eye movement desensitization
not force-feeding should be emphasized (Bright Futures/ and reprocessing. Most, if not all, of these therapies can
AAP, 2020). be delivered as home-based evidence-based treatments to
circumnavigate access-to-care limitations. In-home ther-
Sleep difficulties. Review sleep hygiene recommendations apy options are often used for managing high acuity and
(consistent bedtime, bedtime routine of bath, reading, cud- risk in the home environment. See Table 3 for brief
dling, no screen time before bed, use of night-light, etc.), rec- descriptions of trauma-based therapy modalities.
ognizing that children may need additional reassurance at It is important to note that if physical, emotional, or
bedtime (Bright Futures/AAP, 2020). Transitional items mental abuse is detected during screening, child protective
such as a special blanket, pillow, or a stuffed animal can be services must be made by the law of all health care pro-
recommended. viders. Trauma-informed care includes recognizing the need
to protect those who are experiencing abuse. The provider
Elimination concerns. If trauma symptoms involve toilet- should respond by and focus on child safety and parent sup-
ing or elimination issues, try to eliminate negative associa- port. If the trauma includes parental substance abuse or
tions with toileting and instead offer a reward system. domestic violence, linking the family to specific treatment
Consider increasing fiber if functional abdominal pain is services should be included.
present and treat any accompanying constipation. Coping
skills that can help with toileting include positive self-talk, Resist Re-Traumatization
deep-breathing, and relaxation techniques. Resisting re-traumatization refers to rethinking the clinical
approach to patient care and the organizational support of
Behavioral concerns. Providers should let parents know employees who provide that care. The clinical setting, pro-
that the child may be over-reactive or present with aggres- vider, or office visit may trigger a previous trauma for some
sion and that this should be met with reassurance. They patients. Resisting re-traumatization involves patience and
must remind caregivers not to meet these behaviors with an flexibility in the clinical approach. For example, consider
emotional response and instead reassure safety, praise any having an adolescent who refuses to undress or de-robe par-
desired behavior, and spend additional time with the child ticipate in the physical examination in phases to avoid fully
or adolescent (Masten, 2018). undressing. Reflect more carefully with patients who become
nervous or jump when approach or touch them during the
Treatment referrals examination. Instead, approach all patients explaining the
Trauma-informed care includes responding to treatment next move, such as “I am going to listen to your lungs now”
and community referral resources. Community connect- instead of just touching them on the back with the stetho-
edness, such as after-school programs and activities, spir- scope.
itual connections, and parent support groups, can help A culture of trauma-informed care calls for organiza-
build resiliency and reduce the long-term impacts of tional culture change. Organizations can sometimes create
trauma (Masten, 2018). Mentoring programs (e.g., Big stressful work environments in regard to the clinicians pro-
Brothers Big Sisters) can offer both connectedness and viding trauma-informed care (SAMHSA, 2018). Trauma-
mentorship (Hornor, 2015). Children with academic informed care requires a trauma-informed environment as
struggles may need an individualized education program different organizational practices may trigger painful memo-
or school referral. Coordination with the school-based ries for providers, ultimately causing vicarious traumatiza-
health center should be considered, if available in the tion and countertransference. The emphasis for all health
child’s district, to help access care in the child’s primary care clinicians to understand, respect, and respond to the
environment and provide a source of behavioral therapy effect of trauma at all levels requires organizational proce-
if needed. The AAP trauma toolkit provides a template dures and policies that include supporting clinical providers
to help organize and make referrals in the child’s region, (Bloom, 2010). Introductory and ongoing trainings related
at http://www.aap.org/traumaguide. to ACEs and trauma-informed care should be provided to
Children and families will need behavioral health ther- all health care staff members as part of ongoing professional
apy to help manage and process the trauma performance evaluation. To note, Risking Connections,

152 Volume 35  Number 2 Journal of Pediatric Health CareÒ

 TABLE 3. Trauma-based therapy modalities
Therapy Brief description
ABC For ages 0−2 years, aimed at parents and children based on attachment theory
ARC Involves parent workshops and milieu system interventions that target the child’s surrounding system (such as
the family and community)
Child first For prenatal to age 6 years, a national evidence-based model involving an intensive, home-based environment,
often used for children in high-stress environments who have symptoms of trauma and distress
CBITs School-based program delivered in the school setting aimed at relieving symptoms of PTSD, depression, and
anxiety through skill-based child group intervention
DBT Skills-based treatment addressing emotional problems with unsafe behaviors focuses on mindfulness and
emotion regulation skill-building
EMDR Uses bilateral stimuli to restore distressing memories that have resulted in reductions of memory-related dis-
tress and problem behaviors, aimed at decreasing posttraumatic stress symptoms
ITCT-C or ITCT-A Includes multiple modalities aimed at the individual and family with additional adaptations to families that are
economically disadvantaged and culturally diverse
MDFT Includes different therapy modalities such as PCIT, which aligns an appropriate parent response to child
behaviors; and CPP teaches parents to provide emotional safety for the child
TARGET When used concurrently with evidence-based youth and family therapy, this modality provides skill-building on
symptom management and emotion regulation: focusing on the impact of trauma on the body and brain
resulting in emotions and behaviors
TF-CBT Involves the parent/caregiver and child with a focus on skills-based components in a trauma framework model
(includes psychoeducation, parenting skills, relaxation skills, affective modulation, cognitive coping, trauma
narratives, processing in vivo mastery of trauma reminders, safety planning)
TST Aimed for youth with difficulty regulating emotions from a wide range of traumatic experiences

Note. ABC, attachment and bio-behavioral catch-up; ARC, attachment, self-regulation, and competency; CBITs, cognitive behavioral inter-
vention for trauma in schools; PTSD, posttraumatic stress disorder; DBT, dialectical behavioral therapy; EMDR, eye movement desensitiza-
tion and reprocessing; ITCT-C, integrative treatment of complex trauma for children; ITCT-A, integrative treatment of complex trauma for
adolescents; MDFT, multidimensional family therapy; PCIT, parent−child interaction therapy; CPP, child−parent psychotherapy; TARGET,
trauma affect regulation guide for education and treatment; TF-CBT, trauma-focused cognitive behavioral therapy; TST, trauma systems
therapy.
AAP (2014); Hodas (2006); The National Child Traumatic Stress Network (2008); The National Child Traumatic Stress Network (2011);
SAMHSA (2018).

developed by renowned psychologist Perry (2002, 2009), is a often identified in primary care and then referred out for
service provision specifically aimed at addressing all staff management, with clear delineations between medical or
across all disciplines in the workplace, creating language physical health and behavioral health. Pediatric health clini-
among staff in speaking with clients about trauma. This cians must continue to bridge that gap, with health care
framework includes providing acknowledgment of vicarious emphasis now placed on the integration of medical and
traumatization and countertransference as inevitable out- mental health disciplines.
comes for employees who work with clients who have expe- Identified challenges for pediatric providers include
rienced trauma (Perry, 2009). Organizational response to clinical appointment time allotment to adequately address
trauma should include an emphasis on self-reflection and this critically important area of pediatric and adolescent
self-care with employees in initial training and reimmersion care (Bryant & VanGraafeiland, 2020; Kennedy et al.,
experiences annually. 2011). Furthermore, the availability of adequate behav-
ioral health referral sources for those most affected by
IMPLICATIONS FOR PRACTICE ACEs remains a challenge, especially for rural and
The original ACEs study (Felitti et al., 1998), Felitti and socially marginalized youth (Daniel et al., 2018;
Anda’s subsequent body of research exploring ACEs (2009, Kennedy et al., 2011). Needed expansion of the mental
2010), and Dr. Nadine Burke Harris’s call for action of health profession and workforce is required to continu-
ACEs in pediatrics have become critical factors for the cur- ally support the care and coordination needed to address
rent paradigm shift between medical and mental health over ACEs in our communities.
the last decade in health care delivery services. It is clear that Trauma-informed care is the stepping-stone required
behavioral and mental health pathology results in physical to build a framework for ACEs, especially as it relates to
health outcomes across the lifetime, with both correlational public health implications nationwide (Anda et al., 2010).
and causal inference research supporting these connections The paradigm shift of blending mental health care and
(Anda et al., 2010; Hughes et al., 2017; Johnson et al., 2013). approach as part of medical and physical health training
Historically, mental and behavioral health difficulties were requires foundational work in nursing schools, physician

www.jpedhc.org March/April 2021 153

assistant studies, and medical schools to include the implications of adverse childhood experiences. American Jour-
introduction of ACEs, chronic and toxic stress, and nal of Preventive Medicine, 39(1), 93–98.
trauma-informed care as core concepts as an educational Anda, R. F., Felitti, V. J., Bremner, J. D., Walker, J. D., Whitfield, C.,
Perry, B. D., . . . Giles, W. H. (2006). The enduring effects of
pedagogy. Allied health professions to include physical, abuse and related adverse experiences in childhood. A conver-
occupational, and speech therapy students as well as gence of evidence from neurobiology and epidemiology. Euro-
medical and nursing assistants should be exposed to pean Archives of Psychiatry and Clinical Neuroscience, 256(3),
these concepts as core essentials in patient-centered care 174–186.
Binder, E. B. (2009). The role of FKBP5, a co-chaperone of the glu-
as well, to create a trauma-informed health care network
cocorticoid receptor in the pathogenesis and therapy of affec-
for those receiving care. tive and anxiety disorders. Psychoneuroendocrinology, 34
Recognizing that trauma is complex, there are many types (Suppl. 1), S186–S195.
of traumatic experiences that affect children and adolescents Bloom, S. L. (2010). Organizational stress as a barrier to traumain-
and have long-term effects into adulthood. Providers should formed service delivery. In M. Becker, B. Levin (Eds.), A public
become comfortable with screening and asking questions health perspective of women\220s mental health (pp. 295311).
New York, NY: Springer.
related to trauma in a supportive, nonjudgmental manner. Briere, J., Elliott, D. M., Harris, K., & Cotman, A. (1995). Trauma
Recognizing trauma includes understanding that ACEs are not Symptom Inventory: Psychometrics and association with child-
just limited to physical and sexual abuse. Responding to hood and adult victimization in clinical samples. Journal of Inter-
trauma requires familiarization with care coordination needed personal Violence, 10(4), 387–401.
in the provider’s immediate community and resources available Bright Futures/American Academy of Pediatrics. (2020). Recommenda-
tions for preventive pediatric health care. Retrieved from https://
for families. The educational system must be included as part www.aap.org/en-us/professional-resources/practice-transforma
of this response. Finally, resisting re-traumatization requires tion/managing-patients/Pages/Periodicity-Schedule.aspx
self- and organizational-reflection on the clinical approach to Bruskas, D. (2008). Children in foster care: A vulnerable population
patient care and those providing patient care. at risk. Journal of Child and Adolescent Psychiatric Nursing, 21
(2), 70–77.
Scholars and mental health organizations continue to warn
Bryant, C., & VanGraafeiland, B. (2020). Screening for adverse child-
of the mental and emotional trauma in our youth from recent hood experiences in primary care: A quality improvement proj-
events such as the immigrant and refugee family separations ect. Journal of Pediatric Health Care, 34(2), 122–127.
at U.S. borders, the coronavirus disease 2019 pandemic, and Bucci, M., Marques, S. S., Oh, D., & Harris, N. B. (2016). Toxic
the death of George Floyd and resulting racial tensions nation- stress in children and adolescents. Advances in Pediatrics, 63
wide. The American Psychological Association has called for (1), 403–428.
Burke, N. J., Hellman, J. L., Scott, B. G., Weems, C. F., &
advocacy for services specifically related to the emotional well- Carrion, V. G. (2011). The impact of adverse childhood experi-
being and consequential mental health problems following ences on an urban pediatric population. Child Abuse and
coronavirus disease 2019 as the upcoming second pandemic Neglect, 35(6), 408–413.
(Owings-Fonner, 2020). Recognizing that by definition, these Carrion, V. G., Weems, C. F., Ray, R., & Reiss, A. L. (2002). Toward
an empirical definition of pediatric PTSD: The phenomenology
recent events fit the criteria for ACEs and may result in long-
of PTSD symptoms in youth. Journal of the American Academy
term physical health sequela as well. Clinicians should be pre- of Child and Adolescent Psychiatry, 41(2), 166–173.
pared in the upcoming months and years to incorporate Chapman, D. P., Whitfield, C. L., Felitti, V. J., Dube, S. R.,
trauma-informed care into practice, as future presentations of Edwards, V. J., & Anda, R. F. (2004). Adverse childhood expe-
trauma following these events are expected. riences and the risk of depressive disorders in adulthood. Jour-
nal of Affective Disorders, 82(2), 217–225.
Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M.,
Cloitre, M., . . . van der Kolk, B. (2005). Complex trauma in chil-
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