Version July 2025
INTRODUCTION —
Adverse childhood experiences (ACEs) are intrafamilial and interpersonal traumas that are often experienced in childhood, including abuse, neglect, parental/caregiver mental health problems, and household dysfunction. They have been linked to poor outcomes throughout life, including high-risk health behaviors, chronic physical and mental health problems, decreased productivity, and early death [1].
The effects of ACEs are thought to be mediated by the toxic stress response due to the absence of protective factors such as a positive social environment and parent/caregiver support. Pediatric clinicians are uniquely positioned to mitigate the impact of ACEs and childhood toxic stress by providing trauma-informed care.
This topic will discuss ACEs, their impact on biological and developmental processes, and the components of trauma-informed care. Related topics are discussed in more detail elsewhere.
●(See "Comprehensive health care for children in foster care".)
●(See "Developmental and behavioral implications for children of incarcerated parents".)
●(See "Developmental and behavioral implications for military children with deployed caregivers".)
●(See "Peer violence and violence prevention".)
●(See "Posttraumatic stress disorder in children and adolescents: Trauma-focused psychotherapy".)
DEFINITIONS AND IMPACT
Adverse childhood experiences (ACEs) — ACEs are intrafamilial and interpersonal traumas that are often experienced in childhood and have been linked to poor outcomes throughout life [1]. They are not limited to specific events but include "any potentially traumatic" event that occurs during childhood [1]. The term is derived from a two-part retrospective study based on questionnaires completed by over 17,000 adults who received care within a large health maintenance organization in the United States [2].
Examples of ACEs include [2-4]:
●Psychological, physical, or sexual abuse
●Physical or emotional neglect
●Witnessing or experiencing violence (eg, peer and community violence, violence against mother)
●Losing a parent/caregiver to separation or divorce
●Living with household members who had a mental health problem, were suicidal, abused substances, or had been imprisoned
●Experiencing racism
●Living in foster care
ACEs are common and can be interrelated. Over 60 percent of adults in the United States have at least one, and one in six adults have four or more, ACEs [1]. There is a dose-response relationship between the number of ACEs and poor outcomes in adolescence and adulthood [1,2,4]. For example, in the initial study, individuals with exposure to one ACE were more likely to have exposure to others, and those with exposure to multiple ACEs in childhood were more likely to engage in high-risk behaviors (eg, alcohol and drug abuse) and to have multiple health risks (eg, ischemic heart disease, cancer, chronic lung disease, autoimmune disease, obesity, liver disease, depression) later in life [2]. However, a history of ACEs does not independently predict poor outcomes. (See 'Risk and protective factors' below.)
Although the population sampled in the original study was not representative of the United States population (ie, nearly three-quarters of respondents were white, almost half were over the age of 60, and over half had at least some college education) [2], subsequent studies in more diverse populations have also found a consistent and strong correlation between ACEs and later life outcomes [3-7]. In the 2023 United States Youth Risk Behavior Survey including over 20,000 high school students, approximately 76 percent of youth had one or more ACEs, and 19 percent had four or more ACEs [4]. Youths with four or more ACEs had a significantly higher risk for adverse health outcomes and high-risk behaviors (eg, obesity, suicide attempt, prescription opioid misuse) [4].
Subsequent evidence has also led to a further understanding of causality, including the interplay of childhood trauma with the physiological response and behavioral adaptations to stress (ie, the neuroendocrine stress response) and how this impacts health and well-being in childhood and throughout life [8-10]. (See 'Toxic stress response' below and 'Physiological effects of toxic stress' below.)
Social determinants of health (SDOH) — SDOH (also known as social drivers of health) are the external forces and systems that shape the individual experience and conditions of daily life [11,12]. These forces include broad socioeconomic, political, and cultural policies that interact with individual characteristics (eg, race, gender) and environmental conditions that impact access to safe, stable, nurturing relationships and environments [13-17]. Adverse SDOH are the root causes of inequities that contribute to the disparate distribution of ACEs across populations [16,18-21].
Examples of adverse SDOH include [12,22]:
●Poverty
●Lack of access to health care
●Food insecurity
●Housing instability
●Poor neighborhood conditions
●Limited educational and employment opportunities
●Racism
Although they are closely related, SDOH are not synonymous with ACEs. SDOH occur at the societal or community level, whereas ACEs result from interpersonal relationships or interactions within a child’s home, school, or community [17,23]. As an example, food insecurity in the community that results from poor access to affordable food and food assistance programs is an SDOH; the disrupted sense of safety that a child experiences because of hunger and concern over a lack of food is an ACE. Similarly, structural and systemic forces that perpetuate discrimination based on race (eg, racist hiring practices or housing access) are SDOH that can result in an individual experiencing violence, rejection, or exclusion, which are ACEs.
SDOH may be more benign if the family is otherwise well-functioning but more injurious if they occur in the context of ACEs or lead to significant household dysfunction. Identifying and addressing SDOH may improve child health. For example, referral to programs that make food affordable and accessible (eg, school lunch or Supplemental Nutritional Assistance Program [SNAP]) can mitigate food insecurity.
Toxic stress response — The toxic stress response is the frequent or prolonged activation of the neuroendocrine stress response that occurs when ACEs are not buffered by protective relationships [24]. Growing evidence has described the biological impact of ACEs through dysregulation of this response, which modifies gene expression (epigenetics) and leads to alterations in brain structure and function, immune suppression, and increased inflammation [25-28].
All children experience episodes of stress, which are usually brief, mild to moderate in severity, and occur in the context of caregiving relationships. When a child experiencing stress receives support from others and encounters positive social interactions, the neuroendocrine stress response subsides [29,30]. However, if support is not available or if individuals within the child's environment are hostile, there is a heightened perception of stress, resulting in the toxic stress response [30-33].
When the toxic stress response occurs in the first years of life, it has the potential to cause lifelong impairments in physical and mental health because of its impact on the developing brain and neuroendocrine system [34]. While responses to a chaotic, violent, or otherwise unsafe environment may be adaptive in the short term, they result in long-term behavioral, developmental, and health consequences. Protective factors that build resilience can mitigate this response. (See 'Physiological effects of toxic stress' below and 'Developmental and behavioral effects of toxic stress' below and 'Resilience as protective factor' below.)
RISK AND PROTECTIVE FACTORS
Risk factors for adverse childhood experiences (ACEs) — Some children and families are at particular risk of exposure to ACEs. These include those who are affected by:
●Family disruption – Children who experience family disruption are at high risk for ACEs (eg, involvement in foster care, maltreatment, exposure to parent/caregiver intimate partner violence) [20]. Children who remain at home after child protective investigation, enter foster care, or live with relatives (eg, kinship care) have a high risk of early relational trauma (ie, those that occur within the parent-child or caregiving relationship). In the United States, over 555,000 (8 of every 1000) children were identified by child welfare as victims of child abuse and neglect [35,36] and over 368,000 children were living in foster care [37].
Maltreatment (eg, abuse or neglect), exposure to intimate partner violence, and parental dysfunction are most impactful to children because they adversely impact the parent-child relationship. This is the most fundamental relationship children have and is intended to protect them and nurture healthy development. In turn, these experiences are often due to parents/caregivers struggling with their own ACEs and their resultant effects (eg, history of trauma, mental health or substance use problems) [38-40]. In a meta-analysis of 4872 caregiver-child dyads, a higher number of caregiver ACEs were associated with a higher number of child ACEs [41]. Thus, parental/caregiver ACEs also impact childhood health and development. (See "Child neglect: Evaluation and management", section on 'Epidemiology' and "Physical child abuse: Recognition", section on 'Risk factors' and "Comprehensive health care for children in foster care", section on 'Complex childhood trauma and toxic stress' and "Intimate partner violence: Childhood exposure".)
●Poverty – Poverty and related social determinants of health (SDOH) are risk factors for ACEs [22,42,43]. Globally, approximately one billion children are affected by poverty with 16 percent (330 million) living in extreme poverty (ie, living on <$2.15 per day) [44]. In the United States, 16.3 percent of children are affected by poverty nationally, with up to 26.4 percent of children affected in some states [45].
●Discrimination – Children from underrepresented racial, ethnic, or religious groups and immigrant or refugee populations are more likely to experience bullying and violence due to racism [1,46-48]. (See "Use of race and ethnicity in medicine", section on 'Social and cultural drivers of health' and "Use of race and ethnicity in medicine", section on 'Effects of racism'.)
Similarly, youth who are lesbian, gay, bisexual, transgender, queer, and questioning are more likely than peers to be exposed to discrimination both at home and in the community [4]. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Potential psychosocial and health concerns'.)
●Military deployment – Children of military families experience a higher prevalence of abuse, loss, and grief, particularly during times of deployment and international conflicts [49-51]. (See "Developmental and behavioral implications for military children with deployed caregivers".)
●Other factors – Events such as natural disasters, pandemics, and war can be experienced as ACEs directly, or as SDOH that create conditions leading to ACEs (eg, loss of family, poverty, witnessing or experiencing violence) [52-54].
Resilience as protective factor — Resilience is defined as a dynamic process of positive adaptation to or despite significant adversities [55]. It is not an innate nor a rare trait but involves skills that can be taught, supported, and reinforced over time in the context of positive relationships and through growth by exposure to a variety of resources and activities (eg, play, exploration). Important factors for the development of resilience include:
●Attachment to a committed caregiver
●Mastery of age-appropriate developmental tasks
●Consistent thinking and learning
●Self-regulation
●Self-efficacy
●Belief that life has meaning or a sense of hope for the future
The presence of ACEs does not mean that a child will experience poor outcomes; however, positive childhood experiences and environments are essential to preventing these outcomes [56-59]. Support from committed parents/caregivers can help a child develop resilience well before exposure to a traumatic event, shield children from adverse experiences, and protect children from negative consequences even after adversity has occurred.
Support can also come from other positive factors in a childꞌs life. These are collectively referred to as "Positive Childhood Experiences (PCEs)," which are defined as "interrelated experiences that engage the child, parent, and the parent-child relationship in order to achieve the designated child health outcomes" [60,61]. PCEs fall into three broad categories [55,60-63]:
●Safe, stable, and nurturing relationships with parents/caregivers, peers, and other members of their community.
●Environments for play, learning, and living that support safety, health, and opportunity for individual learning and development.
●Opportunities for engagement to develop interests, positive social interaction, and a sense of connectedness and belonging in families and communities.
Although there is heterogeneity in the literature with regard to the measurement of these factors, there is strong evidence to support the benefits of various PCEs [63,64]. Studies have shown that development can be robust even in the face of severe adversity if these protective factors are present [56,58,65-71]. However, if these factors are impaired, children experience poorer outcomes. (See 'Toxic stress response' above.)
PHYSIOLOGICAL EFFECTS OF TOXIC STRESS —
Adverse childhood experiences (ACEs) and social determinants of health (SDOH) can result in adverse physiological effects through dysregulation of the neuroendocrine stress response (see 'Toxic stress response' above). This results in epigenetic, hormonal, neurologic, and immunologic changes.
Epigenetic changes — Epigenetic changes refer to changes in specific regions of the deoxyribonucleic acid (DNA) sequence that lie in front of or "above" ("epi-") functional genes. Stress due to trauma can impact whether methyl groups or histones bind to these "promotor regions," which can result in adjacent genes being turned on or off, and thus affect protein production.
Studies have found that epigenetic changes affect cortisol production and proteins involved in weight and mood regulation; however, this list is growing [72-74]. In addition, the telomere, which is the protective end of DNA, is subject to injury from stress hormones and oxidative stress. Telomere erosion leads to early cell death and vulnerability of the DNA to altered replication, which can contribute to diabetes, cancer, and other illnesses in adulthood [75-77]. Thus, trauma experienced in childhood can have a lifelong impact on the individual and can continue to impact future generations in a family through genetic alterations. The extent to which these epigenetic changes can be altered with medications or therapy is still being explored.
Hormonal changes — The toxic stress response leads to long-term changes in corticotropin, cortisol, adrenaline, and other hormones. Over-activation of the hormonal stress response impacts blood pressure (eg, by increasing plasma endothelin-1 and vascular tone), leading to an increased risk of cardiovascular disease [78,79]. Alterations in growth hormone, thyroid hormone, and other hormones lead to changes in growth, metabolism, and pubertal development. Early experiences with stress may accelerate pubertal development to allow for early reproduction in conditions, which might not support longevity [80-84].
Hormonal changes due to toxic stress also cause immune function changes. Excessive cortisol suppresses humoral immunity, resulting in increased susceptibility to infection [8,42]. (See 'Immunologic changes' below.)
Neurologic changes — There are certain brain structures that have been found to be most sensitive to toxic stress during childhood. The effects of toxic stress on these structures can result in symptoms that mimic those of other developmental and behavioral disorders (see 'Developmental and behavioral effects of toxic stress' below):
●Amygdala – When the lower brain perceives a threat, the amygdala is activated and sends signals to other parts of the brain and body to rapidly respond to that threat. The amygdala is thus highly susceptible to adversity, but the response appears to vary by age and exposure. Children with early exposure appear to have a hyperactive response to threats and may display rapid or aggressive reactions to minimal threats [28,85-91]. They may also be more impulsive and active; these symptoms mimic those of attention deficit hyperactivity disorder (ADHD) [92-102]. Alternatively, adversity experienced postpubertally may result in a blunted response, which has been associated with substance use disorder and other externalizing disorders.
●Hippocampus – The hippocampus is at the interface of the upper and lower brain and helps to access stored memories and learned information. With early adversity, neuronal development of the hippocampus can slow or even atrophy and impact information recall and retention. Thus, learning and memory are impaired, with negative consequences for child development and educational attainment [88,103-107].
●Prefrontal cortex – The prefrontal cortex is responsible for executive function, which consists of working memory, impulse control, and cognitive flexibility. Toxic stress results in slowed neuronal conduction in the prefrontal cortex [108]. With altered executive function, children are less able to concentrate, suppress impulses and aggression, and work through complex challenges. These signs can be misinterpreted as ADHD, oppositional defiant disorder, or disruptive mood dysregulation disorder [92,109-114].
Immunologic changes — The toxic stress response results in an immune response in which inflammatory markers are upregulated, allowing humans to prepare for injury as a possible consequence of an encounter with a predator. With prolonged stress, this inflammatory response persists, resulting in many of the long-term health consequences of early adversity. For example, in early childhood, effects may manifest as an increased risk for asthma, which can persist through adulthood [8,115,116]. Over time, these changes are associated with increased blood pressure in early adulthood and cardiovascular disease [108]. In addition, persistent activation of the immune response due to stress (eg, physical illness) may lead to physiological effects such as the "sick syndrome," which is a perception of feeling unwell and presents with headaches, abdominal pain, and lethargy [117-119].
DEVELOPMENTAL AND BEHAVIORAL EFFECTS OF TOXIC STRESS —
In children, toxic stress can result in a variety of developmental and behavioral symptoms. These symptoms occur in a spectrum and can present similarly to or be comorbid with other developmental, behavioral, and psychiatric conditions.
Spectrum of symptoms — Exposure to toxic stress can result in externalizing (eg, hypervigilance, sleep disruption, self-harm) or internalizing (eg, dissociation or "daydreaming") symptoms, depending on the child's primary response to the stressor. In general, if a fight or flight response is stimulated, a child will be more likely to display externalizing symptoms. If a freeze or dopaminergic response is stimulated, internalizing symptoms will be noted. These symptoms can be mild and result in short-term functional difficulties or manifest as more severe functional challenges such as posttraumatic stress disorder (PTSD) or developmental trauma disorder (DTD). Children exposed to adverse childhood experiences (ACEs) and social determinants of health (SDOH) are also at higher risk for depressive symptoms and suicidal ideation and completion than peers [120-124].
Functional difficulties are usually short-term disruptions in daily functioning (eg, sleep, eating, elimination, behavior) due to the overactivation of the body's responses. These disruptions of homeostasis can usually be overcome with reassurance, return to predictable routines, and the support of a parent/caregiver who is present and attuned to the child's needs. However, children with prolonged exposure to adversity can develop more severe functional challenges, which can present as adjustment disorder, prolonged grief reaction, or PTSD (eg, intrusive thoughts, nightmares or flashbacks, hyperarousal or irritability). (See "Posttraumatic stress disorder in children and adolescents: Epidemiology, clinical features, assessment, and diagnosis".)
Children with more prolonged or severe exposure to ACEs can also develop symptoms of "complex trauma," or DTD [125,126]. In addition to the functional and PTSD symptoms discussed above, children with DTD may also experience affect dysregulation (eg, violent reckless or self-destructive behaviors, dissociation, or attentional issues), a negative self-concept (eg, persistent beliefs of themselves as diminished, defeated, worthless, and with shame and guilt), and interpersonal disturbances (difficulty with relationships, including with attachment) [127,128].
Furthermore, children with DTD often demonstrate developmental delays, particularly speech and language delays, and act younger than their chronologic age. Exposure to toxic stress is most injurious to social-emotional, cognitive, and language development. In the context of toxic stress without secure attachment, survival skills and tasks may be prioritized over typical developmental skills [129]. Core deficits are noted in [129]:
●Intrapersonal competencies – One's sense of self and self-development.
●Interpersonal competencies – Capacity to form and engage in relationships with others.
●Regulatory competencies – Ability to identify and modulate emotional and physiological experience.
●Neurocognitive competencies – Capacity to learn, engage higher brain and executive functions, and act meaningfully in the world.
Constant exposure to perceived threats has also been reported to result in changes to auditory processing centers, as the brain adapts to listening for the lower pitched sounds associated with danger (eg, depression, voices yelling in anger) and loses the ability to hear the more musical and higher pitched sounds associated with safety (also referred to as "motherese") [130]. This can magnify both receptive and expressive speech and language delays. (See "Expressive language delay ("late talking") in young children" and "Speech and language impairment in children: Etiology", section on 'Neglect and abuse'.)
In a prospective cohort study of over 49,000 children, exposure to one or more ACEs (including parental separation or divorce, parental neglect, involvement in foster care, poverty, housing instability, and/or mental illness in parent or sibling) was associated with lower scores on neurocognitive testing [131].
Conditions that mimic or are comorbid with toxic stress — Toxic stress can be comorbid with or misdiagnosed as other conditions:
●Attention deficit hyperactivity disorder (ADHD) – Hypervigilance and sleep disruption which result from toxic stress can be difficult to distinguish from the inattention and hyperactivity seen in ADHD [128,132]. In addition, internalizing symptoms can be mistaken for symptoms of inattentive ADHD. When children cannot escape a constant or repeated threat, the body can respond with dissociation (ie, a mental separation from the experience), which makes them perceive that they are in a dream or outside of their bodies watching what is happening [98-102,133,134]. This can disrupt learning, and when observed outside of the context of the original trauma, can be mistaken for daydreaming or not paying attention. The clinical features and diagnosis of ADHD are discussed in more detail elsewhere. (See "Attention deficit hyperactivity disorder in children and adolescents: Clinical features and diagnosis".)
●Psychiatric conditions – The dysregulation and interpersonal difficulties that occur with DTD can mimic features of oppositional defiant disorder, conduct disorder, and even bipolar disorder. The negative self-image resulting from PTSD or DTD and the child's attempts to manage this can present as depression, substance use disorder, self-harm, or suicidality. In addition, internalizing symptoms such as dissociation can disrupt social situations and can be misidentified as depression or anxiety [135-138]. The clinical features and evaluation of these conditions are discussed in more detail elsewhere. (See "Overview of prevention and treatment for pediatric depression" and "Anxiety disorders in children and adolescents: Assessment and diagnosis" and "Pediatric bipolar disorder: Assessment and diagnosis" and "Conduct disorder: Epidemiology, clinical manifestations, course, and diagnosis" and "Oppositional defiant disorder: Epidemiology, clinical manifestations, course, and diagnosis".)
●Other conditions – Toxic stress can also be comorbid with or misdiagnosed as other developmental and behavioral conditions, including fetal alcohol spectrum disorder (FASD) and autism spectrum disorder (ASD) [139-143]. The clinical features and pathogenesis of FASD and ASD are discussed in more detail elsewhere. (See "Fetal alcohol spectrum disorder: Clinical features and diagnosis" and "Autism spectrum disorder in children and adolescents: Clinical features" and "Autism spectrum disorder (ASD) in children and adolescents: Terminology, epidemiology, and pathogenesis".)
TRAUMA-INFORMED PEDIATRIC PRIMARY CARE
Importance and barriers — Trauma-informed care recognizes the widespread impact of adverse childhood experiences (ACEs) and social determinants of health (SDOH) and emphasizes the importance of identifying childhood trauma and toxic stress by creating an environment that is both sensitive and responsive to a childꞌs needs. It provides a compassionate, collaborative, and comprehensive evidence-based approach for clinicians to incorporate identification and management of trauma exposure and toxic stress symptoms into their routine clinical practice [144]. ACEs and SDOH are common and can lead to negative physiological, developmental, and behavioral outcomes (see 'Definitions and impact' above). Implementation of trauma-informed care improves support and treatment for children and families [144].
Primary care clinicians engage with children and families frequently throughout infancy and early childhood, which enables them to build effective relationships with children and parents/caregivers [144]. This provides multiple opportunities to identify and intervene for problems that result from trauma, support the development of protective factors (eg, parent- or caregiver-child attachment, self-regulation), and offer resources to prevent or reduce the impact of childhood trauma [144]. Infancy and early childhood are critical periods of development wherein the impact of adversity may be most damaging, making this an ideal time to focus efforts on prevention and intervention.
Although the negative effects of trauma are known, significant barriers (eg, lack of time, unfamiliarity with appropriate screening tools and evidence-based treatments, inadequate availability of community resources) limit many clinicians in their efforts to prevent or mitigate the effects of childhood trauma [144]. Research is ongoing and will continue to refine understanding of the impact of ACEs and the tools that are necessary to prevent, identify, and address childhood toxic stress most effectively.
Examples of resources available to help clinicians incorporate trauma-informed care into their practice are provided below. (See 'Resources' below.)
Goals — Implementation of trauma-informed care in clinical practice starts with a focus on health promotion and prevention of harm [9,144]. The American Academy of Pediatrics (AAP) recommends that pediatric clinicians:
●Understand the physiological, developmental, and behavioral impact of ACEs and the importance of holistic care for children [9].
●Routinely assess for exposure to trauma during pediatric healthcare encounters [144,145].
●Take a leading role in educating communities and stakeholders invested in the well-being of children about trauma and its far-reaching effects [9]. This includes providing education to other clinicians and healthcare staff [144].
●Increase their advocacy efforts in the development and implementation of evidence-based interventions that either reduce stress exposure or mitigate its negative effects [9,145,146].
Routine assessment for all children — Identification of childhood trauma and toxic stress symptoms through routine history taking and screening is an important component of trauma-informed care. Childhood trauma and toxic stress should always be considered as a potential cause of developmental, mental health, behavioral, and physical symptoms in children. (See 'Physiological effects of toxic stress' above and 'Developmental and behavioral effects of toxic stress' above.)
History taking — History taking is the process of asking open-ended questions during the clinical encounter to monitor patients for exposure to trauma and identify those who may be at risk for or who are experiencing symptoms of toxic stress (see 'Definitions and impact' above and 'Risk and protective factors' above). During this process, it is important to destigmatize adversities and validate the patient and family while avoiding retraumatization.
History taking includes the following:
●Provide a supportive environment – Clinicians should create an emotionally safe space where discussions with children and families surrounding issues related to trauma exposure and toxic stress are a routine part of the health care encounter [144]. Engaging with families involves respect between the clinician and the parent/caregiver, who is the expert on their child and their family [144].
In particular, it is important to communicate openness, curiosity, and empathy in a non-judgmental way while obtaining medical, social, and trauma-related histories. Asking questions that focus on "What happened to you?" and "What is strong with you?" instead of "What is wrong with you?" can help to promote the childꞌs and familyꞌs strengths.
Some questions which can be useful to initiate the conversation include [146,147]:
•"Has anything scary or concerning happened to you or your child since the last visit?" [146]
•"Has anyone come or gone from the household lately?"
•"How were you parented? How do you want this child to be parented?"
Providing empathy and exploring child and family strengths (eg, support networks, skills, spiritual and cultural beliefs) provide a positive framework for the ensuing discussion [144]. Additionally, the clinician should ask about any concerns that the child or parent/caregiver has related to the trauma exposure; a positive response invites further discussion and an opportunity to provide support and refer to appropriate resources [146].
●Assess for protective factors – During the history-taking process, the clinician can observe and assess the parent- or caregiver-child relationship, including parenting attitudes and skills, how the child or family copes with stress, and whom the child turns to when they need comfort or safety [144]. In addition, the clinician can assess for factors that promote resilience, including whether the parent/caregiver is attentive and responds to their childꞌs needs in a developmentally appropriate way, and how comfortably the child responds to or interacts with their parent/caregiver [144]. This also provides an opportunity for the clinician to acknowledge the strengths of the child and parent/caregiver, and acknowledge the positive aspects of the relationship observed by the clinician [144]. By considering the potential role of both family strengths and risk factors for trauma, the clinician can more effectively identify trauma and support the child's and family's resilience and recovery.
●Assess for ACEs and other risk factors – The social history may provide additional information on potential exposures to and risk for trauma which may occur in many situations. This can include ACEs such as illness or disability of a family member (eg, physical, mental, developmental, or substance use) or difficult family situations (eg, divorce or separation, death of parent/caregiver or another family member, multigenerational households, adoption, foster or kinship care, etc). Specific populations, as noted above, may be at increased risk for exposure to trauma [144]. (See 'Risk factors for adverse childhood experiences (ACEs)' above.)
Assessment for risk factors also includes evaluation for SDOH. (See 'Social determinants of health (SDOH)' above and 'Routine screening' below.)
●Assess for symptoms of toxic stress (review of systems) – The review of systems may identify symptoms of toxic stress that were not otherwise apparent, particularly functional symptoms such as sleep difficulties, changes in appetite, bowel symptoms (eg, constipation, encopresis, abdominal pain), and school problems (eg, decreased attention, poor attendance) [144]. Obtaining a developmental history can provide additional information, as developmental delays are some of the most easily recognized symptoms of early childhood trauma [144]. (See 'Physiological effects of toxic stress' above and 'Developmental and behavioral effects of toxic stress' above.)
In patients with specific behavioral and mental health concerns (eg, ADHD, depression, anxiety, behavioral problems), trauma-related toxic stress could be a differential or comorbid diagnosis. Screening tools can help to identify symptoms of toxic stress. (See 'Routine assessment for all children' above and 'Additional assessment for at-risk or symptomatic children' below.)
Routine screening — Routine screening for developmental, behavioral, mental health symptoms (eg, by using tools such as the Ages and Stages Questionnaire (ASQ), PHQ-9, GAD-7) and SDOH during health maintenance visits can help to identify symptoms of and risk factors for toxic stress. There is no clear evidence to support routine screening for ACEs [148-153].
●Routine developmental/behavioral screening – As recommended by the American Academy of Pediatrics (AAP), routine screening at health maintenance visits can provide valuable information about the impact of trauma on children. Commonly used screening tools to assess for developmental, behavioral, and mental health symptoms (eg, Pediatric Symptom Checklist, ASQ, Pediatric Health Questionnaire-9, General Anxiety Disorder-7 or Scared for Child Anxiety Related Disorders) may identify symptoms of toxic stress (eg, developmental delays, social-emotional problems, depression, anxiety); this is also true for tools that screen for attention deficit hyperactivity disorder (ADHD; Vanderbilt Forms, Connerꞌs Forms) [144].
In addition, the American Academy of Pediatrics recommends routine screening for maternal post-partum depression with the Edinburgh Postpartum Depression Scale (EPDS) at the one-, two-, and four-month well-child visits [154]. Parental mental health is a known risk factor for ACEs and toxic stress. (See 'Definitions and impact' above and 'Risk factors for adverse childhood experiences (ACEs)' above.)
●Screening tools for SDOH – The American Academy of Pediatrics and American College of Physicians recommend evaluation for SDOH at every health maintenance visit; this leads to earlier intervention and better-informed care [22,144,155]. SDOH can be identified with screening tools to assess for any resource needs and facilitate referral to community resources [144]. There is no consensus regarding the best screening tool to identify SDOH or if the use of these tools results in improved health outcomes [22,156]. Screening tools for SDOH commonly include domains for safety, housing instability, food insecurity, and employment; legal concerns, transportation, child care, and other domains may also be included. Specific screening tools are discussed in more detail separately. (See "Screening tests in children and adolescents", section on 'Screening for poverty'.)
Evaluation for SDOH requires that clinicians identify available community resources to help families address their needs. It is important to identify and address adverse SDOH, as living under negative conditions and systems (eg, poverty, racism, poor housing and neighborhood conditions) exposes children and families to toxic stress [11,12,22]. There is growing evidence that addressing SDOH, such as early childhood education and improved housing, can improve child health [157-159]. Without routine assessment, clinicians may fail to identify many at-risk children and families who could benefit from increased support. (See 'Social determinants of health (SDOH)' above.)
●Limitations of ACEs screening – We do not routinely screen for ACEs in clinical practice. While there are some experts and health organizations that recommend the use of ACEs questionnaires in clinical settings, there is inadequate evidence to support that such screening leads to improved identification of childhood adversity, increased referral to or utilization of supportive services, or improved child health outcomes [148-153,160-162].
Other limitations of ACEs screening include [151-153,163,164]:
•Although ACEs are associated with poor health outcomes at the population level, they do not predict individual health outcomes [151,152].
•ACEs screening includes only a limited number of adversities and does not allow the patient to identify the events that were impactful to them [163]. Knowing about a childꞌs particular adverse experiences does not provide information on the specific effects of that experience on the child [163], which is necessary to perform appropriate interventions.
•ACEs screening does not include information on the presence of protective factors or current trauma-related (ie, toxic stress) symptoms [164].
•ACEs screening questionnaires lack sensitivity and specificity, particularly when used for Black, Indigenous, and other populations; these questionnaires can both over- or under-identify ACEs depending on ethnicity, age, or gender [153].
•ACEs screening can lead to stigmatization or anxiety, particularly for individuals who are disproportionately affected by ACEs, and potentially disrupt the healthcare relationship [162,163].
Additional assessment for at-risk or symptomatic children — For patients with a history of exposure to a potentially traumatic event or for whom there are specific behavioral and mental health concerns (eg, ADHD, depression, anxiety, behavioral problems), we perform targeted screening for trauma-related toxic stress, consistent with AAP recommendations [144]. Targeted screening can help to identify symptoms of PTSD or other trauma-related disorders and to better direct management [144]. (See 'Routine assessment for all children' above and 'Spectrum of symptoms' above.)
Available tools that can be used to assess for symptoms of toxic stress and correlate well with DSM-5 criteria for posttraumatic stress disorder include:
●Child Trauma Screen (CTS) – CTS is a brief (10 questions), freely accessible instrument for children 6 to 17 years of age (an instrument for children 3 to 6 years is in development) [165-167].
●Child and Adolescent Trauma Screen (CATS) – CATS (40 questions) is a freely accessible screening instrument for children 7 to 17 years of age [168].
●Pediatric Traumatic Stress Screening Tool (PTSST) – This is a brief (15 questions), freely accessible screening instrument for children 6 to 18 years of age. This tool includes questions to assess for recent or past exposure to trauma, symptoms of toxic stress (from the UCLA Brief Screen for Trauma and PTSD [169]), and suicide risk (from the Patient Health Questionnaire for Adolescents).
These screening tools include specific questions about trauma exposure and toxic stress symptoms and can identify children who may benefit from further evaluation and evidence-based trauma therapy. They can be used independently or in conjunction with other brief screening tools to assess for conditions such as anxiety and depression and to distinguish if overlapping symptoms are due to the effects of adverse experiences or other disorders. They can also be used to monitor symptoms. Psychotherapy and other treatments for toxic stress symptoms are discussed in more detail separately. (See 'Treatment for severe toxic stress' below.)
Screening is tailored based on the age and developmental stage of the child and the availability of a parent/caregiver to report on that childꞌs exposure and symptoms. Symptoms of toxic stress may be difficult to assess in young children (eg, ages <6 years) or in children new to foster care whose caregivers may not be aware of this information. In these children, a comprehensive history can help to identify known exposures to adversities and behavioral concerns that may indicate the effects of toxic stress, such as mood dysregulation or sleep difficulty. (See 'History taking' above.)
An example of a trauma-informed care model that incorporates the PTSST to assess for symptoms and stratify responses by symptom severity following a potentially traumatic event is available through Intermountain Health Care [170]. (See 'Resources' below.)
Discussing results — The clinician should share results of the assessment with the patient and parent/caregiver and discuss how they inform the next steps. It is important to explain that the childꞌs feelings are expected given the events that have happened and discuss recommendations for any treatments. As an example: "You indicated on the form that you are having a lot of trouble with nightmares, and with images of the accident popping into your head. Those are not uncommon reactions to the accident you mentioned, and it is your brainꞌs way of trying to keep you safe. Even though it is a normal response, it doesn't feel good to have that happen, so we'd like to refer you to a therapist that specializes in helping kids feel better" [43].
Treatment for toxic stress symptoms is discussed separately. (See 'Education and anticipatory guidance' below and 'Treatment for severe toxic stress' below.)
Education and anticipatory guidance — Education and anticipatory guidance are warranted for all children and families to prevent and manage the effects of trauma by promoting resilience and healthy child development and addressing toxic stress symptoms. The clinician can present and readdress this guidance at appropriate points during routine health maintenance visits. Anticipatory guidance is a hallmark of pediatric health maintenance and prepares children and parents/caregivers for future growth and development; it has also been shown to decrease stress and improve parenting practices [171,172].
●Provide education – All parents/caregivers need to understand the potential impact of trauma and the effects of toxic stress [144]. By providing information on these effects, the clinician can help make discussions about trauma an expected part of the healthcare visit and empower families to respond proactively to protect their children from its negative effects. It is important for clinicians to validate the child's and family's experiences and symptoms.
It is also important to educate parents/caregivers about the impact of protective factors such as the provision of safe, stable, environments and nurturing relationships; establishment of daily routines and family rituals (eg, mealtime and bedtime routines, weekly movie nights); school or community engagement; and establishment of care with a medical home [144]. (See 'Definitions and impact' above and 'Risk and protective factors' above.)
●Strengthen protective factors (positive parenting and emotional regulation) – The clinician can strengthen protective factors by counseling parents/caregivers on positive parenting techniques (eg, "time-in," positive discipline, responsive parenting, and sleep training). In addition, clinicians can educate parents/caregivers on how to help their child learn emotional regulation skills by first recognizing their child's emotions and needs, modeling self-regulation behaviors, and then helping their child practice those skills [144]. For example, they can teach their child to name their feelings and use relaxation techniques (eg, belly breathing, guided imagery) to help their child with emotional self-regulation [144]. Electronic applications and online resources are available to help families learn more about and use these techniques. (See 'Resources' below.)
Examples of specific positive parenting and emotional regulation techniques include [173-177]:
•"Time in" child-directed play – "Time in" is a positive parenting technique in which parents/caregivers set aside a short time (typically 10 to 20 minutes) each day to participate without distraction in a play activity chosen and led by their child [178]. The parent/caregiver follows their childꞌs lead in the activity but is curious and interacts one-on-one with their child. Imaginative and creative activities work well for the "time in" technique [179].
•Cognitive triangle – The cognitive triangle technique is based on the concept that a child's behavior is closely related to their thoughts and feelings [178]. The clinician can discuss with parents/caregivers that thoughts lead to emotions and that emotion is what usually drives behavior. This allows them to appreciate that their child can control their own thoughts and to help their child dissociate the thought from the emotion, or the emotion from the behavior, which improves their ability to regulate emotions and behavior [178].
As an example: "AJ is playing with a classmate, who is quieter than usual. This makes AJ think that the playmate does not like them anymore and makes them angry (thought leading to emotion). Because of this, AJ yells at their classmate to go away (resultant behavior). We could talk to AJ about other reasons why their classmate would be quiet (eg, they are hungry, tired, or upset about a test). If AJ knew these things, they would feel empathy for their classmate and then likely help their classmate with their problem (AJ can change their thoughts to include other considerations, which leads to emotional regulation and changed behavior)."
•Emotional container – This technique teaches that children do not know how to manage their strong emotions; thus, they must depend on their parents/caregivers to contain those emotions and their resultant behaviors [178]. When a child experiences these strong reactions, a parent/caregiver who is an "emotional container" is one who can remain calm with the child, is curious about why the child is having this response, can facilitate naming the emotion at play, and can validate the childꞌs feelings [178].
●Restore a sense of safety and calm – In the setting of trauma, it is important that parents/caregivers restore a sense of safety by providing reassurance and establishing routines and rituals. The predictability of day-to-day activities can help halt the toxic stress response. For example, parents/caregivers can reassure the child with words, touch (eg, hugs, high-fives), and safe spaces (eg, a tent in the room); establish routines by making charts for mealtime and bedtime activities; and create family rituals such as "pizza Friday" or weekly movie nights. Resources are available to help families learn more about and use these techniques. (See 'Resources' below.)
In addition to promoting a sense of safety by establishing bedtime routines, sleep hygiene can be particularly important to manage stress. Parents/caregivers should be counseled on using consistent and calming bedtime routines, increasing the childꞌs sense of safety at night (eg, using a night light, staying in the room until the child falls asleep), and use of guided imagery and breathing techniques, as discussed above.
●Provide referrals – Clinicians can promote healthy child development by providing referrals to early childhood education programs (eg, Early Intervention, Head Start, home-visiting programs) and social services to address developmental and behavioral challenges and SDOH, as needed [159,180,181].
Following exposure to trauma, referrals for mental health, behavioral, and other interventions may also be needed to address symptoms of toxic stress (see 'Treatment for severe toxic stress' below). When access to treatment interventions is not immediately available, clinicians can provide ongoing support ("bridging") to the child and family by providing counseling on positive parenting and emotional regulation techniques, as discussed above.
TREATMENT FOR SEVERE TOXIC STRESS —
In most children, symptoms of toxic stress will resolve with family support, relaxation and affect management techniques, and psychoeducation, as discussed above (see 'Education and anticipatory guidance' above). For children with severe symptoms, psychotherapy and/or adjunctive medication may be warranted.
Psychotherapy — Treatment for children with severe symptoms that fit criteria for trauma-related disorders (eg, adjustment disorder, prolonged grief reaction, posttraumatic stress disorder [PTSD], developmental trauma disorder [DTD or complex trauma]) includes trauma-focused psychotherapy [182]. (See "Posttraumatic stress disorder in children and adolescents: Treatment overview", section on 'Trauma-focused psychotherapy: First line for most'.)
Examples of evidence-based outpatient treatments for children with significant PTSD symptoms include:
●Child-parent psychotherapy (CPP) – CPP provides therapy for children <6 years of age, typically over 40 to 50 home-based sessions. It focuses on helping parents/caregivers develop positive parenting skills [170,183].
●Parent-child interaction therapy (PCIT) – PCIT provides therapy for children 2 to 7 years of age, typically over approximately 20 sessions. It focuses on helping parents/caregivers develop positive parenting skills (eg, encourage positive and discourage negative behaviors) and strengthen their relationship with their child [170,184].
●Trauma-focused cognitive behavioral therapy (TF-CBT) – TF-CBT provides therapy for children 3 to 18 years of age, typically over 8 to 25 sessions. It focuses on psychoeducation (eg, trauma and trauma responses), parenting skills, coping strategies (eg, relaxation techniques such as belly breathing), cognitive processing, and development of a trauma narrative [170,185].
Child and family traumatic stress intervention (CFTSI) is a treatment for children (ages 7 to 18 years) who experience a traumatic event or disclose abuse and their parents/caregivers to reduce trauma symptoms (eg, fear, sleep problems, anxiety) and prevent PTSD [170,186]. It focuses on psychoeducation, symptom monitoring, and coping strategies. It is usually provided 30 to 45 days after the event or disclosure and occurs over three to eight sessions.
Evidence for and additional details regarding the use of trauma-focused psychotherapy for children and adolescents with PTSD and other psychiatric conditions are discussed separately. (See "Posttraumatic stress disorder in children and adolescents: Trauma-focused psychotherapy" and "Psychotherapy for anxiety disorders in children and adolescents" and "Pediatric unipolar depression: Psychotherapy".)
Adjunctive medication — Medication has a limited role in the management of trauma related or toxic stress symptoms in children and should only be used to augment trauma psychotherapy. (See "Posttraumatic stress disorder in children and adolescents: Treatment overview".)
Symptoms that may warrant specific pharmacotherapy include:
●Hyperarousal, intrusive thoughts, and reactive behavior – (See "Posttraumatic stress disorder in children and adolescents: Treatment overview", section on 'Sleep disruption/dyssomnia'.)
●Sleep disruption – (See "Posttraumatic stress disorder in children and adolescents: Treatment overview", section on 'Sleep disruption/dyssomnia' and "Pharmacotherapy for insomnia in children and adolescents: A rational approach", section on 'Melatonin'.)
●Depression and anxiety – (See "Posttraumatic stress disorder in children and adolescents: Treatment overview", section on 'Combined modality for co-occurring anxiety and/or depression' and "Overview of prevention and treatment for pediatric depression" and "Pharmacotherapy for anxiety disorders in children and adolescents".)
RESOURCES —
Resources for clinicians, patients, and parents/caregivers include:
●Trauma-informed primary care and educational resources
•American Academy of Pediatrics (AAP) Trauma-informed Care – Provides information and resources for clinicians on incorporating trauma-informed care into the medical home and providing education and resources to families.
•The National Child Traumatic Stress Network (NCTSN) – Provides information on the impact of trauma and resources for children and families who experience or witness traumatic events.
•The California Evidence-Based Clearinghouse for Child Welfare (CBEC) – Provides information and resources for clinicians and families to implement evidence-based trauma therapies and services [144,187].
•Harvard Center on the Developing Child – Information for clinicians, parents/caregivers, and policymakers about trauma, resilience, and strategies to help manage toxic stress and promote resilience.
•Intermountain Health Care – Provides an example of a systematic approach to incorporating trauma-specific screening tools in their clinical practice to assess for trauma exposure and toxic stress symptoms [170].
●Positive parenting and emotional regulation
•Calm App and Breathe, Think, Do with Sesame App (or video Belly Breathe: Sesame Street) – Electronic applications/videos that teach families about how to use techniques for emotional regulation.
•PC-Care Learning Center – Resources to teach families about techniques to help with emotional regulation.
•American Academy of Pediatrics (AAP) 3 R's (Reassure, Return to routine, Regulate) – Techniques for restoring a sense of safety and calm during or after trauma.
•Sesame Street Workshop – Videos, worksheets, and other tools to promote mental health in young children.
INFORMATION FOR PATIENTS —
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Stress (The Basics)" and "Patient education: Coping with worry and stress (The Basics)" and "Patient education: Coping in times of crisis (The Basics)")
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Anxiety and trauma-related disorders in children".)
SUMMARY AND RECOMMENDATIONS
●Definitions and impact – Adverse childhood experiences (ACEs) are intrafamilial and interpersonal traumas that are often experienced in childhood and are related to the external systems that shape the individual experience and conditions of daily life (ie, social determinants of health [SDOH]). Toxic stress is the frequent or prolonged activation of the neuroendocrine stress response that occurs when ACEs are not buffered by protective relationships or positive environments. This can cause lifelong impairments in physical and mental health. (See 'Definitions and impact' above.)
●Risk and protective factors – Factors that increase the risk for ACEs include family disruption, poverty, being a member of a military family, and experiencing discrimination or events such as natural disasters and war. Resilience is a process of positive adaptation to or despite adversity. It is protective and can be promoted by stable and nurturing relationships and environments. (See 'Risk and protective factors' above.)
●Effects of toxic stress – Toxic stress leads to physiological changes that can result in adverse health effects. Children who are affected by toxic stress can present with a variety of developmental, behavioral, or psychiatric symptoms , which can mimic or be comorbid with conditions such as attention deficit hyperactivity disorder (ADHD), anxiety, depression, and autism spectrum disorder (ASD). (See 'Physiological effects of toxic stress' above and 'Developmental and behavioral effects of toxic stress' above.)
●Trauma-informed care – Trauma-informed care recognizes the impact of ACEs and SDOH and provides an evidence-based approach for clinicians to identify and manage exposure to childhood trauma and symptoms of toxic stress as part of their routine clinical practice. (See 'Importance and barriers' above and 'Goals' above.)
Our approach to trauma-informed care is as follows:
•Routine assessment for all children – Routine assessment for exposure to trauma and resultant toxic stress begins with the use of open-ended questions during the clinical encounter to identify those who may be at risk for or who are experiencing symptoms of toxic stress. During this process, it is important to destigmatize adversities and validate the patient and family while avoiding retraumatization. (See 'History taking' above.)
Routine screening for developmental, behavioral, and mental health concerns and evaluation for SDOH during health maintenance visits can also identify symptoms of and risk factors for toxic stress. We suggest against routine ACEs screening using any of the available screening tools (Grade 2C). Available ACEs screening questionnaires have important limitations including poor sensitivity and specificity, and there is inadequate evidence to support that screening improves child health outcomes. (See 'Routine screening' above.)
•Additional assessment for at risk or symptomatic children – For patients with a history of exposure to a potentially traumatic event or for whom there are specific behavioral or mental health concerns, we perform targeted screening for trauma-related toxic stress, consistent with AAP recommendations. Targeted screening can help to identify symptoms of PTSD or other trauma-related disorders and to better direct management. (See 'Additional assessment for at-risk or symptomatic children' above.)
•Education and anticipatory guidance – Education and anticipatory guidance are warranted for all children and families to prevent and manage the effects of trauma by promoting resilience and healthy child development and address toxic stress symptoms. Clinicians should provide (see 'Education and anticipatory guidance' above):
-Education about the effects of trauma and toxic stress
-Counseling on positive parenting and emotional regulation techniques (eg, relaxation and affect management)
-Counseling on the establishment of routines to restore a sense of safety and calm after experiencing trauma
-Referrals to address developmental or behavioral challenges and address toxic stress symptoms
●Treatment of toxic stress – In most children, symptoms of toxic stress will resolve with family support, relaxation and affect management techniques, and psychoeducation. Treatment for children with severe symptoms (eg, PTSD) includes trauma-focused psychotherapy. Medications have a limited role and are used as adjunctive therapy to treat specific symptoms (eg, sleep disruption, depression). (See 'Treatment for severe toxic stress' above and "Posttraumatic stress disorder in children and adolescents: Trauma-focused psychotherapy" and "Posttraumatic stress disorder in children and adolescents: Treatment overview".)
