CHAPTER 142

Adverse Childhood Experiences: Trauma-Informed Care

Suzanne Roberts, MD, FAAP, and Geeta Grover, MD, FAAP

Children require safe, stable, nurturing relationships at home and in their community to promote optimal health and well-being throughout the life span. Children’s responsive relationships with caregivers build healthy brain architecture and wiring over time. Adverse childhood experiences (ACEs) during the first 18 years after birth include exposure to abuse, neglect, and household dysfunction; disrupt healthy development; and can have a negative effect on adult mental and physical health and functioning. The ACE score is a determination of the number of ACEs to which a patient has been exposed. This score is based on the types of trauma included in the 3 categories of ACEs (ie, abuse, neglect, household dysfunction) (Box 142.1). Each individual ACE type counts for 1 point. The lowest score achievable is zero (no ACEs) and the highest is 10 (every ACE type). A child who has been exposed to emotional abuse and parental divorce, for example, is assigned an ACE score of 2.

The detrimental effects of these ACEs include adoption of unhealthy behavioral coping strategies, increased risk of chronic disease in adulthood, and difficulty with interpersonal relationships and work performance (Box 142.2). A dose-response relationship is observed, with exposure to more ACEs being associated with increased risk for more adverse outcomes later in life. Experience of 6 or more of these ACEs can result in up to a 20-year reduction in life span. Exposure to ACEs can affect the next generation as well, with the children of parents who experienced childhood adversity being at increased risk for developmental delays and health-harming behaviors.

More recently, other forms of adversity experienced in the environments in which children live, learn, and play (eg, poverty, racism, bullying, community violence) have been recognized as having similar negative effects on lifetime health. These environmental conditions in which children are born, grow, live, work, and age are referred to as the social determinants of health (see Chapter 141). According to the World Health Organization, the social determinants of health are responsible for most health inequities, that is, “the unfair and avoidable difference in health status seen within and between countries.” In the United States, the wealthiest segment of the population has a 10- to 15-year longer life span than the poorest segment, an outcome that is related to differences in health-related behaviors, chronic disease, and injury. Together, ACEs and adverse community environments comprise the “Pair of ACEs” (Figure 142.1).

The Pair of ACEs tree illustrates how adversity within the family and adversity in the community together negatively affect children. Adverse childhood experiences exert their deleterious effect on health through excessive activation of the body’s stress response on the developing brain and body. A child adapts to the negative home and world experiences the child encounters at the expense of longer term health. Positive supportive experiences at home and in the community can buffer and mitigate the effects, however. Because of the pervasive nature and long-lasting consequences of childhood adversity, addressing its roots and effects is an urgent public health concern.

Epidemiology

The original Adverse Childhood Experiences (ACE) Study published in 1998, based on information from more than 17,000 middle-class Americans, documented clearly that childhood adversity contributes significantly to negative adult physical and mental health outcomes. Sixty-four percent of adults recalled having at least 1 ACE, with 12% reporting 4 or more ACEs. Subsequent surveys have confirmed similar results in many states and many countries. Exposure to ACEs cuts across all strata of society. However, exposure to a higher number of ACEs disproportionately affects adults identifying as low income, low education, multiracial, or bisexual. The most common ACEs recalled by adults were emotional abuse, parental separation or divorce, and household substance abuse. Several ACEs tend to co-occur and can have intergenerational effects.

Figure 142.1. Pair of ACEs (adverse childhood experiences) tree.

Reprinted with permission from Ellis WR, Dietz WH. A new framework for addressing adverse childhood and community experiences: the building community resilience model. Acad Pediatr. 2017;17(7 suppl):S86–S93.

In the 2012 National Survey of Children’s Health, parents in the United States reported that 46% of children had exposure to at least 1 ACE and, depending on the state of residence, 8% to 17% of children had 4 or more ACEs. The most common ACEs parents reported were economic hardship, parental separation or divorce, and parental alcoholism and/or substance abuse. In some states, parental mental illness and community violence were also prevalent. A recent study of more than 700 children, most of whom (67%) had experienced 1 or more ACEs and 12% of whom had experienced 4 or more ACEs, found that increased ACE score correlated with increased risk of learning and behavior problems and obesity. This correlation was especially marked for learning and/or behavior problems. Children with 4 or more ACEs were 32 times more likely to have learning and/or behavior problems in school than children with no ACEs.

Clinical Presentation

In a clinic setting in which a physician might see 20 patients per day, at least 2 patients may have experienced at least 4 ACEs. In the pediatrics clinical setting, a patient may be actively experiencing the pair of ACEs. The presentation is variable and related to the child’s developmental stage, temperament, and family protective factors. A high number of ACEs in childhood may present as behavior concerns at any age (eg, aggression in a toddler, attention-deficit/hyperactivity disorder [ADHD] in the school-age child, and promiscuity or drug use in the teenager); developmental delays in the preschool-age child and learning concerns in the school-age student; physical symptoms, including functional symptoms (eg, stomachache, headache, poor sleep); and medical or psychiatric conditions (eg, poorly controlled asthma, encopresis, depression, suicidality). Nonadherence to medical treatment plans and missed appointments may also be signs of family adversity (Box 142.3).

Pathophysiology

Early childhood experiences influence the neural wiring for learning, memory, and behavior, and they shape the evolution of the neuroendocrine, autonomic, metabolic, and inflammatory systems. The architecture of the brain is built over time through experiences the child has in the child’s family and community environments. In the first few years after birth, new neural connections (ie, synapses) are formed every second, and the brain reaches 80% of its adult size by age 3 years. Responsive interactions between child and caregiver are the building blocks that support healthy brain and body circuitry. Learning occurs when certain neural connections are strengthened resulting from use and others are pruned away because of lack of stimulation.

After the early childhood years, another major critical period of brain development occurs during adolescence, from puberty through the young adult years. Especially important during this time is the development and maturity of the prefrontal cortex of the brain. The prefrontal cortex has been dubbed “the CEO” of the brain, because it is the area responsible for executive function skills, including impulse control, attention, working memory, organization, planning, and mood modulation. Unbuffered stress and insults such as tobacco, alcohol, and other substance use during this second sensitive period of brain development can adversely affect the wiring of the prefrontal cortex.

During childhood and adolescence, the wiring of the brain’s stress regulation system is under construction to respond in positive, tolerable, or toxic ways to perceived threats in the environment. When a person perceives a threat to his, her, or their safety, the brain and body adaptively release the hormones cortisol, norepinephrine, and epinephrine in preparation for a “fight, flight, or freeze” response. This evolutionarily conserved hormonal response results in the physiologic changes that allow the person to respond to the stressor. With a positive stress response, the elevations in heart rate, blood pressure, and hormone levels are short-lived and return to normal after the threat has passed. With a tolerable stress response, stronger threats may produce a more prolonged but not damaging response, because of the presence of buffers, such as the presence of supportive adults in a child’s life. With a toxic stress response, however, the stress response system remains chronically activated, resulting in changes in brain and body physiology (Figure 142.2). In the absence of buffers assuring the child he or she is safe, exposure to ACEs can trigger the excessive activation of the stress response that is the biologic mechanism by which social and environmental circumstances result in detrimental effects on health (Figure 142.3).

Differential Diagnosis

Recognition that childhood adversity is common and pervasive should lead the health professional to consider ACEs-related trauma and consequences of excessive stress activation in the differential diagnosis of many common childhood reports. The child who presents with learning or behavior concerns (eg, aggression, excessive tantrums, speech delay, classroom disruption, ADHD); mental health problems (eg, depression, suicidality, substance abuse); and other health issues (eg, morbid obesity, poorly controlled chronic illness, treatment nonadherence, missed appointments) should undergo ACEs screening to help inform the child’s treatment plan.

Figure 142.2. Levels of stress response.

Reprinted with permission from Center on the Developing Child at Harvard University. http://developingchild.harvard.edu

Evaluation

Because ACEs occur across all populations, routine screening would be ideal. Addressing exposure to traumatic events in a primary care practice can be considered challenging, however. Barriers to screening may include the health professional’s lack of time during the office visit, lack of comfort in addressing sensitive family topics, and lack of training in managing positive screening results, as well as lack of community resources for family linkage. Starting such a screening practice can seem daunting. As a first step, the pediatrician may consider ACEs screening for the child with unexplained somatic symptoms, behavioral concerns, or changes in educational or socioemotional functioning. Sometimes the right question to ask is not, “Why are you behaving this way?” but, “Can you tell me what has happened to you?” For the younger child, the physician may ask the caregiver, “Since the last time I saw your child, has anything really scary or upsetting happened to your child or anyone in your family?” This same question may be addressed directly to the older child. The pediatrician must take the time to understand what has happened to the child before trying to “fix” the problem.

The practice with interest in implementing broader screening can use any of several standardized measures to identify factors that put children at risk for ACEs, including screenings for maternal depression, food insecurity, parental substance abuse, and domestic and/or community violence. Currently, no universally agreed on standard screening instrument exists for ACEs exposure in pediatrics. However, several tools have been developed for a pediatric population that can help the medical home in identifying these children, including Bright Futures Pediatric Intake Form, Center for Youth Wellness ACE-Q materials, Survey of Well-being of Young Children (SWYC), and Safe Environment for Every Kid (SEEK) questionnaire (Table 142.1). These and other clinical assessment tools are available on the American Academy of Pediatrics website, The Resilience Project (www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/resilience/Pages/Resilience-Project.aspx). Practices that implement ACEs-related screening should identify supportive resources in the local community with which to link families with at-risk screening results. Additionally, the physician should evaluate the family for protective factors that contribute to resilience in the presence of adversity (Box 142.4).

Figure 142.3. Adverse childhood experiences pyramid.

Reprinted from Centers for Disease Control and Prevention. About the CDC–Kaiser ACE Study. The ACE pyramid. CDC.gov website. www.cdc.gov/violenceprevention/acestudy/about.html.

Abbreviation: ACEs, adverse childhood experiences.

Management

Recognition of the role of ACEs as contributors to the presenting symptom facilitates the development of a more comprehensive treatment plan. Trauma-informed care in the medical setting involves delivering services in an environment of physical and emotional safety for families and health professionals, helping caregivers and children gain a sense of agency and control in their lives by sharing information with them, and involving the caregivers and children as active participants making decisions about the treatment plan. Children need to regain expectations that they are safe and lovable and that life has meaning. Attention to nutrition, exercise, sleep hygiene, and daily routines are important, as is addressing the psychosocial needs of children and their parent(s)/guardian(s).

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