Skip to main content

To prevent childhood trauma, pediatricians screen children and their parents…and sometimes, just parents...for ACEs

Tabitha Lawson and her two children
When parents bring their four-month-olds to a well-baby checkup at the Children’s Clinic in Portland, OR, Drs. Teri Petersen, R.J. Gillespie and their 15 other partners ask the parents about their adverse childhood experiences (ACEs).

When parents bring a child who’s bouncing off the walls and having nightmares to the Bayview Child Health Center in San Francisco, Dr. Nadine Burke Harris doesn’t ask: “What’s wrong with this child?” Instead, she asks, “What happened to this child?” and calculates the child’s ACE score.


In rural northern Michigan, a teacher tells a parent that her “problem” child has ADHD and needs drugs. The parent brings the child to see Dr. Tina Marie Hahn, who experienced more childhood trauma than most people. Instead of writing a prescription, Hahn has a heart-to-heart conversation with the parent and the child about what’s happening in their lives that might be leading to the behavior, and figures out the child’s ACE score.

What’s an ACE score? Think of it as a cholesterol score for childhood trauma.


Why is it important? Because childhood trauma can cause the adult onset of chronic disease (including cancer, heart disease and diabetes), mental illness, violence, becoming a victim of violence, divorce, broken bones, obesity, teen and unwanted pregnancies, and work absences.


The CDC’s Adverse Childhood Experiences Study (ACE Study) measured 10 types of childhood adversity: sexual, physical and verbal abuse, and physical and emotional neglect; and five types of family dysfunction – witnessing a mother being abused, a household member who’s an alcoholic or drug user, who’s been imprisoned, or diagnosed with mental illness, or loss of a parent through separation or divorce. (There are, of course, other types of trauma, but those were not measured in this study. Other ACE surveys are beginning to include other types of trauma.)


Each type of trauma — not the number of incidents of each trauma — was given an ACE score of 1. So, a person who has been emotionally abused, physically neglected and grew up with an alcoholic father who beat up his wife would have an ACE score of 4.


The ACE Study found that childhood trauma was very common -- two-thirds of the 17,000 mostly white, middle-class, college-educated participants (all had jobs and great health care because they were members of Kaiser Permanene) experienced at least one type of severe childhood trauma. Most had suffered two or more.

The more types of childhood trauma a person has, the higher the risk of medical, mental and social problems as an adult (Got Your ACE Score?). Compared with people who have zero ACEs, people with an ACEs score of 4 are twice as likely to be smokers, 12 times more likely to attempt suicide, seven times more likely to be alcoholic, and 10 times more likely to inject street drugs. Compared to people with zero ACEs, people with an ACE score of 6 have a shorter lifespan – by 20 years.


Twenty-two states and Washington, D.C., have done their own ACE surveys, with similar results.

The ACE Study is part of a perfect storm of research emerging over the last 20 years that is revolutionizing our understanding of human development. Brain research shows how the toxic stress of trauma damages the structure and function of children’s brains, which can explain their hyperactivity, inattentiveness, angry outbursts and other behavior. This affects their ability to learn in school, and leads them to use drugs, alcohol, thrill sports, food and/or work as coping mechanisms.


Biomedical researchers discovered that toxic stress experienced as a child can linger in the body to cause chronic inflammation as an adult, resulting in heart and auto-immune diseases, such as arthritis. And epigenetic research shows that the social and emotional environment can turn genes on and off, and childhood trauma can be passed from parent to child to grandchild.


Let’s put this another way: A huge chunk of the billions upon billions of dollars that Americans spend on health care, emergency services, social services and criminal justice boils down to what happens – or doesn’t happen -- to children in their families and communities.

The pediatricians mentioned in this article know that, and they also know that if they intervene early enough to stop or prevent childhood trauma by building resilience factors in children and families, children won’t suffer, and they’ll have happier, healthier lives as adults.


Pediatricians aren’t just about sore throats and ear infections anymore, says Gillespie. “This is a culture shift. We’re here to support families.”


The profession is moving away from looking solely at healing a child, to healing a family and a community. For the last several years, the American Academy of Pediatrics has been helping pediatricians create medical homes where all needs of children and their families are met, including “specialty care, educational services, out-of-home care, family support, and other public and private community services that are important for the overall health of the child and family.”


Two years ago, the AAP encouraged pediatricians to also address adverse childhood experiences and toxic stress in early childhood. Last month, AAP President Dr. James Perrin launched a new initiative, the Center on Healthy Resilient Children, to “coordinate the academy’s response to the issue of adverse childhood experiences, the promotion of healthy development, and the prevention of toxic stress.”


Feeling overwhelmed...and having someone to turn to

When Tabitha Lawson brought her four-month-old son in to the Children’s Clinic in Portland, OR, they both were having a hard time. Unlike her 6-year-old daughter, he wasn’t an easy baby. He had colic, and Tabitha and her husband were under stress from his long bouts of crying.


“I was feeling overwhelmed,” she recalls. “I had no breaks. I work full time. From my job to my house is five minutes, where I’d go into my other life mode, and every evening, the scream-outs.”


She filled out a survey with 10 questions about her adverse childhood experiences (ACEs) and another 15 questions about protective factors. (Here is the ACESandResilienceQuestionnaire.) The 10 ACEs include physical, sexual and verbal abuse, and physical and emotional neglect; and five types of family dysfunction – a family member addicted to alcohol or other drug, a family member in prison or diagnosed with a mental illness, witnessing a mother being abused, and loss of a parent through separation or divorce.


Her pediatrician, Dr. R.J. Gillespie, went over the survey with her. He said it was helpful for him to know what she experienced while growing up, so that he could think about how to support her own parenting skills through what might be challenging times or experiences.


Lawson had suffered through her parents’ acrimonious divorce, her father had been an alcoholic, and had retained custody of Lawson and her sister in a poisonous dispute. Her mother withdrew, neglecting Lawson, and her father was emotionally abusive. That’s an ACE score of 4, which can be a red flag. In Lawson’s case, she was already aware of how harmful those experiences were.


“I had decided to rise above the cycle of dysfunction and divorce,” says Lawson, and she and her husband were very clear about the loving environment they wanted to create for their children. She believes in the mantra, “It takes a village to raise a child,” so welcomed the support and involvement of her husband’s parents and aunt.


Nevertheless, Gillespie knew that the addition of a colicky baby was putting stress on Lawson and her family. “He gave me a worksheet to fill out, so that I knew in advance who I could call when I was under extreme stress,” she says. He also gave her tips on how to reduce her stress level by doing breathing exercises, yoga, and stopping for 10 minutes on her way home to give herself some alone time. He told her to call him anytime she needed to talk with him.


“Just knowing that he was taking the time to listen to me, and validating that I was doing everything right, and that I was doing a great job, meant a lot to me,” she says. “I have no idea how I got through it, but I did. Having the support of my pediatrician who genuinely cared about me definitely helped. By the six-month appointment, things were much better.”


A child’s behavior can reveal a parent’s ACE score

Perhaps the first pediatrician to do anything with the ACE Study was Dr. David Willis, who was medical director at the Artz Center for Developmental Health in Portland. The center received referrals from pediatricians for children who had behavioral or developmental problems. Willis had learned about the ACE Study in 2005, and its implications had hit him like a thunderbolt.


“I knew that trauma in previous generations could play a big part in parenting,” he says. “The ACE data could clearly help us move upstream, targeting how to begin to work with families, to understand how the trauma endured by parents in their childhood impacted attachment with their own children. That’s what got me going.”


Willis, who is now director of the Division of Home Visiting and Early Childhood Systems in the U.S. Department of Health and Human Services’ Health Resources and Services Administration, began using the ACE questionnaire with all families who came to him. “It got to the point where I could predict the parents’ ACE score after they described the child’s behavioral pattern,” he says. Having the parents fill out the ACE survey enabled him to have frank discussions with them.


“We could now freely talk about when they were in conflict with the child,” he says. This enabled him to help the parents help their child regulate, instead of dissociating or avoiding the child when the child was angry with them. He taught them the importance of being firm, fair and friendly in an atmosphere of struggle and conflict, while listening and acknowledging the child’s frustrations and fears.


“After three or four visits in which I counseled them to go home and try these approaches, if they returned unsuccessful, I knew that they probably needed their own psychological care, because it was difficult for them to do the work they wanted to do,” he continues. “So I would ask: ‘Have you considered why this is so hard?’ Then we would have 90 to 100 percent of the parents agree to see a counselor. The hook was their desire to improve their child's space, so it made them willing to confront when they were afraid to seek their own mental health counselor.”


David Willis says that his experience of integrating an awareness of how adversity affects a child’s development and behavior “sensitized me to figure out ways for this to become a natural part of the health system,” he says. “We ask our patients about their family medical histories, we tell them to undress, we do intimate exams. Bringing this unspoken history of life experiences into doctor-patient communication is the first step in the beginning of the healing process.”


The Children’s Clinic pediatricians began screening for ACEs after Dr. Teri Pettersen took a sabbatical to observe and work with Willis in 2011. In March 2013, she and eight of her partners started a pilot to screen the parents of four-month-old babies because, generally speaking, “four-month-olds are the happiest critters on the planet,” she says. “They smile at everything their parents do. As a result, parents feel more confident. They’re not as exhausted as they were at the beginning. It’s a positive time to ask them about these topics.”


Pettersen knows that parents who’ve experienced chronic trauma in their childhoods have a good chance of passing that on to their children.


“I wanted to create the relationship so that when parents are struggling, they’ll come to us and say they’re struggling and ask for help,” she says. Otherwise, she worries that parents may abuse or neglect their children until there’s “necessity for a punitive approach.”


Screening for ACES wasn’t a huge leap, explains Gillespie, because the clinic began screening for developmental disability and autism in 2008, and for peripartum mood disorders in 2009. But none of those screening tools helped them understand what was going on in the family, or to help parents understand why childhood trauma is such a critical issue.


This is how the screening works, says Petersen: The parents fill out the questionnaire [ACESandResilienceQuestionnaire] in the waiting room.  Pettersen quickly reviews the results, and, on meeting with the parents, says one of two things:

  • “It looks like you had pretty supportive family, so you're going to be a pretty good parent without even having to think about it. And most parents’ response has been: ‘I’m so glad you're asking. I think this is important stuff.’
  • “Or, if they do have higher ACEs, I say: It looks like you had some very difficult experiences during your childhood. Most parents I talk to with similar experiences feel they have worked through some of these experiences but still get tripped up by others. I am wondering if that is the case for you?”

The responses, says Petersen, have ranged from, “This one's kind of hard for me still,” or “I've gone back into counseling for this one”, or “I plan to go back into counseling.


The pediatricians don’t ask the parents how their ACEs are affecting their parenting, because the clinic does not yet have a therapist on site, although it’s planning on adding one. They just focus on how their childhood trauma is affecting them at this point in their lives. If it’s an issue, they advise talking with a counselor. Petersen says that the overwhelming response from parents has been: “Thank you so much for asking about these things. It's really a load off my mind. I feel like I can come to you if I need help.”


When asked what kinds of support they needed, most parents said parenting classes, support groups, or more information on the web. “Only three said a respite nursery (where stressed parents can bring their children),” says Pettersen. “That's very telling, because it says that they want to do it themselves. They want to have the support so they can do the best job they can.” Two of the three who wanted a respite nursery were the parents of one baby. “I am really concerned about that baby,” says Pettersen. The other was a woman who was widowed shortly after her baby was born; her desire for intense support made sense.


The pediatricians also emphasize the resilience questions, to point out resources the parents had or have, so that they can build on them.


How this new knowledge works in practice, says Gillespie, can be subtle and “impacts a lot of the little things we do on a day-to-day basis,” he says. Take the example of a mother whose ACE score revealed that when she was two years old, she’d been abandoned by her mother. When Gillespie coached her on how to help her baby learn to go to sleep by itself, and said it was okay to let her baby cry a little, that “triggered a lot of fear,” he says. “She couldn’t and didn’t do it. We’d talked about sleep problems many, many times, and I never got to why she wasn’t following my advice until she filled out the ACE survey. I don’t think she thought about how her experience interfered with letting her baby cry for 10 minutes to settle down and get to sleep.”


“The real take-home message,” of screening parents for ACEs, says Pettersen, “is that my partners who are doing this say they cannot imagine going back to the way things were. The amount of intimacy they have with their patients has increased. Their comfort level with this was much easier to come to than they expected.” All of the clinic’s pediatricians now do ACEs screening.


This approach — screening parents of infants — “more closely approaches prevention than screening for kids for ACEs when they’ve already happened,” says Gillespie. Parents are screened while they’re young, they’re receiving reinforcement, and they haven’t slipped into bad habits yet. They can be prepared for the time when their toddler hits them, “because it will happen,” he says, “and they can respond better if they’ve thought about it ahead of time.”


The pediatricians provide parents resources, such as brochures and web sites, and programs such as Connected Kids, which is recommended by the American Academy of Pediatrics, or age-specific activities recommended by Zero to Three. Pediatricians don’t have to think of everything, says Gillespie: “We’re changing parents’ perception about their own childhood and parenting. If we get parents reflecting, that is the intervention.”


One of the side effects of screening for ACEs and peripartum mood disorders, says Gillespie, is that mothers have felt more comfortable asking the pediatricians to help them with domestic violence. In turn, the clinic developed responses, including arranging immediate entry for a woman and her children to an emergency shelter, providing referrals to attorneys, and/or support groups.


During the pilot phase, the pediatricians gathered data that showed there was little difference in ACE scores 2, 3 or 4+ between patients who had private (economically well-off) or public health insurance (lower income brackets). This brings up a policy question, says Pettersen. If the state is rolling out a program for kids who have publicly funded insurance because the state believes these children are at higher risk, it may need to examine children in families with private insurance, too, as the incidence of trauma may be just as great.


The next steps for the clinic, says Gillespie, include:

— Adding other types of childhood trauma to the ACE questions, including bullying, involvement in the foster care system, witnessing community violence, or discrimination based on race, ethnicity or sexual orientation.

— Working closely with their Spanish-speaking populations to understang cultural differences that may require different questions. “We find that one-third of our Spanish-speaking patients never attest to more than one ACE,” says Gillespie.

— Expanding the ACEs and resilience questionnaires to different age groups. Research has shown that ACEs is a significant factor in elementary students failing in school. “We need different screening for the kids for their experiences than the screening that asks parents what’s going on in household,” says Gillespie. “Asking parents if kids are being abused….we haven’t figured out best way to do that yet.”


One of the issues that Gillespie believes will emerge is to identify how to build resiliency in families and communities. “We don’t know how to build resiliency in the family yet,” he explains. “If certain aspects of resilience were stronger, that would protect people from ACEs. We want to take a strength-based approach. ACEs is not strength-based.”


A medical home that addresses ACEs and toxic stress

A strength-based approach is what Dr. Nadine Burke Harris and her team are taking at the Center for Youth Wellness in San Francisco, which provides wrap-around services for children and families at Bayview Child Health Center. The two organizations are in the same building; to the families they serve, there’s no distinction.


Dr. Nadine Burke Harris founded the Bayview clinic in 2007 to serve families in the long-marginalized neighborhood of Bayview-Hunters Point in San Francisco. When she learned about the Centers for Disease Control and Prevention’s Adverse Childhood Experiences (ACE) Study in 2008, “The clouds parted,” she told Paul Tough, in “The Poverty Clinic”, which appeared in The New Yorker in 2011.

“To understand the mechanism,” says Burke Harris, “is to know what to target.” If children’s exposure to trauma was causing illness, then it was important to target the trauma.


To understand how trauma was affecting her clinic’s patients, she and Dr. Victor Carrion, a psychiatrist at Stanford School of Medicine’s Early Life Stress and Pediatric Anxiety Program, did a study of 701 children who had come through Bayview’s doors between 2007 and 2009.


The study, published in the Journal of Child Abuse and Neglect in 2011, found that 67% of the children had experienced at least one type of trauma. Twelve percent had experienced four or more. The average age of the children was seven — which showed that the kids in this neighborhood were accumulating adverse childhood experiences (ACEs) at a fast clip.


The outcomes were striking: Of the kids with zero ACEs, 97% had no learning problems. But half the kids with an ACE score of 4 or higher had learning problems. Kids with an ACE score of 4 or more also had higher rates of obesity.


“These exposures are critically important,” says Burke Harris. “That informed our system.”


Now Bayview’s pediatricians screen every child for ACEs at a well-child check. For children who have 1-3 ACEs with symptoms, or 4 or more ACEs with or without symptoms, they and their families are referred to services provided by CYW, which include mental health practitioners, case managers who connect families with social services and do home visits, and people who work with the children’s schools. CYW is also exploring solutions ranging from teaching kids how to regulate their stress levels through mindfulness and biofeedback, to working with the local district attorney, police, and schools to develop community resilience.

One of the reasons Burke Harris decided to do the study in 2009 was because so many parents who showed up at the clinic were asking for ADHD medication for their kids; they’d been told by their children’s school teachers that their children had ADHD.


Out of 100 cases of kids with behavioral issues, she says, on average 50 will reveal a history of trauma. Another 47 show up at the clinic with an ADHD diagnosis and are already on medication. “Part of my work is to help the parent understand that there may be something more going on and that we also need to get to the root cause of their child’s behavior problems,” says Burke Harris.


Only three children out of 100 will have true ADHD, she says. In these cases, there’s no history of trauma, the child lives in a supportive household and there are no major stressors. Nevertheless, if Burke Harris writes a prescription, she also prescribes therapy and provides parents with guidance to change their behavior so that they can bond more closely with their child.


Challenging tradition in rural Michigan

Dr. Tina Marie Hahn has such a unique perspective on childhood trauma that she says she knows ACEs without asking about ACEs. When she was four years old, she watched her raging father push her grandmother, who was Hahn's protector, down a set of steps into the basement, where she died. For the next 13 years, her father brutalized her and her two younger siblings physically, emotionally and sexually before she was emancipated and child protective services separated her siblings from her parents. Hahn has an ACE score of 9. She describes herself as the “educational perfectionist” of the family, who excelled enough to graduate from medical school.


She’s now in a pediatric practice with two other physicians in the small town of Alpena. “I have a hard time seeing foster kids or kids living in poverty, whose parents or school believe he or she has ADHD, oppositional defiant disorder, or another behavioral disorder and wish to have him placed on medication,” she says. “Often little attempt is made to obtain a psychosocial history let alone an ACE history or trauma history. This isn’t an effective management strategy. The first medication usually doesn’t work, multiple medication changes are made; the child is referred to Community Mental Health, often waiting for months, only to have more medications added to the milieu, including medications with dangerous side effects such as mood stabilizers or antipsychotic drugs. I see this occurring in children as young as 3 or 4. I cringe when I see the list of medications these children are given, knowing the root cause of the concern may never be addressed.”


When parents bring a child in for a behavioral health evaluation, she runs them and the child through a series of behavioral health questionnaires to which she’s added ACE questions: Who’s in the home? What are the recent changes regarding home and school? How is the child doing in school? Who are the child’s friends and how do they get along? What activities is the child involved in after or outside of school? Is there a family history of mental health or drug and alcohol problems? Is there a social history of family members in jail or prison? What community and family resilience resources are available (after school, church, caring relatives)?


“I’m not necessarily asking the ACE questions directly, but I’m getting the information out of the parent and child,” she explains. “I ask the parent: ‘He doesn’t seem happy. Am I right? Why do you think that may be?’ I learn things -- the child is being teased or bullied at school, or mom and dad just had an acrimonious divorce. Mom is stressed and the child is upset because financial resources have been reduced, the family is not together, and the family can no longer afford what they could before, such as hockey camp. I ask the parent and child things like, ‘How did the experience make you feel? Did you feel sad or frightened or angry?’ I especially like letting the child participate in the discussion, if age appropriate. I do this with a lot of compassion and empathy, letting the child and parent know I am concerned about them. It ‘s actually pretty simple and I can calculate an ACE of 4 or 6 without asking a single ACE question. Then I know this family has a lot of stuff going on.”


“So, I gauge the parent. Does this parent seem as if they’re willing to listen to me if I bring out a couple of ACE graphs or just talk about the association between childhood adversity and behavioral concerns? If she’s ready, I’ll bring out the graphs that show the links between adversity and depression or suicide attempts. I give the family information in a nonjudgmental, compassionate manner. I’ve had several parents tell me: ‘You’re the best doctor we’ve ever had. Nobody has ever asked us this. I didn’t know how to ask these questions. We’re so grateful you did’.”


She’s taken it upon herself to educate physicians and nurses in her town of Alpena and in the surrounding area. She’s experienced physicians who dismiss cutting in adolescents as a “fad”, and who ignore the trauma symptoms of children – such as a toddler violently banging his head against the wall during a visit– and explaining that it wasn’t related to why the parent brought the child in. She wants every pediatrician to screen children for ACEs, and to make ACEs screening a part of the maintenance of certification required by the American Board of Pediatrics.


“I teach physicians why preventing ACEs is so important,” she says. “I have every medical student I teach read the ACE Study. I give it to pediatricians, internists, family practice docs, psychiatrists, and to anyone I can think of. However this work has been frustrating. It is very difficult to get psychiatrists (and medical professionals) to understand the deep significance of preventing childhood adversity and to act. However, I have been making inroads in the Department of Psychiatry at the University of Michigan and in my own community, and I will continue.”


A children’s hospital starts screening for ACEs

At Phoenix Children’s Hospital in Arizona, about a dozen pediatricians, more than 40 medical residents, all nurses, attendants and front desk staff are undergoing final training to start screening parents and their newborn- to five-year-old children for ACEs. They plan to start screening after reviewing the screening tools other pediatricians around the U.S. are using.  


“We’re rethinking the entire idea about how we take care of kids,” says Dr. Sara Bode, director of community pediatrics. “We’re getting away from the old model of treating only ear infections and colds. This may be more important than anything else we do.”

The clinic, which handles about 20,000 visits annually, has been making this transition over the last couple of years. Besides adverse childhood experiences, the staff also asks about basic necessities, such as housing and food.


Asking all these questions can mean the difference between a healthy and an unhealthy child, says Bode. She tells the story of a woman and her young son, who was born with a heart condition. Over the last couple of years, when the mother brought him in for checkups, the physicians talked with her about the child’s medical complexities and urged her to make sure he was given a specialized formula.


“I’ve seen him at least six times,” says Bode. “And he hasn’t been doing well. We finally did an ACEs and basic needs screening and found out that the mother was a victim of domestic violence, was intermittently homeless because she wanted to leave her partner but was unable to afford it, and couldn’t afford the child’s specialized formula.


“I thought I had been doing a good job because I had been telling her about his medication needs, and how to promote his health. But because I didn’t ask the other questions, I didn’t find out about the things that were affecting his health even more than his heart condition. Yes, they’re social problems, but we know as pediatricians that they are just as important.”


When the mother was asked about ACEs and her basic needs, she broke down in tears, relieved that someone was finally asking her about things that she needed help with, says Bode. The staff found her a place in a domestic violence shelter and signed her up for the WIC program so that she could obtain the specialized formula. Now, both she and her child are thriving, says Bode.


In making the transition to addressing ACEs and basic needs, the clinic’s pediatricians were concerned about two issues: that the screening process be integrated into the flow of the clinic, and making sure they had the tools to help their patients.


The clinic has integrated Healthy Steps, a national program started by the Commonwealth Fund, the American Academy of Pediatrics, and Boston University that includes a developmental and behavioral specialist who works with the parents and pediatrician at every well-baby checkup, a parent hotline, home visits, support groups for parents and families, counseling for parents, referrals to children’s specialists, and social services.


In testing the project, when parents filled out ACE scores for themselves and their children, they were provided information about adverse childhood experiences, and how they affect their own health and the health of their child.


“In our testing of this, we’ve never had any resistance to it,” says Bode. “The physicians and staff understand how important the answers to these questions are in providing the best medical care possible.”


They’re screening for ACEs on parents and their newborns to five-year-olds first to focus on early childhood brain development and develop ways to support attachment between parents and children. “As we get that going, we’ll expand from kids from five to 18 years old,” says Bode.


Developing screening tools for ACEs

In the Bronx, New York, Dr. Rahil Briggs is preparing to take a similar approach to a much larger scale to prevent childhood ACEs that can lead to behavioral issues and physical health problems. She’s developing a program to do ACE screening on tens of thousands of children and their families in the 22 pediatric clinics that are part of Montefiore Medical Group, part of Montefiore Medical Center. The center established wrap-around services for high-risk families in 2006, also with the Healthy Steps program. Briggs, a clinical psychologist, is director of Montefiore’s Healthy Steps, where they’ve been piloting ACEs screening on parents and children for about a year.


“We know our program works,” says Briggs. So far, their research shows that mothers who are part of Healthy Steps use emergency room services less, and the children have healthy social and emotional development, despite their mothers’ history of childhood trauma.


“But now we want to make sure the right people get in the program,” says Briggs. “We don’t have infinite resources. So, we want to identify those who will benefit the most.”


In the pilot, each of the parents reports his or her ACE score, and that of their baby at the first well-baby visit. If either parent has an ACE score of 4 or higher, the family is automatically offered enrollment in Healthy Steps.

The reaction of the parents has been overwhelmingly positive, says Briggs. One mother said, “Now I understand the reason things felt so challenging in my life.” Another said: “I used to think I was just a bad seed. Now I know it’s because I have an [ACE score of] 8.”


“My hope is that people know their ACE score and use it, much like the APGAR scores for babies,” says Briggs. “Any way that provides concrete information about ACEs and experiences, and where they might be at risk, will help parents in trying to keep their baby’s score low,” and thus decrease the risk of their child experiencing trauma and developing behaviors that are currently treated by most pediatricians, psychologists and psychiatrists as abnormal and requiring medication.


In Loma Linda, CA, Dr. Ariane Marie-Mitchell is developing a similar screening tool in the Pediatrics Department at Loma Linda University Medical Center. She hopes to make the tool available to any pediatrician to identify high-risk families. In a pilot study she conducted in Rochester, NY, parents filled out a modified ACE survey on their four- to five-year-old children. They were asked seven questions – the original ACE Study questions minus the queries about physical, sexual and emotional abuse and neglect, because Marie-Mitchell didn't think that parents would answer them accurately. She added a question about maternal education.


She found that the screener identified children at risk for behavioral problems, developmental delay and injury. The study – Adverse childhood experiences: translating knowledge into identification of children at high risk for poor outcomes -- was published in the journal Academic Pediatrics last year.


She’s now doing focus groups on the screening tool at two clinics in Loma Linda – one that serves low-income families and the other that serves patients who have private insurance. Then she’ll gather information about how feasible it is to integrate the tool into practice. She wants to know how the tool affects the patient experience, specifically the effects on visit time, risk factors identified by the pediatrician, community referral rates and patient satisfaction.


“Once we feel we’ve got it right, then we’ll go into an actual trial to test not only the screening tool, but the success of interventions,” she says. She intends to develop screening tools for parents to complete on young children, and for adolescents to complete on themselves. She also wants to experiment with adding questions that predict the risk of maltreatment, in addition to history of maltreatment.


From what she’s learned so far, she believes an ACEs screening tool would be useful no matter what population pediatricians serve. “Low-income kids do accumulate a lot of risk factors and they might be higher for some ACEs,” she says, “but we know that children with high ACE scores can be found across income groups.” The ACE Study participants, who were mostly white, middle- and upper-middle class and had jobs and great health care, reported that childhood maltreatment and family dysfunction were common.

Marie-Mitchell relates the story of a pediatrician who served a wealthy clientele and had particularly good rapport with one parent who was friendly and outgoing. The pediatrician was stunned when she learned the mother had died in her sleep of alcohol intoxication.


“This pediatrician was kicking herself,” says Marie-Mitchell. “She thought she knew this mom so well. She never thought to ask her about alcohol use. Our challenge is how do we get at these things that people don’t volunteer easily, especially if they worry if we’re going to take their kids away from them.”


Some of Marie-Mitchell’s patients tell her that they assume their physicians aren’t interested in that side of their lives; they think their physicians just want to identify the medical problem, prescribe medication and move on.

Marie-Mitchell believes that screening for ACEs in children should be a standard part of well-child care. “It has tremendous power to change the course of someone’s life, if that identification of risk factors is combined with getting the child, family or both the kind of help that they need,” she says.









Add Comment

Comments (4)

Newest · Oldest · Popular

Hi, Kathy -- Thank you for your kind words. Yes, feel free to post....will you link it to the ACEsTooHigh story? It's a little easier to read on there. So honored to be your first guest blogger! 

-- J. 

Dear Jane,

    Congratulations on a fabulous post which can also really get to a total layman!

    Dr. Felitti keeps telling me: "The action is in general primary care medicine."

    Your blog is so clear, I'd love to post your opening paragraphs above and a link jumping to your blog here, on my website, next week Friday August 15.  May I?  Yours would be my very first "Guest Blog" ever and it also goes to my 1,000-person mailing list.



I have a few comments to this most excellent article.

1. I like the cover letter (that at least initially was used with the children’s clinic) in their ACEs screening process. It is readily available on the resilience project website under educational opportunities (ACEs screening questionnaire). I will include it however. In our clinic we aren’t all doing ACEs screening yet but first we will do SEEK (safe environment for every kid). This is because our doctors want to get MOC credit and it is an approved activity – also Dr. Hurowitz is involving the original set with a webinar inservice for those who want to SEEK Moc activity on August 28th. He is the link to the cover letter:

2. Here is a series of correspondence I had with Dr. Teicher about his research on affects on brain development in the context of witnessing violence against siblings. I believe this is an important form of trauma. So I believe question 7 needs tweaking to include not only violence against a parent but also against a sibling.

Here is an Abstract from Dr. Teicher’s Article “Witnessing Violence Towards Siblings: an Understutied but Potent form of Early Adversity”


Research on the consequences of witnessing domestic violence has focused on inter-adult violence and most specifically on violence toward mothers. The potential consequences of witnessing violence to siblings have been almost entirely overlooked. Based on clinical experience we sought to test the hypothesis that witnessing violence toward siblings would be as consequential as witnessing violence toward mothers. The community sample consisted of unmedicated, right-handed, young adults who had siblings (n = 1,412; 62.7% female; 21.8±2.1 years of age). History of witnessing threats or assaults to mothers, fathers and siblings, exposure to parental and sibling verbal abuse and physical abuse, sexual abuse and sociodemographic factors were assessed by self-report. Symptoms of depression, anxiety, somatization, anger-hostility, dissociation and ‘limbic irritability’ were assessed by rating scales. Data were analyzed by multiple regression, with techniques to gauge relative importance; logistic regression to assess adjusted odds ratios for clinically-significant ratings; and random forest regression using conditional trees. Subjects reported witnessing violence to siblings slightly more often than witnessing violence to mothers (22% vs 21%), which overlapped by 51–54%. Witnessing violence toward siblings was associated with significant effects on all ratings. Witnessing violence toward mother was not associated with significant effects on any scale in these models. Measures of the relative importance of witnessing violence to siblings were many fold greater than measures of importance for witnessing violence towards mothers or fathers. Mediation and structural equation models showed that effects of witnessing violence toward mothers or fathers were predominantly indirect and mediated by changes in maternal behavior. The effects of witnessing violence toward siblings were more direct. These findings suggest that greater attention be given to the effects of witnessing aggression toward siblings in studies of domestic violence, abuse and early adversity.

Email Correspondance:

Dr. Teicher,

Hello. I am a pediatrician and am working on using the ACE screening questions in the pediatric office along with resiliency questions. I strongly suspect that observing sibling violence may be more harmful than experiencing that against adults. I saw your article on witnessing violence towards siblings: an understudied but potent form of early adversity, and wondered if you could comment. I have a hard time understanding “relative importance – variance decomposition”. I am a pediatrician and I believe that the question 7 of the ACE screening may miss some significant negative psychological impact in adults exposed during childhood by not including violence towards siblings (anecdotally — my experience of seeing sibling violence was much worse that anything I saw against a parent). Thank you for your time. Your response is much appreciated.

Dear Tina,

I expect that you are correct. We certainly see the predominant effect of witnessing violence to siblings in our data. The “relative importance – variance decomposition” is just a statistical way of accurately indicating the percent variance in clinical ratings that could be accounted for by exposure to different types of maltreatment. It’s a sophisticated way of determining it, which is important because exposure to one type of maltreatment is often correlated with exposure to another type, and this approach untangles the interrelationships.

We’re just starting to look at whether there are brain differences associated with witnessing violence to siblings, and preparing an abstract for presentation as part of a symposium on witnessing interparental violence. I’m hoping for the opportunity to open more eyes to the importance of this type of domestic violence. It also fits with my clinical experience.

We’ve developed a scale to serve as an alternative to the ACE that does include sibling violence (and also physical and emotional peer victimization). Right now it exists as a lengthy research instrument, but it’s more that 2X better than the ACE in predicting adverse psychiatric outcome. I’m about to produce a shortened version and can send you a copy when it is ready, if you wish.

3. I also believe a couple of the other questions should also be modified:

Did you ever live in a foster home or group home to include (were you ever homeless as an adolescent or did you move from friend’s to friend’s house because you could not go back home?)


add: When you were growing up, did you have stable housing (i.e. family wasn’t homeless or living out of an automobile?)

Just a few comments. Thanks

Copyright © 2021, PACEsConnection. All rights reserved.
Link copied to your clipboard.