How to talk to parents about adverse childhood experiences: Tips for physicians
An estimated 62% of adults surveyed across 23 states reported that they had experienced one ACE during childhood and nearly one out of four reported that they had experienced three or more ACEs. ACEs and toxic stress can have profound impacts on the physical and mental health of pediatrics.
Through clear education, active listening, and actionable recommendations, physicians can assess and mitigate the effects of ACEs and toxic stress in their patients.
Here, Dr. Sheila Modir, pediatric psychologist at CHOC, provides scripting recommendations and strategies for assessing ACEs to community physicians.
View the ACEs scripting strategies in the following video from CHOC:
What are ACEs?
Adverse Childhood Experiences, or ACEs, are traumatic events that happen during the first 18 years of life and can result in physical, developmental, and behavioral health problems, including a shortened lifespan.
Examples of these types of traumatic events include experiencing or witnessing physical violence at home; being repeatedly put down, humiliated, or ignored by a caregiver; and not being protected from unsafe situations or cared for when sick or injured.
Situations influencing a child’s sense of safety, stability, and bonding may also be considered ACEs. These may include growing up in a household with substance misuse, mental health problems or instability due to parental separation or the incarceration of a family member.
What are some examples of ACEs-related health conditions?
Research has found that ACEs, and exposure to other stressful things can lead to something called toxic stress in your body. Toxic stress has been associated with several health conditions. Below are some of the physical, behavioral, and mental health outcomes for children who have experienced trauma.
Health
- Failure to thrive
- Obesity
- Diabetes
- Cancer
- Heart disease
- Stroke
- Asthma
Behaviors
- Alcoholism
- Smoking
- Drug use
- Unsafe sex
Mental Health
- Depression
- Anxiety
- Suicide attempts
- Posttraumatic stress (PTSD)
ACEs scripts and screening techniques for physicians
ACES Aware, an initiative led by the Office of the California Surgeon General and the Department of Health Care Services, says that because ACEs are common and their impact on health is under-recognized, routine screening offers an important opportunity for prevention by educating all patients about ACEs, toxic stress, and protective factors; helping patients make the connection between toxic stress and health; and providing anticipatory guidance to help them effectively manage stress.
Depending on the patient’s score on the ACEs and Toxic Stress Risk Assessment Algorithm for pediatrics, physicians should use the following strategies:
Lower risk of toxic stress: 0 ACEs
If the patient displays a lower risk of toxic stress of zero ACEs, physicians should provide education and anticipatory guidance on ACEs, toxic stress and buffering factors.
Physicians should use the following scripting strategies with their patients and families:
“Thank you for completing the form about certain events your child has experienced. It gives us information that helps us to better care for your child. From what I see on the form, your child has not experienced any of the things listed here. Is that correct?”
“We know that ACEs may occur at different points in life, so if you do experience any of these, don’t hesitate to check in with us because the science tells us that early intervention can help prevent negative physical and mental health outcomes.”
“These things may include having healthy relationships with family and friends, eating healthy foods, getting regular exercise, spending time outside in nature, having a regular bedtime and getting enough sleep.”
Intermediate risk of toxic stress: 1 to 3 ACEs
If a patient displays an intermediate risk of toxic stress, or a score of one to three ACEs, without ACE-associated health conditions, physicians should also provide education and anticipatory guidance on ACEs, toxic stress and buffering factors.
Physicians should use the following scripting strategies with their patients and families:
“I see from this form that your child has experienced some of the things listed here. We now understand that exposure to stressful or traumatic experiences may alter the amount of stress hormones that your child’s body makes, and this can increase the risk for health and developmental problems.”
“The good news is that we also have strategies that have been shown to help children and adults calm the stress response. These include things like good nutrition, healthy sleep, spending time in nature, regular exercise, mental health support, mindfulness, and healthy relationships.”
“Which of these strategies would you be interested in trying to help manage stress? Let’s make a plan for how you can try these strategies during your day.”
For further resources and handouts for patients on stress busters, visit www.acesaware.org/managestress
High risk of toxic stress: 1-3 ACEs with ACE-associated health conditions OR 4 + ACEs with/without ACE-associated health conditions
If a patient displays a high risk of toxic stress, or one to three ACEs with ACE-associated health conditions or four or more ACEs with/without ACE-associated health conditions, physicians should provide education about toxic stress and its likely role in the patient’s health condition(s).
They should also assess protective factors, jointly formulate a treatment plan and link families to support services and interventions, as appropriate.
Physicians should use the following scripting strategies with their patients and families:
“I see that you answered “yes” to several questions, and your child’s ACEs may be contributing to their [poor growth/ asthma/ diabetes/other ACE-associated health condition].”
“It is possible that because of what your child has experienced or is experiencing, their body is making more stress hormones than it should. This could be what’s affecting their growth.”
“I want to refer you to a specialist that can help you and your child and help reduce the amount of stress hormones that your child’s body is making.”
“We also know that a healthy caregiver is one of the most important ingredients for healthy children so an important part of helping your child heal will involve managing your own stress level and practicing taking care of yourself.”
References
- ACEs AWARE: Official website for the ACEs AWARE initiative
- ACEs AWARE Screening Tools
- ACEs AWARE Provider Toolkit
- Link Tree of Resources
CHOC ACEs resources for parents:
- CHOC’s guide to trauma and ACEs for parents and caregivers
- Tips for parents and caregivers to support children through trauma and ACEs
- How to increase resiliency in children overcoming ACEs
- Tips for kids and teens overcoming trauma and ACEs
CHOC ACEs resources with video for kids and teens:
Learn more about CHOC’s pediatric mental health services
At CHOC, we specialize in providing a full continuum of pediatric mental healthcare, including inpatient, intensive outpatient and outpatient program services.
