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Accounting for ACE to Maximize Outcomes in Pediatric Patients


Old sins cast long shadows.

Bad things happen to everyone ... but for some, an onslaught of adverse childhood experiences translates into physical, mental and emotional health issues that linger long into adulthood.

The landmark Adverse Childhood Events (ACE) study was conducted just over two decades ago as a collaborative research project between the Centers for Disease Control and Prevention and Kaiser Permanente's Health Appraisal Clinic in San Diego. The study - which was led by Vincent Felitti, MD, and Robert Anda, MD, MS - looked at the data of more than 17,000 HMO members and found a clear correlation between being exposed to adverse childhood experiences and long-lasting health issues as adults. Furthermore, risk increased alongside the ACE score, with those experiencing four or more adverse events having a significantly higher risk for later health complications.

Jack Levine, MD, FAAP, who sits on the executive committee of the American Academy of Pediatrics (AAP) Section on Developmental and Behavioral Pediatrics and is board certified in the subspecialty, said the original ACE study included 10 adverse experiences in calculating a child's score:

  • Physical Neglect,
  • Physical Abuse,
  • Emotional Neglect,
  • Emotional Abuse,
  • Sexual Abuse,
  • Domestic Violence,
  • Household Substance Abuse,
  • Parental Mental Illness,
  • Separation from Parents or Divorce, and
  • Incarcerated Household Member.

The original findings have been reaffirmed over the last 20 years, and the AAP in conjunction with the Harvard Center on the Developing Child has added to that body of knowledge by highlighting the negative impact of toxic stress, which disrupts and/or damages neural functioning during periods of extreme or repetitive stress. As a result, the AAP created a technical report and a policy statement that included a framework outlining the need for pediatricians and family practitioners to actively participate by helping translate advances in developmental sciences into effective interventions in the home, clinic, and community.

Jack Levine, MD, FAAP

A practicing pediatrician in Queens, N.Y., for more than 30 years, Levine said toxic stress encompasses ACEs but is broader. "It's also unrelenting stress ... ongoing stress with no buffer such as poverty and racism," he explained. He added no one is immune to stress, but there are different levels of trauma. Not getting a gaming system for a birthday or holiday might be stressful to a child, but it is transitory. Larger stressors, including natural disasters, clearly have a greater impact on children but often lessen over time with family and community supports to help bring back a sense of normality. Toxic stress, however, is relentless.

"The response to stress - increased adrenaline, cortisol - is protective. If you see a tiger, you run or climb a tree," said Levine. "Toxic stress is like when the tiger lives in the house with you. You're constantly in this heightened state of awareness and that causes permanent effects on the body and on the brain."

Levine continued, "The area of the brain that can be damaged is the prefrontal cortex, which controls impulsivity, problem-solving, and higher abstract thinking." He noted there is also evidence the hippocampus and amygdala, which are part of the limbic system and associated with the functions of feeling and reacting, are also susceptible to permanent damage with toxic stress.

Some of the long-term consequences of such damage include higher rates of substance abuse, poor lifestyle choices and impulse control, anger, anxiety, depression, suicidal ideation, developmental delays, lower immune function, early heart disease, and diabetes. The overwhelming evidence of the negative impact of ACE and toxic stress led the AAP to strongly oppose the recent separation of children from parents at the border.

In a statement, AAP President Colleen Kraft, MD, MBA, FAAP, noted, "Separating children from their parents contradicts everything we stand for as pediatricians - protecting and promoting children's health. In fact, highly stressful experiences, like family separation, can cause irreparable harm, disrupting a child's brain architecture and affecting his or her short- and long-term health. This type of prolonged exposure to serious stress - known as toxic stress - can carry lifelong consequences for children."

Levine added, "The thing about the children separated at the border is they have already suffered significant, significant trauma in their home country and on the way here."

He added the boys on the soccer team in Thailand, which also dominated recent headlines, were separated from family and endured a prolonged state of fear, as well. However, he noted, the team had the advantage of having strong support from a worldwide audience, knowledge that there were people who cared for them and were trying to rectify their situation, and medical care waiting at the end of the ordeal. Levine was quick to add that doesn't mean the boys and coach won't have emotional issues down the road, but they do seem to have a support system in place to monitor their ongoing progress.

For those separated at the border, many of whom had still not been reunited with parents at press time, Levine said, "It's going to take a long time for them to be able to trust people again and be able to form normal social relationships ... certainly without intensive help."

While migrant children and a Thai soccer team might seem far removed, Levine said the issues highlighted from these two recent news events mirror what children face in the local community, as well. Children throughout the area face stressors ranging from ongoing food insecurity to having a parent deployed on active military duty to being part of the foster care system.

Considering the evidence of the generational impact of childhood trauma, Levine said he believes physicians should be screening for ACEs. "It's come around slowly that we're screening for food insecurity and domestic violence now routinely ... and we're also screening pretty routinely for post partum depression. I think it's just a matter of time before screening for toxic stress becomes part of the routine well visit," Levine stated.

However, he cautioned, providers shouldn't take on a fatalistic attitude that having four ACEs dooms a child. "The proper intervention can be very productive," he pointed out. In fact, Levine continued, such screening can help uncover misdiagnoses that often occur based on outward behaviors. "Kids can become very lethargic because of toxic stress, and people think it's depression," he said. "Some of these effects (of toxic stress) look like psychiatric disorders, and kids are being medicated."

The good news, Levine continued, is dispensing trauma-informed care and helping connect caregivers with community resources can go a long way. "More and more people are understanding the effects of early trauma and how it can look like other things. It's changed the whole course of how we deal with young people. There's a lot of hope," he concluded.


American Academy of Pediatrics

The AAP Resilience Project

AAP Policy Statement on Toxic Stress and Role of Pediatrician:


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AAP, ACE, Adverse Childhood Event, Adverse Childhood Experience, American Academy of Pediatrics, Behavioral Health, Childhood Development, Jack Levine, Toxic Stress
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