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Behavioral screening instruments for children in Primary Care.

Research in primary care settings has recently begun to examine the association between “adverse” childhood experiences (ACE) and physical or psychological health and development, including health risk behaviors and disease.1 These adverse experiences can include any of the following:2

• Lived with a parent or guardian who got divorced or separated;
• Lived with a parent or guardian who died;
• Lived with a parent or guardian who served time in jail or prison;
• Lived with anyone who was mentally ill or suicidal, or severely depressed for more than a couple of weeks;
• Lived with anyone who had a problem with alcohol or drugs;
• Witnessed a parent, guardian, or other adult in the household behaving violently toward another (e.g., slapping, hitting, kicking, punching, or beating each other up);
• Was ever the victim of violence or witnessed any violence in his or her neighborhood;
• Experienced economic hardship “somewhat often” or “very often” (i.e., the family found it hard to cover costs of food and housing).

National studies in the U.S. highlight that up to 67.3% of children have been exposed to at least one of the above listed adverse childhood experiences.3 Furthermore, if an individual has experienced a single ACE, the likelihood of them having another can be anywhere from 2 to 18 times higher than those reporting no adverse experiences. Economic hardship tends to be the most common ACE reported nationally and in almost all states, followed by divorce or separation of a parent or guardian.2 The prevalence of most ACEs naturally increases by age; older children are more likely than younger to have ever experienced each of the ACE, except for economic hardship (which is reported for 25 to 26% of children regardless of age in the U.S.) families.2 In Florida, economic hardship tends to be the most prevalent ACE (30% prevalence), followed by divorce (20%), and incarceration (8%).

The impact of exposure to these stressful, adverse, experiences can be detrimental to a child’s development and can include “functional scars” in brain regions necessary for emotional regulation, attention, problem-solving, and learning.4 These changes in brain function and development can negatively impact executive functioning, which is essential for self-regulation.5, 6

Unmitigated adverse childhood experiences are also associated with a host of poor mental health outcomes, including depression, suicidality, anxiety disorders, personality disorders, and substance use disorders. 7 Of more concern is that with the accumulation of four or more adverse exposures during childhood, the risk for depression increases four to five-fold and the risk for suicidality increases 12-fold.8

Not only is poor mental health a risk, but exposure to adverse childhood experiences has also been linked to multiple short and long-term physical consequences.9 For instance, children exposed to ACE are at high risk for a number of negative health outcomes in adulthood, including cardiovascular disease, obstructive pulmonary disease, cancer, asthma, and autoimmune disease. 10

For decades, leaders in the field of pediatrics have argued that addressing a child’s social needs falls within the purview of the child health provider.11, 12 Numerous American Academy of Pediatrics policy statements and Bright Futures health supervision guidelines support this view and have been published in an effort to reinforce this practice.13 Many clinicians, however, fail to screen for adverse childhood experiences. In one study, for instance, nearly one-third of pediatricians did not usually ask about any ACE, and those who did not feel responsible for screening for family factors had significantly lower odds of usually asking about ACE.14 One step to help improve the frequency of screening for ACE is including appropriate screening measures into clinical workflows.


1Kalmakis, K. A., & Chandler, G. E. (2014). Adverse childhood experiences: towards a clear conceptual meaning. Journal of advanced nursing, 70(7), 1489-1501.

2Sacks, V., Murphey, D., and Moor, K. (2014). Adverse childhood experiences: National and state-level prevalence. Child Trends, 1-11.

3Dong M, Giles W. H., Felitti V. J., Dube S. R., Williams J. E., Chapman D. P., Anda R. F. (2004). Insights into causal pathways for ischemic heart disease: adverse childhood experiences study. Circulation, 110(13).

4Bock J., Riedel A., Braun K. (2012). Differential changes of metabolic brain activity and interregional functional coupling in prefronto-limbic pathways during different stress conditions: functional imaging in freely behaving rodent pups. Frontier in Cellular Neuroscience, 6(19).

5Johnson, S., Riley, A., Granger, D., & Riis, J. (2013). The science of early life toxic stress for pediatric practice and advocacy, Pediatrics, 131, 319-327.

6Shonkoff, J. P., Boyce,W. T., & McEwen, B. S. (2009). Neuroscience, molecular biology, and the childhood roots of health disparities: Building a new framework for health promotion and disease prevention. Journal of the American Medical Association, 301(21), 2252–2259.

7Chapman, D. P., Dube, S. R., & Anda, R. F. (2007). Adverse childhood events as risk factors for negative mental health outcomes. Psychiatric Annals, 37(5), 359–364.

8Burke-Harris, N. (2014). How childhood trauma effects health across a lifetime. TED Talk. Retrieved from:

9Felitti, V. (2009). Adverse childhood experiences and adult health. Academic Pediatrics, 9, 131-132.

10Garner, A., & Shonkoff, J. (2012). Early childhood adversity, toxic stress, and the role of the pediatrician: Translating developmental science into lifelong health. Pediatrics, 129(1), e224-e231.

11Haggerty, R. J., Roghmann, K. J., & Pless, I. B (1975). Child Health and the Community. New York, NY: John Wiley and Sons.

12Palfrey J. S., Tonniges, T. F., Green, M., & Richmond, J. (2005). Introduction: addressing the millennial morbidity - the context of community pediatrics. Pediatrics, 115: 1121-1123.

13Hagan, J. K., Shaw, J.S., & Duncan, P.M. (2008). Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.

14Kerker, B.D., Storfer-Iser, B.D., Garner, A., Szilagy, M., O’Connor, K., Hoagwood, K., Stein, R.E.K., & Horwitz, S.M. (2015). Identifying adverse childhood experiences (ACEs) in Pediatric Primary Care. Paper presented at the 2015 Pediatric Academic Societies Annual Meeting.