Adverse Childhood Experience Screening in the Primary Care Setting: The Importance of Resilience 11/7/19

Ever since Dr. Vincent Felitti led the 1998 study of adverse childhood experiences (ACEs), the impact of trauma on health outcomes has been more closely studied and more widely appreciated.

Of course, in the realm of behavioral health, trauma has long been seen as a factor shaping more often than not a damaged sense of self and provoking deleterious symptoms. Yet, it was not until the lifelong impacts of ACEs were more broadly studied and appreciated that the full, and at times profound, implications to physical health and to emotional development have become fully appreciated.  The bottom line: exposure to trauma in childhood increases the risk and prevalence of negative health and psychological outcomes throughout the lifespan.

We are now in an era where the primary care setting is attempting to adjust to these findings, and in consequence the call for screening for trauma in primary care has increased.  The endeavor to implement trauma screening in the primary care setting generally, and in the pediatric setting in particular, however brings challenges. To do so effectively will require a system-wide effort, including changes at the policy level, increased coordination of resources in clinical practice, and ultimately more in-depth research about efficacy and outcomes.

For the individual practitioner, the prospect of screening for trauma can be daunting. A recent review  (Barnes et al, 2019) proposed several recommendations for clinicians, which are worth reviewing for those who are getting ready to start or in the process of implementing screening.  For all practitioners, however, it is important to consider the following recommended perspective and practices:

“Concurrently identify protective factors and social determinants of health along with ACEs, to better understand strengths and resources.

Discuss with all families ways to prevent ACEs, and mitigate/moderate the effects of existing ACEs, using a resilience-informed approach” (Ibid, pg 6)

Understanding the types and mechanisms of resilience and learning how to help patients and families enhance protective factors is thus a critical parallel field for clinical intervention and study.  We’ve got lots to learn and lots to do.

Fortunately, there are multiple approaches to identifying and promoting resiliency, and these should play a key part in the effective implementation of trauma screening.

Traub and Boynton propose several modifiable resilience factors (Traub and Boynton, 2017) that have potential for enhancement through appropriate clinical intervention.

These include:

– recognition of and support for the individuals’ (child’s and parent’s) positive cognitive traits, including positive appraisal style and effective executive function skills

– enhancing parenting skills and capacities

– recognizing and attending to maternal (and paternal) mental health and practical life needs

– advancing self-care skills and promoting positive household and daily life routines

– advancing awareness, appreciation and understanding of trauma responses and the means by which ameliorative interventions can be provided.

Attention to these factors can better enable clinicians to assist their patients in coping with their trauma exposure and, when indicated, finding practical therapeutic interventions and supports.   Whether provided solely in the primary care office or made available through referrals, new protocols for intervention need to be developed and clinician education in this arena needs to be advanced.

While but just one component of a comprehensive screening and intervention plan, defining means for promoting resiliency is likely to expand in the future.


American Academy of Pediatrics Task Force on Mental Health. Appendix S4: the case for routine mental health screening. Pediatrics 125, S133–S139 (2010).

Barnes, A. J., Anthony, B. J., Karatekin, C., Lingras, K. A., Mercado, R., & Thompson, L. A. (2019). Identifying adverse childhood experiences in pediatrics to prevent chronic health conditions. Pediatric Research, (April).

Felitti et al. (1998) Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults The Adverse Childhood Experiences (ACE) Study. The American Journal of Preventative Medicine Vol 1 No. 4 1998. 

Masten, A., & Barnes, A. (2018). Resilience in Children: Developmental Perspectives. Children5(7), 98.

Traub, F., & Boynton-Jarrett, R. (2017). Modifiable resilience factors to childhood adversity for clinical pediatric practice. Pediatrics139(5).

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