Toxic Stress Screening
Other Names
Child maltreatment
Psychosocial distress
Social determinants of health
Overview
Adverse Childhood Events (ACEs)
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Surveillance and Screening for Toxic Stress
- Overview: 17-19 item tool to identify patients at increased risk for ACEs. It takes approximately 2-5 minutes to complete. The Child and Teen versions are parent-reports; the Teen SR is a self-report.
- Ages: 3 age-specific versions spanning ages 0-19 years
- Languages: English and Spanish
- Scoring: Those with scores of 0-3 without symptoms should be provided anticipatory guidance; those with scores of 1-3 with symptoms should be provided with referrals for treatment.
- Sensitivity/specificity: N/A (not a validated instrument)
- Overview: 16 yes/no questions that take 2-3 minutes to complete. Parent-completed to identify prevalent psychosocial problems that are risk factors for child maltreatment and that generally jeopardize children's health, development, and safety.
- Ages: 0-5 years. The authors suggest using at the 2-, 9- and 15-month, and the 2-, 3-, 4-, and 5-year visits.
- Languages: English, Spanish. PQ (older version) is available in Chinese, Swedish, and Vietnamese
- Sensitivity/specificity: N/A
- Scoring: Any “yes” responses to key questions is considered abnormal.
- Overview: Comprehensive screening instrument incorporating toxic stress and adverse events as well as routine screening of parental depression, development, social-emotional skills, and autism. Time to implement varies depending on whether one opts to implement individual screening components or the whole package at each well-check.
- Ages: There is a SWYC form for each well-child check from 2 months-5 years.
- Languages: English, Spanish, Khmer, Burmese, Nepali, Portuguese, Haitian-Creole, Arabic, Somali, and Vietnamese
- Sensitivity/specificity: The SWYC forms and components were compiled from various validated screens and have compared well to different gold-standard screens; validation studies are ongoing.
- Scoring: The Survey of Well-Being of Young Children Manual (Tufts Medical Center) has scoring details for each screen.
- Overview: Part of a Child Traumatic Stress Care Process Model, this tool provides an easy way for primary care clinics to either use universal or targeted screening for higher risk individuals. The screens include 15 questions and typically take less 5 minutes to complete.
- Ages: 6-10 years, 11-18 years • Languages: English, Spanish
- Scoring: 0-10 mild – protective approach indicated, 11-20 moderate - resilient approach indicated, >=21 severe – restorative approach indicated. Respond to any positive suicide screening questions. See Child Traumatic Stress Care Process Model for more information on response to screening.
- Sensitivity/specificity: The screens are based on the UCLA PTSD Brief Reaction Index, a validated instrument with sensitivity and specificity of 100%/86% using a cutoff score of 21 when tested in an outpatient pediatric clinic serving potentially traumatized youth. [Rolon-Arroyo: 2020]
- Overview: A 6- to 12-question parent-report tool; component of Well-child visit, Evaluation, Community Resources, Advocacy, Referral, Education model of primary care. Takes <2 minutes to complete. This questionnaire enables families to request assistance with the following: obtaining a GED, employment, housing, daycare, food, and paying bills.
- Ages: Any pediatric visit
- Scoring: Any positive response is considered abnormal. Positive responses are followed-up with the option to discuss with a care provider.
- Sensitivity/specificity: N/A. The original study explained that the content was validated by expert review and showed high test-retest reliability.

What to Do with a Positive Response
Coding
Use CPT code 99420 when assessing a child’s risk for adverse childhood events.
The following codes are appropriate for the common presentations of toxic stress and the experiences leading to it. Consult ICD10Data.com for other presentations.
F43.1x, Post-traumatic stress disorder
F43.2x, Adjustment disorder
F43.8, Other reactions to stress (trauma)
F43.9, Reaction to severe stress, unspecified
T74.x, Child maltreatment, confirmed
T76.x, Child maltreatment, suspected
Z92.49, History of psychological trauma
Resources
Information & Support
For Professionals
Poverty & Child Health: Practice Tips (AAP)
A succinct guide to screening for basic social needs and connecting families to community resources - includes suggested screening
tools; American Academy of Pediatrics.
Helping Foster and Adoptive Families Cope with Trauma: A Guide for Pediatricians (AAP) ( 3.6 MB)
Designed to strengthen clinicians' abilities to identify traumatized children, educate families about toxic stress, and empower
families to respond to children’s behavior in ways that acknowledge past traumas but promote the learning of adaptive reactions
to stress; American Academy of Pediatrics.
Adverse Childhood Experiences (CDC)
Extensive information and resources pertaining to ACEs, including the original CDC-Kaiser Permanente Adverse Childhood Experiences
(ACE) Study; Centers for Disease Control and Prevention.
Social Determinants of Health (Intermountain Healthcare) ()
A care process model with practical strategies for screening, brief intervention at the point of care, and resources to help
address the social determinants of health.
Tackling Toxic Stress (Harvard University)
A series of articles that re-thinks services for children and families based on the science of early childhood development
and an understanding of the consequences of adverse early experiences and toxic stress; Center on Developing Child.
The National Child Traumatic Stress Network (NCTSN)
In-depth information about trauma-informed clinical interventions, screening and assessment practices, disaster behavioral
health response and recovery, culture and trauma, and more.
Child Welfare Information Gateway
Connects child welfare, adoption, and related professionals as well as the public to information, resources, and tools covering
topics on child welfare, child abuse and neglect, out-of-home care, adoption, and more; service of the Children's Bureau,
Administration for Children and Families, U.S. Department of Health and Human Services.
For Parents and Patients
What is Child Traumatic Stress? (NCTSN)
Education and questions and answers about child traumatic stress; National Child Traumatic Stress Network.
Trauma-Focused Cognitive Behavioral Therapy (Therapist Certification Program)
Learn about and find a TF-CBT therapist.
Prevent Child Abuse America
Nonprofit organization that provides information to help providers and parents help prevent child abuse.
Practice Guidelines
Garner AS, Shonkoff JP.
Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong
health.
Pediatrics.
2012;129(1):e224-31.
PubMed abstract
Reaffirmed in 2016, this policy statement explains how the effective reduction of toxic stress in young children could be
advanced considerably by pediatricians.
Keeshin B, Forkey HC, Fouras G, MacMillan HL.
Children Exposed to Maltreatment: Assessment and the Role of Psychotropic Medication.
Pediatrics.
2020.
PubMed abstract
A clinical report that focuses on 2 key issues necessary for the care of maltreated children and adolescents in pediatric
settings: trauma-informed assessments and the role of pharmacotherapy in maltreated children and adolescents.
Patient Education
Bring Out the Best in Your Children (AAP) ( 241 KB)
A 5-page guide for parents with principles (modeling behavior, giving attention, time-outs, motivating with rewards, and seeking
help) to help shape children's behavior; American Academy of Pediatrics.
SEEK Parent Handouts (University of Maryland)
Information for parents about depression, substance abuse, discipline, stress, intimate partner violence, and food insecurity.
Includes lists of national hotlines and other resources.
Trauma-Informed Patient Education (Children's Hospital of Philadelphia)
Downloadable patient education to help: parents help their children cope, children and teens cope with injury and pain or
dealing with traumatic stress reminders, and siblings cope with their brother's or sister's hospitalization, illness, injury,
and recovery. Also includes workbooks for coping with hospitalization.
Tools
Eliciting Parental Strengths and Needs Checklist (Bright Futures) ( 335 KB)
A 7-item checklist to help identify what family concerns should be included in the primary care visit; from the American Academy
of Pediatrics.
Trauma Toolbox for Primary Care (AAP)
This 6-part series was designed with the primary care practice in mind – those who may or may not be familiar with adverse
childhood experiences (ACEs), toxic stress, and the process of asking families about exposure to ACEs or other traumatic events;
American Academy of Pediatrics.
Services for Patients & Families in New Mexico (NM)
Service Categories | # of providers* in: | NM | NW | Other states (5) (show) | | ID | MT | NV | RI | UT |
---|---|---|---|---|---|---|---|---|---|---|
Child Abuse Counseling | 21 | 4 | 1 | 1 | 42 | |||||
Crisis/Emergency Respite | 1 | 1 | 1 | 1 | 19 | |||||
Family Counseling | 231 | 66 | 19 | 22 | 19 | 75 | ||||
Foster Care/Kinship Care | 33 | 2 | 50 | 15 | 10 | 12 | 38 | |||
Mental Health Evaluation/Assessment | 197 | 32 | 11 | 12 | 10 | 158 | ||||
State Abuse/Neglect Agencies | 34 | 31 | 4 | 13 | 1 | 59 |
For services not listed above, browse our Services categories or search our database.
* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.
Studies
Implementing an Intervention to Address Social Determinants of Health in Pediatric Practices (PROSWECARE)
Studies looking at better understanding, diagnosing, and treating this condition; from the National Library of Medicine.
Helpful Articles
Shonkoff JP, Garner AS.
The lifelong effects of early childhood adversity and toxic stress.
Pediatrics.
2012;129(1):e232-46.
PubMed abstract
Reaffirmed in 2016, this technical report presents a framework that illustrates how early experiences and environmental influences
can leave a lasting signature on the genetic predispositions that affect emerging brain architecture and long-term health.
The report also examines extensive evidence of the disruptive impacts of toxic stress.
Eismann EA, Theuerling J, Maguire S, Hente EA, Shapiro RA.
Integration of the Safe Environment for Every Kid (SEEK) Model Across Primary Care Settings.
Clin Pediatr (Phila).
2019;58(2):166-176.
PubMed abstract
This research assesses the generalizability, barriers, and facilitators of implementing the Safe Environment for Every Kid
(SEEK) model for addressing psychosocial risk factors for maltreatment across multiple primary care settings.
Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS.
Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood
Experiences (ACE) Study.
Am J Prev Med.
1998;14(4):245-58.
PubMed abstract
Describes the relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple
risk factors for several of the leading causes of death in adults.
Page Bibliography
Garner AS, Shonkoff JP.
Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong
health.
Pediatrics.
2012;129(1):e224-31.
PubMed abstract
Reaffirmed in 2016, this policy statement explains how the effective reduction of toxic stress in young children could be
advanced considerably by pediatricians.
Keeshin B, Forkey HC, Fouras G, MacMillan HL.
Children Exposed to Maltreatment: Assessment and the Role of Psychotropic Medication.
Pediatrics.
2020.
PubMed abstract
A clinical report that focuses on 2 key issues necessary for the care of maltreated children and adolescents in pediatric
settings: trauma-informed assessments and the role of pharmacotherapy in maltreated children and adolescents.
Rolon-Arroyo B, Oosterhoff B, Layne CM, Steinberg AM, Pynoos RS, Kaplow JB.
The UCLA PTSD Reaction Index for DSM-5 Brief Form: A Screening Tool for Trauma-Exposed Youths.
J Am Acad Child Adolesc Psychiatry.
2020;59(3):434-443.
PubMed abstract
This article summarizes two studies used to develop and validate a brief screen for children and adolescents at risk for developing
posttraumatic stress disorder (PTSD).
Shonkoff JP, Garner AS.
The lifelong effects of early childhood adversity and toxic stress.
Pediatrics.
2012;129(1):e232-46.
PubMed abstract
Reaffirmed in 2016, this technical report presents a framework that illustrates how early experiences and environmental influences
can leave a lasting signature on the genetic predispositions that affect emerging brain architecture and long-term health.
The report also examines extensive evidence of the disruptive impacts of toxic stress.