Toxic Stress Screening

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Other Names
Overview
Adverse Childhood Events (ACEs)
Surveillance and Screening for Toxic Stress
What to Do with a Positive Response
Coding
Resources

Other Names

Adverse childhood events
Child maltreatment
Psychosocial distress
Social determinants of health

Overview

Toxic stress is the strong, unrelieved activation of the body's stress management system in the absence of protective adult support. Moderate, short-lived stress responses can promote emotional growth, but toxic outcomes may result when a child experiences strong, frequent, and/or prolonged adversity or trauma without adequate support from adults to help them cope. Screening for common adversities (often described as Adverse Childhood Experiences or ACEs) and toxic stress by the medical home helps to identify possible risk factors for future medical and mental health conditions, increase communication with families, provide resources to promote resiliency and mitigate the impact of ACEs, and monitor for stress-related health problems in at-risk patients and family members.

The American Academy of Pediatrics (AAP) advises clinicians to consider implementing standardized measures to identify adversities that put children at risk for toxic stress (e.g., maternal depression, parental substance abuse, domestic or community violence, food scarcity, or poor social connectedness). [Garner: 2012] [Shonkoff: 2012] The AAP also advises using structured, trauma-informed assessments to identify and monitor stress-related responses in high-risk families. [Keeshin: 2020]

Adverse Childhood Events (ACEs)

Adverse childhood experiences are common and may include a loss of a parent or divorce, trauma or serious illness, mental illness or incarceration of a family member, exposure to domestic violence, abuse, and neglect. Substantial and growing evidence details the negative impact of ACEs on subsequent development, health, and well-being. The Adverse Childhood Experiences (ACE) Study is one of the largest investigations.

The original Ace Study from 1995 - 1997 involved more than 17,000 members of Kaiser Permanente HMO who answered a questionnaire used to identify 10 different ACEs. Almost 2/3 of the study participants reported at least 1 ACE, and more than 1:5 reported ≥3 ACEs. The short- and long-term outcomes of these childhood exposures include a multitude of health and social problems. The ACE score, which reflects the number of ACEs experienced, is strongly associated with adults, in a graded fashion, with an increased risk for:

Alcoholism and alcohol abuse
Chronic obstructive pulmonary disease
Depression
Fetal death
Poor health-related quality of life
Illicit drug use
Ischemic heart disease
Liver disease
Intimate partner violence

Multiple sexual partners
Sexually transmitted diseases
Smoking
Suicide attempts
Unintended pregnancies
Early initiation of smoking
Early initiation of sexual activity
Adolescent pregnancy

Surveillance and Screening for Toxic Stress

The AAP encourages ongoing screening and surveillance for ACEs and toxic stress. Some pediatricians present a screener at all well-child checkups, whereas others selectively offer screening (e.g., at the 2-, 9- and 15-month, and the 2-, 3-, 4-, and 5-year visits). A limited number of tools are available to screen for ACEs that could lead to toxic stress or for the stress-related symptoms. Most are questionnaires to gather information; a few are formal screens with a cut-off point indicating increased risk.

The following provides some examples of accessible screens and questionnaires that are free or low-cost and relatively easy to integrate into primary care use.

Center for Youth Wellness ACE-Questionnaire (CYW ACE-Q Child, Teen, Teen SR)

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)

Clinicians can register for free to access the questionnaires and users guide: Center for Youth Wellness ACEQ & User Guide.

Safe Environment for Every Kid – SEEK Parent Screening Questionnaire, Revised (PSQ-R)

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.

Available at SEEK Parent Screening Questionnaire (PSQ-R). There is no fee for residents or small practices, or if a physician uses SEEK to obtain MOC 4 credits or Performance Improvement Activity; however, practices with 10 or more physicians or healthcare systems should contact SEEK to inquire about fees.

Survey of Wellbeing of Young Children (SWYC)

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.

Freely available at The Survey of Well-Being of Young Children (Tufts Medical Center).

Pediatric Traumatic Stress Screening Tool

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]

Available at Pediatric Traumatic Stress Screening Tool (Intermountain).

WE CARE Survey

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.

A related clinical trial, Implementing an Intervention to Address Social Determinants of Health in Pediatric Practices (PROSWECARE), is underway. See WE Care Study for more information.

Available at WE Care Survey ( PDF Document

131 KB) - subscription required.

What to Do with a Positive Response

A positive response on a screen for adverse childhood events and toxic stress can be difficult to manage in a short clinic visit. Before using a new tool in clinic, develop a plan for how to respond to positive screens, whether it is through providing empathy, focusing on family strengths, referring to a social worker, or Help Me Grow. The Safe Environment for Every Kid (SEEK) and Poverty & Child Health: Practice Tips (AAP) websites provide guidance to bolster clinician’s efficacy at responding to positive screens and to promote “the 7Cs of resilience (competence, confidence, connectedness, character, contribution, coping, and control), optimism, Reach Out and Read, emotional coaching, and numerous positive parenting programs (e.g., Triple P, Incredible Years, Home visiting, and Nurturing Parenting).” [Garner: 2012]

The AAP offers several courses and interactive learning experiences; every 1-2 years, the AAP offers a 3-day, in-person course, Trauma-Informed Pediatric Provider Course: Addressing Childhood Adversity and Building Resilience (AAP)), which focuses on the day-to-day issues on addressing ACEs and trauma in primary care.

Also, the AAP, through PATTeR, a Category II Center of the National Child Traumatic Stress Network, offers 2 ECHO-based learning experiences focused around addressing ACEs, toxic stress, and trauma from a developmental and attachment-based framework. See Pediatric Approach to Trauma, Treatment and Resilience (PATTeR).

The medical home team should provide ongoing identification and evaluation of primary prevention programs, community resources, and interventions that fit their patient population.

Coding

CPT Coding
Use CPT code 99420 when assessing a child’s risk for adverse childhood events.

ICD-10 Coding
The following codes are appropriate for the common presentations of toxic stress and the experiences leading to it. Consult ICD10Data.com for other presentations.

F43.0, Acute stress reaction
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

Related material on the Medical Home Portal:

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) ( PDF Document 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) ( PDF Document )
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) ( PDF Document 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) ( PDF Document 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	NM	NW		ID	MT	NV	RI
Child Abuse Counseling	21			4	2	1	41
Crisis/Emergency Respite			1	1	1	1	20
Family Counseling	231		66	19	24	20	76
Foster Care/Kinship Care	33	2	50	20	10	12	38
Mental Health Evaluation/Assessment	197		32	12	12	10	154
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.

Authors & Reviewers

Initial publication: September 2015; last update/revision: August 2020

Current Authors and Reviewers:

Author:	Jennifer Goldman-Luthy, MD, MRP, FAAP
Reviewer:	Brooks Keeshin, MD

Authoring history

2020: update: Jennifer Goldman-Luthy, MD, MRP, FAAP^A; Brooks Keeshin, MD^R

2015: first version: Chuck Norlin, MD^A

^AAuthor; ^CAContributing Author; ^SASenior Author; ^RReviewer

Page Bibliography

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).