Guidance for primary care clinicians to screen children and youth for toxic stress

Adverse childhood events (ACEs)
Child maltreatment
Psychosocial distress
Social determinants of health
Traumatic stress

Toxic stress is the strong, unrelieved activation of the body's stress management system at molecular, cellular, and behavioral levels in response to unrelenting adversity without social and emotional support. [Shonkoff: 2012] 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.

Toxic stress response to childhood adversities can be caused by specific and discrete events (such as abuse, bullying, and disasters) and persistent and chronic hardships (such as poverty, racism, neglect). [Garner: 2021]

Screening for common adversities (often described as Adverse Childhood Experiences or ACEs) and toxic stress by the medical home helps 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] In August 2021, the AAP published an updated policy statement in Pediatrics emphasizing the importance of positive childhood experiences in preventing toxic stress and how safe, stable, and nurturing relationships can prevent toxic stress. [Garner: 2021]

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:

The AAP encourages ongoing screening and surveillance for ACEs and toxic stress. Options include screening for experiences that can lead to the development of toxic stress, and other screens focus on detecting symptoms that could be indicative of toxic stress, such as behavioral health and traumatic stress symptoms. 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 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 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 Self Report)

• Available at: Center for Youth Wellness ACEQ & User Guide
• Overview: 17-19 questions screening for stressful or traumatic events experienced before age 18. They are grouped into 3 categories: abuse, neglect, and household dysfunction. The Child and Teen versions are parent-reports; the Teen SR is a self-report.
• Time: 2-5 minutes to complete
• Ages: Child (0-12 yo), Teen (13-19 yo)
• Languages: English and Spanish
• Scoring: ACE scores of 0-3 without symptoms should be provided anticipatory guidance; ACE scores of 1-3 with symptoms or ≥4 should be referred for treatment.
• Sensitivity/specificity: N/A (not a validated instrument)

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

• Available at: SEEK Parent Screening Questionnaire (PSQ-R)
• Overview: 16 yes/no questions. Parent-completed to identify prevalent psychosocial problems that are risk factors for child maltreatment and that generally jeopardize children's health, development, and safety.
• Time: 2-3 minutes to complete
• 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, Italian, Chinese & Portuguese. (Variations in Vietnamese, Swedish, Sorani, Thai, Tigrinya, Turkish, Arabic, Bengali, Dari, Finnish, Kurmanji, Russian and Somali)
• Scoring: Any “yes” response is a positive screen. SEEK provides algorithms to help assess and address key positive screens
• Sensitivity/specificity: N/A

Survey of Wellbeing of Young Children (SWYC)

• Available at: The Survey of Well-Being of Young Children (SWYC)
• Overview: Comprehensive screening instrument incorporating developmental milestones, behavioral/emotional development, and family risk factors. At certain ages, a section for autism-specific screening is also included.
• Time: Varies depending on whether one opts to implement individual screening components or the whole package at each well-check
• Ages: 2 months-5 years
• Languages: English, Spanish, Burmese, Nepali, Portuguese, Haitian-Creole, Vietnamese, Somali and Arabic
• Scoring: The Survey of Well-Being of Young Children Manual (Tufts Medical Center) has scoring details for each screen (cut-offs vary by age).
• Sensitivity/specificity: The SWYC forms and components were compiled from validated screens and compared well to different gold-standard screens; validation studies are ongoing.

Pediatric Traumatic Stress Screening Tool

• Available at: Child Traumatic Stress Care Process Model
• Overview: Provides an easy way for primary care clinics to either use universal or targeted screening for higher-risk individuals. The screens include 15 questions.
• Time: 5 minutes to complete
• Ages: 6-10 years, 11-18 years
• Languages: English
• 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 cut-off score of 21 when tested in an outpatient pediatric clinic serving potentially traumatized youth. [Rolon-Arroyo: 2020]

WE CARE Survey

• Available at: WE CARE Survey
• Overview: 6- to 12-questionnaire about social determinants of health screening and a referral intervention tool
• Time: 2 min to complete.
• Ages: Any pediatric visit
• Scoring: Any “yes” responses are followed up with the option to discuss with the care provider; an additional “yes" requires guidance with community resources.
• Sensitivity/specificity: N/A. The original study explained that the content was validated by expert review and showed high test-retest reliability.

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 responding to positive screens, whether it is through providing empathy, focusing on family strengths, referring to a social worker, or Help Me Grow National Center. Safe Environment for Every Kid (SEEK) and Poverty & Child Health: Practice Tips (AAP) provide guidance to bolster clinicians' efficacy at responding to positive screens and 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 (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 [case-based webinar]-based learning experiences focused on 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.

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