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Child Psychiatrist /Adult Psychiatrist

What Toxic Stress Can Do to Health

We recently shared a clinical case drawn from a family medicine practice about the effect of adverse childhood experiences (ACEs) on health. The widespread epidemiology and significant health consequences require a focus on the prevention and management of ACEs.


Toxic Stress

The Centers for Disease Control and Prevention published an important monograph on ACEs in 2019. Although it is evidence based, most of the interventions recommended to reduce ACEs and their sequelae are larger policy and public health efforts that go well beyond the clinician's office. Important highlights from these recommended strategies to reduce ACEs include:


  • Strengthen economic support for families through policies such as the earned income tax credit and child tax credit.

  • Establish routine parental work/shift times to optimize cognitive outcomes in children.

  • Promote social norms for healthy families through public health campaigns and legislative efforts to reduce corporal punishment of children. Bystander training that targets boys and men has also proven effective in reducing sexual violence.

  • Facilitate early in-home visitation for at-risk families as well as high-quality childcare.

  • Employ social-emotional learning approaches for children and adolescents, which can improve aggressive or violent behavior, rates of substance use, and academic success.

  • Connect youth to after-school programs featuring caring adults.


But clinicians still play a vital role in the prevention and management of ACEs among their patients. Akin to gathering a patient's past medical history or family history is initiating universal ACE screening in practice and exploring related topics in conversation.

The ACEs Aware initiative in California provides a comprehensive ACE screening clinical workflow to help implement these conversations in practice, including the assessment of associated health conditions and their appropriate clinical follow-up. While it is encouraged to universally screen patients, the key screenings to prioritize for the pediatric population are "parental depression, severe stress, unhealthy drug use, domestic violence, harsh punishment, [and] food insecurity." Moreover, a systematic review by Steen and colleagues shared insight into newer interpretations of ACE screening which relate trauma to "[...] community violence, poverty, housing instability, structural racism, environmental blight, and climate change."


These exposures are now being investigated for a connection to the toxic stress response. In the long term, this genetic regulatory mechanism can be affected by "high doses of cumulative adversity experienced during critical and sensitive periods of early life development — without the buffering protections of trusted, nurturing caregivers and safe, stable environments." This micro and macro lens fosters a deeper clinician understanding of a patient's trauma origin and can better guide appropriate clinical follow-up.


ACE-associated health conditions can be neurologic, endocrine, metabolic, or immune system–related. Early diagnosis and treatment of these conditions can help prevent long-term healthcare complications, costly for both patient and the healthcare system.

After the initial clinical assessment, physicians can educate patients about the ways that ACE-associated health conditions are a consequence of toxic stress exposure. From there, physicians should rely on a broader integrated health team, within the health system and the community to offer clinical interventions and services to mitigate patients' toxic stress. The ACEs Aware Stress Buster wheel highlights seven targets to strategize stress regulation. This wheel can be used to identify existing protective factors for patients and track treatment progress, which may buffer the negative impact of stressors and contribute to health and resilience.


The burden of universal screenings in primary care is high. Without ACE screening, however, the opportunity to address downstream health effects from toxic stress may be lost. Dubowitz and colleagues suggest ways to successfully incorporate ACE screenings in clinical workflow:


  • Utilize technology to implement a streamlined referral processing/tracking system

  • Train clinicians to respond competently to positive ACE screens

  • Gather in-network and community-based resources for patients


In addition, prioritize screening for families with children younger than 6 years of age to begin interventions as early as possible. Primary care clinicians have the unique opportunity to provide appropriate intervention over continual care. An intervention as simple as encouraging pediatric patient involvement in afterschool programs may mitigate toxic stress and prevent the development of an ACE-associated health condition.


Note: This article originally appeared on Medscape.

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