Welcome to the training on Addressing Adverse Childhood Experiences through Trauma-Informed Care provided by the Texas Health and Human Services Commission (HHSC) and the Texas Department of State Health Services (DSHS).
The goal of this module is to equip Texas Health Steps providers and other health-care professionals to recognize adverse childhood experiences (ACEs), the resulting trauma and toxic stress, screen for health consequences and provide culturally sensitive trauma-informed care for children and adolescents.
Texas Health Steps providers and other interested health-care professionals.
Specific Learning Objectives
After completing the activities of this module, you will be able to:
- Specify the nature of adverse childhood experiences (ACEs), their impact on short- and long-term health and the providers’ role in addressing them.
- Apply ethical guidelines for reporting suspected abuse and neglect.
- Assess the steps required to provide culturally effective and equitable trauma-informed care to children, adolescents and caregivers affected by ACEs.
Please note this module expires on 4/23/2024.
This module was released on 4/23/2021.
Continuing Medical Education
The Texas Department of State Health Services, Continuing Education Service is accredited by the Texas Medical Association to provide continuing medical education for physicians.
The Texas Department of State Health Services, Continuing Education Service designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The Texas Department of State Health Services, Continuing Education Service is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. The Texas Department of State Health Services, Continuing Education Service has awarded 1.25 contact hour(s) of Continuing Nursing Education.
Licensed Marriage and Family Therapists
The Texas Department of State Health Services, Continuing Education Service, the continuing education provider, ensures that the education provided is related to the practice of marriage and family therapy; and that the individuals presenting the information have the necessary experience and knowledge in the topics presented. The Texas Department of State Health Services, Continuing Education Service has awarded 1.25 hours of credit.
Licensed Professional Counselors
Up to 1.25 LPC hours may be earned at this event.
The Texas Department of State Health Services, Continuing Education Service, the continuing education provider, ensures that the education provided is directly related to the practice of social work; and that the individuals presenting the information have the necessary experience and knowledge in the topics presented. The Texas Department of State Health Services, Continuing Education Service has awarded 1.25 hours of credit.
Certificate of Attendance
The Texas Department of State Health Services, Continuing Education Service has designated 1.25 hour(s) for attendance.
Certified Community Health Worker
The Texas Department of State Health Services, Promotor(a)/Community Health Worker Training and Certification Program has certified this course for 1.25 contact hour(s) of continuing education for Certified Community Health Workers and Community Health Worker Instructors.
One of the requirements of continuing education is disclosure of the following information to the learner:
- Notice of requirements for successful completion of continuing education activity. To receive continuing education credit the learner must successfully complete the following activities:
- Create a Texas Health Steps account.
- Complete on-line registration process.
- Thoroughly read the content of the module.
- Complete the on-line examination.
- Complete the evaluation.
- Commercial Support.
The THSTEPS Web-based Continuing Education Series has received no commercial support.
- Disclosure of Relevant Financial Relationships.
The THSTEPS Continuing Education Planning Committee and the authors of these modules have no relevant financial relationships to disclose.
- Non-Endorsement Statement.
Accredited status does not imply endorsement of any commercial products or services by the Department of State Health Services, Continuing Education Service; Texas Medical Association; or American Nurse Credentialing Center.
- Off-Label Use.
Using a disclosure review process, the THSTEPS Continuing Education Planning Committee has examined documents and has concluded that the authors of these modules have not included content that discusses off-label use (use of products for a purpose other than that for which they were approved by the Food and Drug Administration).
The following are policies and definitions of terms related to continuing education disclosure:
The intent of disclosure is to allow Department of State Health Services (DSHS) Continuing Education Service the opportunity to resolve any potential conflicts of interest to assure balance, independence, objectivity and scientific rigor in all of its Continuing Education activities.
All faculty, planners, speakers and authors of Department of State Health Services (DSHS) Continuing Education Service sponsored activities are expected to disclose to the Department of State Health Services (DSHS) Continuing Education Service any relevant financial, relationships with any commercial or personal interest that produces health care goods or services concerned with the content of an educational presentation. Faculty, planners, speakers and authors must also disclose where there are any other potentially biasing relationships of a professional or personal nature.
Glossary of Terms
Conflict of Interest: Circumstances create a conflict of interest when an individual has an opportunity to affect Continuing Education content about products or services of a commercial interest with which she/he has a financial relationship or where there are any other potentially biasing relationships of a professional or personal nature.
Commercial Interest: Any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
Financial Relationships: Those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, teaching, membership on advisory committees or review panels, board membership, and other activities for which remuneration is received or expected. Relevant financial relationships would include those within the past 12 months of the person involved in the activity and a spouse or partner. Relevant financial relationships of your spouse or partner are those of which you are aware at the time of this disclosure.
Off Label: Using products for a purpose other that that for which it was approved by the Food and Drug Administration (FDA).
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- Adverse Childhood Experiences (ACE) Study. Major findings, statistics and other tools housed on the Centers for Disease Control and Prevention (CDC) website.
- Ages and Stages (ASQ). Parent-completed developmental and social-emotional screening tools designed to help pinpoint delays as early as possible.
- American Academy of Pediatrics. Bright Futures Tool and Resource Kit.
- American Academy of Pediatrics, Committee on Child Abuse and Neglect. (2010). Child Abuse, Confidentiality, and the Health Insurance Portability and Accountability Act. Pediatrics, 125(1), 197-201.
- American Academy of Pediatrics, Committee on Substance Use and Prevention. Key Resources.
- American Academy of Pediatrics, Evidence-Based Child and Adolescent Psychosocial Interventions.
- American Academy of Pediatrics’ Healthy Foster Care America. Trauma Guide.
- American Academy of Pediatrics. Mental Health Initiatives.
- American Academy of Pediatrics. National Resource Center for Patient/Family-Centered Medical Home.
- American Academy of Pediatrics. Screening Time website. Resources for screening for developmental concerns and social determinants of health.
- American Academy of Pediatrics. (2014). Trauma Toolbox for Primary Care.
- Center for the Study of Traumatic Stress. Comprehensive fact sheets on all aspects of military trauma and its effects on military children and families.
- Child and Adolescent Needs and Strengths Trauma Exposure and Adaptation Version (CANS-TEA). An information integration tool for children and adolescents exposed to traumatic events.
- Children’s Mental Health Child & Youth Assessment Services. Texas Health and Human Services Commission.
- Clinical Assessment Tools, from the AAP Resilience Project.
- Culturally-Sensitive Trauma-Informed Care. Part of the Children’s Hospital of Philadelphia Health Care Toolbox, featuring key component explanations and provider materials that include questions to ask patients and care delivery tips.
- Evidence-Based Child and Adolescent Psychosocial Interventions, a chart of evidence-based child and adolescent psychosocial interventions that includes traumatic stress as one of the presenting problems. Updated by the AAP as new research emerges.
- Links to Commonly Used Screening Instruments and Tools. From the AAP’s Bright Futures Tool & Resource Kit, includes Edinburgh Postpartum Depression Scale, Patient Health Questionnaires (PHQs) PHQ-9 and more.
- National Child Traumatic Stress Network. Clearinghouse of materials on child traumatic stress arranged by audience, topics and online research.
- Parents’ Evaluation of Developmental Status (PEDS). Texas-specific information about PEDS, a developmental-behavioral screening and surveillance tool for ages birth through age 8 years, available in paper and online.
- Safe, Stable, and Nurturing Relationships May Shield Children Against Poor Health Later in Life. A CDC web page with information about promoting healthy, safe, stable and nurturing surroundings to counter adverse experiences in childhood, promote optimal development and reduce disparities in health.
- Seeking Safety. A model of counseling to help improve coping skills, originally developed for trauma, substance use and/or post-traumatic stress disorder (PTSD). Applies broadly to increase coping and stabilization.
- The Resilience Project. This AAP site includes symptom-specific video vignettes demonstrating how to discuss trauma and its impact with children and their caregivers in a clinical setting.
- Texas Department of Family and Protective Services. 3 in 30: A Complete Approach to Better Care for Children.
- Texas Department of Family and Protective Services, Child Protective Services. Report Abuse, Neglect, or Exploitation.
- Texas Department of Family and Protective Services. Human Trafficking Resources web page.
- Texas Health Steps Anticipatory Guidance Provider Guide.
- Texas Health Steps Periodicity Schedule. Medical checkup Periodicity Schedule for infants, children, and adolescents (birth through 20 years of age)
- Texas Local Mental Health Authorities and Local Behavioral Health Authorities. List and locations of 37 Local Mental Health Authorities (LMHAs) and two Local Behavioral Health Authorities (LBHAs) overseen by the Texas Health and Human Services Commission.
- Texas State Legislature. (1975-2011). Texas Penal Code § 21.11. Sexual Offenses.
- 2-1-1 Texas. A free, confidential information and referral phone line answered 24/7 by nationally certified specialists with access to a comprehensive database of community organizations, government agencies and nonprofits in Texas.
- American Academy of Pediatrics. (n.d.). Bright Futures Tool and Resource Kit.
- American Academy of Pediatrics. (2017). Policy Statement: Detention of Immigrant Children.
- American Academy of Pediatrics. (2012/2016). Policy Statement: Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health. Pediatrics, (129)1, 224-231.
- American Academy of Pediatrics & Dave Thomas Foundation for Adoption. (2016). Helping Foster and Adoptive Families Cope with Trauma.
- American Academy of Pediatrics, Council on Foster Care, Adoption, and Kinship Care, Committee on Adolescence, & Council on Early Childhood. (2015). Policy Statement: Health Care Issues for Children and Adolescents in Foster Care and Kinship Care. Pediatrics, (136)4: e1131-40.
- American Academy of Pediatrics. (2014). Trauma Toolbox for Primary Care.
- American Academy of Pediatrics. (2014). Adverse Childhood Experiences and the Lifelong Consequences of Trauma.
- American Academy of Pediatrics. (2013). Policy Statement: Enhancing Pediatric Workforce Diversity and Providing Culturally Effective Pediatric Care: Implications for Practice, Education, and Policy Making. Pediatrics, 132(4), e1105-e1116.
- Bartlett, J. D., & Steber, K. (2019). How to Implement Trauma-informed Care to Build Resilience to Childhood Trauma. Child Trends.
- Bethell, C. D., Newacheck, P., Hawes, E., & Halfon, N. (2014). Adverse Childhood Experiences: Assessing the Impact on Health And School Engagement and The Mitigating Role Of Resilience. Health Affairs, (33)12.
- Briggs-Gowan, M. J., Ford, J. D., Fraleigh, L., McCarthy, K., & Carter, A. S. (2010). Prevalence of exposure to potentially traumatic events in a healthy birth cohort of very young children in the northeastern United States. Journal of Trauma Stress, 23(6): 725-733.
- Center on the Developing Child at Harvard University. (n.d.). The Impact of Early Adversity on Children's Development (video).
- Centers for Disease Control and Prevention. (2020). Adverse Childhood Experiences (ACE) web page.
- Centers for Disease Control and Prevention. (2020). Estimated Cost of Child Abuse and Neglect in 2015.
- Centers for Disease Control and Prevention. (n.d.). Adverse Childhood Experiences, looking at how ACEs affect our lives & society.
- Chemtob, C. M., Gudiño, O. G., & Laraque, D. (2013). Maternal Posttraumatic Stress Disorder and Depression in Pediatric Primary Care Association With Child Maltreatment and Frequency of Child Exposure to Traumatic Events. JAMA Pediatrics, 167(11), 1011-1018.
- Child Welfare Information Gateway. (n.d.) Adverse Childhood Experiences.
- Colby, S., & Ortman, J. (2015). Projections of the Size and Composition of the U.S. Population: 2014 to 2060. U.S. Census Bureau.
- Dierkhising, C. B., Ko, S. J., Woods-Jaeger, B., Briggs, E. C., Lee, R., & Pynoos, R. S. (2013). Trauma histories among justice-involved youth: findings from the National Child Traumatic Stress Network. European Journal of Psychotraumatology, 4.
- Ellis, W. R. & Dietz, W. H. (2017). A New Framework for Addressing Adverse Childhood and Community Experiences: The Building Community Resilience Model. Academic Pediatrics, 17(7S).
- Felitti, V., & Anda, R. (2010). The relationship of adverse childhood experiences to adult health, well being, social function and health care (Chapter 8). The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease, Cambridge University Press.
- Finkelhor, D., Turner, H. A., Shattuck, A., & Hamby, S. L. (2015). Prevalence of Childhood Exposure to Violence, Crime, and Abuse: Results from the National Survey of Children's Exposure to Violence. JAMA Pediatrics, 169(8):746-54.
- Gabrielli, J., Lund, E. (2020). Acute-on-chronic stress in the time of COVID-19: assessment considerations for vulnerable youth populations. Pediatric Research, 88, 829–831.
- Gerson, R., & Rappaport, N. (2013). Traumatic stress and posttraumatic stress disorder in youth: Recent research findings on clinical impact, assessment, and treatment. Journal of Adolescent Health, 52(2), 137-143.
- Harris, N. B. (2015). TedMed video. How childhood trauma affects health across a lifetime.
- Harvard University, Center on the Developing Child. (2017). Toxic Stress.
- Horner, G. (2016). Resilience. Journal of Pediatric Health Care, 31(3): 384-390.
- Indian Country Child Trauma Center. (2006). Historical Trauma Among the Native American Population: What Service Providers Need to Know.
- Jones, R., Flaherty, E. G., Binns, H. J., Price, L. L., Slora, E., Abney, D., … Sege, R. D. (2008). Clinicians’ Description of Factors Influencing Their Reporting of Suspected Child Abuse: Report of the Child Abuse Reporting Experience Study Research Group. [Abstract]. Pediatrics, 122(2), 259-266.
- Luthar, S. S., & Eisenberg, N. (2017). Resilient Adaptation Among At-Risk Children: Harnessing Science Toward Maximizing Salutary Environments. Child Development, 88(2):337-49.
- Merrick, M., Ford, D. C., Ports, K. A., & Guinn, A. S. (2018). Prevalence of Adverse Childhood Experiences From the 2011-2014 Behavioral Risk Factor Surveillance System in 23 States. JAMA Pediatrics, 172(11):1038-1044.
- National Child Traumatic Stress Network. (n.d.). Resilience and Child Traumatic Stress
- National Child Traumatic Stress Network. (n.d.). Trauma Types.
- Peterson, C., Florence, C., & Klevens, J. (2018). The economic burden of child maltreatment in the United States, 2015. Child Abuse & Neglect: The International Journal, 86, 178–183.
- Sege, R. D., & Amaya-Jackson, L., American Academy of Pediatrics, American Academy on Child and Adolescent Psychiatry, & National Center for Child Traumatic Stress. (2017). Clinical Report: Clinical Considerations Related to the Behavioral Manifestations of Child Maltreatment. Pediatrics, 139(4): e1-13.
- Shanley, J. R., Shropshire, D., & Bonner, B. L. (2009). To Report or Not Report: A Physician’s Dilemma. AMA Journal of Ethics, State of the Art and Science, 11(2).
- Shonkoff, J. P., Garner, A. S., & AAP. (2012/2016). Technical Report: The Lifelong Effects of Early Childhood Adversity and Toxic Stress. Pediatrics, 129(1), 232-246.
- Southammakosane, C., & Schmitz, K. (2015). Pediatric Psychopharmacology for Treatment of ADHD, Depression, and Anxiety. Pediatrics, 136(2): 351-9.
- Soleimanpour, S., Geierstanger, S., & Brindis, C. (2017). Adverse Childhood Experiences and Resilience: Addressing the Unique Needs of Adolescents. Academic Pediatrics, 17(7): S108-S114.
- Szilagyi, M., Kerker, B. D., Storfer-Isser, A., Stein, R. E., Garner, A., O’Connor, K. G, . . . McCue Horwitz, S. (2016). Factors Associated With Whether Pediatricians Inquire About Parents' Adverse Childhood Experiences. Academic Pediatrics, 16(7):668-75.
- Substance Abuse and Mental Health Services Administration, Trauma and Justice Strategic Initiative. (2014). Concept of Trauma and Guidance for a Trauma-Informed Approach.
- Substance Abuse and Mental Health Services Administration, GAINS Center. (n.d.). How Being Trauma Informed Improves Criminal Justice System Responses. Fact Sheet: Historical Trauma.
- Texas Department of Family and Protective Services. (2020). Texas Department of Family and Protective Services Data Book.
- Texas Health and Human Services Commission. Texas Health Steps Checkup Components.
- Texas Health and Human Services Commission. Texas Health Steps Periodicity Schedule.
- Texas Medicaid & Healthcare Partnership. (2021). Texas Medicaid Provider Procedures Manual (TMPPM).
- Texas State Legislature. (2011). Texas Family Code. The Parent-Child Relationship and the Suit Affecting the Parent-Child Relationship.
- The Child and Adolescent Health Measurement Initiative, Data Resource Center for Child and Adolescent Health. (2019). 2016/2017 NSCH Fact Sheets on ACEs.
- The Child and Adolescent Health Measurement Initiative. (n.d.). ACEs Project. Childhood Trauma and Positive Health.
- The Child and Adolescent Health Measurement Initiative, Texas Fact Sheet 2019.
- Turney, K., & Wildeman, C. (2016). Mental and Physical Health of Children in Foster Care. Pediatrics, 138(5): e20161118.
- U.S. Department of Health and Human Services, Children’s Bureau. (2018). Child Maltreatment 2018.
- U.S. Department of Justice, Office for Victims of Crime. (2013). Through Our Eyes: Children, Violence, and Trauma—Introduction video.
- American Academy of Pediatrics. (n.d.). AAP Mental Health Initiatives.
- Center for Pediatric Traumatic Stress. (2010). Culturally-Sensitive Trauma-Informed Care. Children’s Hospital of Philadelphia.
- Center on the Developing Child at Harvard University. (n.d.). Toxic Stress.
- Johnson, S. B., Riley, A. W., Granger, D. A., & Riis, J. (2013). The Science of Early Life Toxic Stress for Pediatric Practice and Advocacy. Pediatrics, 131(2), 319-327.
- National Child Traumatic Stress Network. (n.d.). Military and Veteran Families and Children.
- U.S. Department of Justice Attorney General’s National Task Force on Children Exposed to Violence. (2012). Defending Childhood: Protect, Heal, Thrive: Report of the Attorney General's National Task Force on Children Exposed to Violence final report.
- Find Treatment. Substance use treatment locator from the federal Substance Abuse and Mental Health Services Administration (SAMHSA).
- National Child Traumatic Stress Network. Families and Caregivers web page of resources.
- Parenting After Trauma: Understanding Your Child’s Needs. A Guide for Foster and Adoptive Parents. A guide from the AAP that explains how trauma affects children and provides tips for making them feel safe. Pediatricians can copy and provide this handout to foster and adoptive parents.
- Partnering with Parents: Apps for Raising Happy Healthy Children. A booklet with phone numbers, cell phone apps, ideas and websites for all types of caregivers of children.
- National Child Traumatic Stress Network. Resources for birth parents, adoptive parents, resource or foster parents, grandparents, caregivers and all others who care for children and adolescents.
- The Trauma Informed Care Project. Publications, links, videos and books focused on understanding, recognizing and responding to the effects of all types of trauma.
- Sesame Street in Communities. Videos and other resources to educate and help children deal with ACEs such as divorce and incarceration of a loved one.
- Triple P - Positive Parenting Program. Triple P is an evidence-based program that gives caregivers simple and practical strategies to help them build strong and healthy relationships, confidently manage their children’s behavior, and prevent problems from developing.
- U.S. Department of Health and Human Services, Child Welfare Information Gateway. Resources on Trauma for Caregivers and Families.
- U.S. Substance Abuse and Mental Health Services Administration. Resources for Parents and Caregivers.
Recognizing, Reporting and Preventing Child Abuse
Implement best practices to effectively screen for child abuse, comply with legal reporting requirements and promote protective factors that prevent child abuse.
Preventing Unintentional Injury: Birth through 20 Years
Learn to identify risk factors for unintentional injury in children and adolescents, provide age-appropriate anticipatory guidance and apply state law and best practices to prevent unintentional injury and death.