Texas Health Steps

Addressing ACEs During Texas Health Steps Checkups

Adverse childhood experiences (ACEs) describe stressful or traumatic events of abuse, neglect, or household dysfunction early in life and have been shown to increase lifelong risk for many of the leading causes of morbidity and mortality in the US.

American Academy of Pediatrics, 2020

The high prevalence of ACEs

Childhood experiences shape physical, mental and emotional development. They create the foundation for the adults we become. These experiences can make the difference between a well-adjusted and healthy adulthood and a continuous struggle for steady and secure relationships, happiness, and physical and mental health.

If poverty is included, about half of all pediatric patients in Texas have had an adverse childhood experience. Nationwide, the rates of ACEs are higher for children who are Black, indigenous or people of color and those in families with low incomes.

Lasting effects of ACEs

The physical and emotional consequences of ACES may put children at risk for immediate and lifelong negative effects. Experiencing childhood trauma may expose a young person to toxic stress, which can permanently alter the brain’s structure and function.

Children with ACEs are more likely to experience:

  • Learning problems
  • Behavioral issues
  • Physical health issues and chronic conditions
  • Risk for sexual activity earlier than their peers
  • Pregnancy during adolescence

Adults who had ACEs are more likely to struggle with obesity, heart disease, substance use disorders, cancer and suicide.

The provider’s role

Using nonjudgmental screening and guidance during Texas Health Steps preventive medical checkups can help you identify ACEs and mitigate the impact of trauma and stress.

Health-care providers are encouraged to:

  • Create a trauma-informed office environment
  • Perform developmental and mental health screenings as part of medical checkups
  • Provide prevention messages and education during anticipatory guidance
  • Promote the protective effects of resilience
  • Support safe and stable relationships between young patients and the caring adults in their lives

Case study

portrait of young boy
Rudy 7 years

Rudy, age 7 years, is in your clinic with his aunt, who is also his guardian. Rudy’s second-grade teacher reports the boy has trouble focusing and controlling his impulses and is prone to pick fights with classmates. The teacher suspects Rudy may have attention-deficit/hyperactivity disorder (ADHD). You take a health history and learn that Rudy moved in with his aunt last year after his parents divorced because of domestic violence and his father’s incarceration. Rudy has started wetting his bed at night. “He's a loving boy,” his aunt says. “What am I doing wrong?”

What are your next best steps?

Rudy needs firmer consequences and possibly medication to stop the bed-wetting.

Rudy’s experiences and symptoms are consistent with traumatic stress, which can appear similar to ADHD. Additional screening is needed. Explain to the aunt the consequences of traumatic stress and what she can do to buffer the detrimental impact of trauma and help build resilience in Rudy.

Rudy may be suffering from toxic stress, which is best treated with stimulants.

Why it matters

Addressing the consequences of ACEs is an essential part of routine pediatric patient care. As a Texas Health Steps provider, you have access to validated, standardized screening tools to help identify trauma and toxic stress during patient checkups as well as resources for families to build resilience. Providing trauma-informed care can help put a child on a path to lifelong health and well-being.

Related courses


American Academy of Pediatrics, California Chapter 2. (2020). Adverse Childhood Experiences.

Child and Adolescent Health Measurement Initiative, Data Resource Center for Child and Adolescent Health. (2019). Texas: Fact Sheet 2019.

Child Trends. (2018). The prevalence of adverse childhood experiences, nationally, by state, and by race or ethnicity.

Southammakosane, C., & Schmitz, K. (2015). Pediatric Psychopharmacology for Treatment of ADHD, Depression, and Anxiety. Pediatrics, 136(2): 351-9.

The National Child Traumatic Stress Network. (n.d.). Resilience and Child Traumatic Stress.