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While some degree of trauma and exposure to adversity in childhood is both commonplace and may even be an asset to healthy development, sustained exposure to trauma or severe trauma can result in long-term negative health consequences. This trauma may be physical, but it is often the more insidious emotional, psychological, or social forms of trauma. Early traumatic experiences can affect the way the genome is read, the development of the hypothalamic–pituitary–adrenal (HPA) axis, and the way the developing brain is wired. Because a child’s brain continues to grow long after birth, environmental exposures, both positive and negative, can profoundly impact the developing child. The first 3 years of life are a particularly vulnerable period, given the plasticity of the brain in infancy and early childhood. Traumatic exposures (often collectively referred to as adversities) can influence learning, behavior, and health in children as well as result in adult risky behaviors, serious health problems, and early death. An understanding of the ways in which adversity affects the growing child can help the pediatric provider both to mitigate the influence of traumatic exposures in children and to shore up community resources that promote resiliency and protect against some of the negative lifelong consequences of childhood trauma.


Pediatricians began to appreciate the importance of developmental, social, and behavioral problems in children in the 1970s. These problems were dubbed the “new morbidities,” as they represented new threats to the well-being of children. This shift in focus on aspects of child health beyond infectious diseases, nutritional deficiencies, high infant mortality, and epidemics to include emotional disorders, educational needs, and family dysfunction paved the way for the consideration of other important realms of child health and functioning. These include child abuse and neglect, community violence, parental mental health, food insecurity, poverty, and socioeconomic disparity and social inequality.

The lifelong impact of childhood adversity was most clearly reported in the landmark Adverse Childhood Experiences (ACE) Study in the late 1990s. This study linked childhood exposure to trauma and adversity, particularly the cumulative exposure, to multiple negative downstream health outcomes in adults. This study, which enrolled over 17,000 members of an employment-based health insurance plan, queried participants about their exposure to a list of ACEs including abuse, neglect, and household dysfunction such as parental substance abuse and having a family member become incarcerated. See Table 28-1 for a list of the original ACEs.


There were 2 main findings of the original ACE Study that transformed our appreciation and understanding of the importance of childhood adversity. First, the study found an extremely high prevalence of ACEs in ...

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