Clinical Assessment & Treatment
Identifying ACEs and risk of toxic stress to inform treatment
Screening for ACEs and responding with evidence-based interventions and trauma-informed care can prevent and treat toxic stress to improve patients’ physical and mental health.
Screening for ACEs involves assessing for exposure to adversity (using the ACE score), clinical manifestations of toxic stress (ACE-Associated Health Conditions), and protective factors. Clinical teams should use the ACEs and Toxic Stress Risk Assessment Algorithm to assess whether a patient is at lower, intermediate, or higher risk for having a toxic stress physiology.
Clinicians routinely gather information from patients about their medical history, family history, and any specific health concerns during the primary care visit. Incorporating ACEs and toxic stress into the conversation involves reviewing the patient’s ACE screening results, asking about protective factors – including toxic stress mitigation strategies – that may be present, and taking note in the physical exam of any neurologic, endocrine, metabolic, or immune findings that could be associated with ACE-Associated Health Conditions.
Conducting the Clinical Assessment
Using the information gathered – including the ACE score and indications of ACE-Associated Health Conditions – clinicians use the ACEs Aware ACEs and Toxic Stress Risk Assessment Algorithm to assess the patient’s risk for toxic stress. Taken together, the ACE score and ACE-Associated Health Conditions indicate if a patient is likely to be at lower, intermediate, or higher risk for toxic stress physiology.
Developing the Clinical Response
The clinical response is informed by the patient’s risk for toxic stress in the clinical assessment and the protective factors that are in place, including the presence of toxic stress mitigation strategies.
The clinical response involves providing the following based on the level of risk of toxic stress:
- Patient education about toxic stress and its likely role in ACE-Associated Health Conditions;
- Clinical interventions and support services, including evidence-based toxic stress mitigation strategies (which starts with the clinician but may be supplemented by the broader clinical team within the clinic/system and/or by community-based organizations); and
The clinical response to identification of toxic stress should include:
1. Applying principles of trauma-informed care, including establishing trust, safety, and collaborative decision-making.
2. Supplementing usual care for ACE-Associated Health Conditions with patient education on toxic stress and discussing strategies that can help regulate the stress response, including:
- Supportive relationships, including with caregivers (for children), other family members, and peers
- High-quality, sufficient sleep
- Balanced nutrition
- Regular physical activity
- Mindfulness and meditation
- Experiencing nature
- Mental health care, including psychotherapy or psychiatric care, and substance use disorder treatment, when indicated
3. Validating existing strengths and protective factors.
4. Providing referrals to patient resources or interventions, such as educational materials, social workers, school agencies, care coordination or patient navigation, and community health workers.
5. Following up as necessary, using the presenting ACE-Associated Health Condition(s) as indicators of treatment progress.
Increasing ACEs awareness and training has never been so important. Together, we can significantly improve the health and well-being of children, adults, and families to help save lives.
See the ACE Screening Implementation How-To Guide on Preparing the Clinical Response for more detailed information about prevention, the clinical assessment, and treatment of toxic stress. Find additional patient & family education handouts in the ACEs Aware Resource Library.
- ACE Screening, Clinical Assessment, and Treatment Planning for Toxic Stress
- Overview: A Tiered Clinical Response Framework for Addressing Toxic Stress
- ACE Screening Clinical Workflows, ACEs and Toxic Stress Risk Assessment Algorithm, and ACE-Associated Health Conditions: For Pediatrics & Adults
- ACE Screening Clinical Workflows, ACEs and Toxic Stress Risk Assessment Algorithm, and ACE-Associated Health Conditions: For Pediatrics & Adults (ADA Version)
- ACEs Aware Self-Care Tool for Pediatrics (To Print)
- ACEs Aware Self-Care Tool for Adults (To Print)