ACEs Training and the COVID-19 Pandemic: Reflections from Dr. Eric Ball

How ACE Training Helps My Patients Through the COVID-19 Pandemic

I am a primary care pediatrician. My usual day consists of seeing a few dozen kids in my office. Most of them are healthy and happy. We discuss growth and development, give some immunizations, and answer parental questions. Then COVID-19 hit, and everything changed.

My role has dramatically shifted in the last seven months. Now I spend a great deal of time each day helping families deal with the psychological impacts of COVID-19 and the unintended consequences of our response to the coronavirus.

Children thrive on structure and predictability. Most crave social interactions and play, and all children rely on stable and healthy adult relationships. This has all been affected by the COVID-19 emergency. Most children were sent home to conduct school online. Playdates and social interactions were cancelled. Their caregivers were stressed, some lost their jobs, or went off to work in high-risk frontline positions. We are now seeing the aftereffects of this in a new mental health crisis.

In early April, I started to see more and more children with mental health problems. Many had anxiety, some had depression, some were suicidal, and they all needed help. Pediatricians are not well trained in psychology and mental health, and there are not enough community resources to help this deluge of children in crisis. To help my patients, I turned to my training in Adverse Childhood Experiences (ACEs) and the resources located on the ACEs Aware website.

In the world of ACEs, we often talk about different types of stress:

  • Positive stress: These are the normal, everyday stresses that we all encounter. They are critical to normal development and allow for people to build strategies to handle adversity. An example would be a child’s first day of school or a challenging day at work.
  • Tolerable stress: These are more severe or more long-lasting stressors, but the effects are buffered by supportive relationships. An example would be a child experiencing a severe illness while being supported by her family and community.
  • Toxic stress: There are prolonged stressful conditions that occur in the absence of protective relationships. An example would be a child being raised in a household experiencing domestic violence.

COVID-19 has been stressful for all of us, but our response to the pandemic and its effects is largely dependent on our buffering relationships and resiliency. Most of my patients are experiencing tolerable stress due to COVID-19, but some (often the ones in crisis) are suffering with toxic stress.

COVID-19 has been stressful for all of us, but our response to the pandemic and its effects is largely dependent on our buffering relationships and resiliency.

ACEs research has taught us that the negative effects of stress can be mitigated by supportive relationships and the use of stress-busting techniques. California Surgeon General Dr. Nadine Burke Harris says, “Safe, stable, and nurturing relationships and environments in which children feel safe emotionally and physically can protect children’s brains and bodies from the harmful effects of stress.”

I have been teaching these resiliency techniques to my patients since the beginning of the pandemic. My ACEs training has taught me that children can better deal with stressful situations if they employ the following techniques:

  • Maintain supportive relationships. One of the few positives of the pandemic is there is often more time now for family meals, family walks, and increased positive interactions.
  • Exercise daily. I try to aim for at least one hour per day.
  • Get high-quality healthy sleep. I tell my patients to try to go to bed at a “reasonable” time each day and to stick with a schedule.
  • Eat a nutritious diet. I discuss with my patients the importance of eating lots of fruits and vegetables (at least five servings per day).
  • Practice mindfulness meditation and/or prayer. I often recommend one of the many mindfulness applications available for smartphones.
  • Refer to mental health services when needed.

Now, when I see patients in my office, I still talk about their growth and development, but I also focus on these resiliency factors. I ask families about their child’s sleep, nutrition, and exercise habits. We talk about positive family time, and I introduce them to mindfulness resources. For some, I refer them to mental health professionals. I have also been turning to the excellent ACE resources on, including the California Surgeon General’s Playbook for Stress Relief During COVID-19.

When I initially did my ACEs training and education on the ACEs Aware website in January 2020, I believed that I would only need these resources for patients in crisis or suffering from toxic stress. We continue to screen for ACEs, and now I apply these resources and training with almost every patient I encounter whether they screen positive for ACEs or not.

The stress involved with COVID-19 has acted like a collective societal adverse experience, and we are using our training to help patients mitigate the extreme negative effects of the pandemic. My ACEs training has certainly improved my pediatric care and has hopefully allowed my patients to develop strategies to better manage their stress during these difficult times.

Eric H. Ball, MD, FAAP

American Academy of Pediatrics, California