In 1998, Dr. Vincent Felitti and his colleagues published a groundbreaking article in which the role of adverse childhood experiences (ACEs) on adult health was first identified ( They studied ten risk factors across three types of abuse—psychological, physical, and sexual—and four types of household dysfunction—substance abuse, mental illness, intimate partner violence, and criminal behavior.  As the number of risk factors increased, so did the likelihood that the individual experienced diseases such as heart disease, cancer, stroke, chronic bronchitis or emphysema, and diabetes in later life.  Research in the intervening years has indicated other effects of ACEs—depression, alcoholism and alcohol abuse, illicit drug use, risk for intimate partner violence, and suicide attempts.  For youth, ACEs may mean early initiation of smoking, early initiation of sexual activity, teen pregnancy, and poor academic achievement.

In 2012, Dr. Jack Shonkoff and his colleagues published research that promoted the need for physicians to take a more active role in alleviating toxic stress in childhood ( Their premise was that early adversity leads to later impairments in learning, behavior, and both physical and mental well-being.

As of July 2017, an estimated 22.7% or 2,332,066 persons were under the age of 18 in North Carolina. Because a large percentage of children ages 0 to 3 years visit primary care, pediatric, and public clinics, physicians, nurse practitioners, and physician assistants are in an ideal position to have a positive impact on the development of child outcomes by promoting positive parenting behaviors; offering anticipatory guidance; educating parents about optimal child development outcomes; conducting routine screening, targeted skill-building interventions, and problem-focused counseling; and referring families to community services and supports. Through these measures, primary care clinicians have the opportunity to change the trajectory of children experiencing early adversity by offering evidence-based interventions and support services to mothers and significant others before and after delivery. For example, an estimated 7.5% of children ages 2 to 5 years are abused and neglected.  Primary care providers, pediatricians, and staff at public clinics should have basic skills to provide support and guidance on how to manage negative child behaviors, identify ways to manage both caregiver and child stress, and basic parenting tips. They should also be aware of when a referral to a community partner is needed, and be able to provide a list of where individuals can go to receive the support and services they need. An estimated 11% of women suffer from postpartum depression and maternal depression.  All providers that work with women who are postpartum—obstetrician/gynecologists, pediatricians, primary care providers, and family physicians—should become familiar with the symptoms of postpartum depression, integrate appropriate postpartum screening tools into visits, and ensure that, when clinically indicated, referrals are made to psychiatrists and therapists that have training in supporting women with postpartum or maternal depression.

Social determinants include health and access to medical care, adequate housing, education, economic stability, lifestyle, and social and community context. When ACEs are viewed as a component of the social determinant of health, healthcare professionals are in the position to effect changes during pregnancy and early childhood by adopting a nonjudgmental, educative role and offering evidence-based interventions that promote supportive and nurturing relationships and reduce toxic stress. Research has indicated that safe, stable, nurturing relationships have a significant protective effect on breaking the cycle of violence and improving health.

The Centers for Disease Control and Prevention has played a large role in issuing a series of prevention guides and tools to assist clinicians and staff of child-serving agencies (

For more on ACEs, go to