Addressing Parental ACEs in the Pediatric Setting

Abstract

Parents’ own adverse childhood experiences (ACEs) impact their children’s physical and emotional health. Causal mechanisms are not fully understood but are likely multifactorial, affecting parent resiliency and attachment behaviors, with possible intergenerational transmission. Although universal screening for parental ACEs is controversial, they may be identified during pediatric care. Providers can address parental ACEs by consistently using trauma-informed, healing-centered approaches that acknowledge the impact of trauma and the presence of resilience, promote positive parenting skills, and provide compassionate support universally. When necessary, more targeted interventions may include referral to community social support services and parenting programming. Incorporating a two-generation approach in pediatrics may enhance and support child health and well-being more robustly.

Introduction

A 27-year-old mother of an asthmatic 8-year-old struggles with anxiety and depression and feels overwhelmed with her parental responsibilities. Her child has been hospitalized three times in the past year with severe asthma exacerbations. A 30-year-old father responds to his four-year-old’s challenging behaviors with anger and harsh verbal discipline. He wants his child prescribed something to “calm him down.” From comments made by these parents you understand that each of them had what they both refer to as a “tough” upbringing. You ponder the relationship between those parental experiences and the children’s health and development challenges.

Adverse childhood experiences (ACEs) are part of the contemporary pediatric lexicon. The term describes traumatic experiences occurring prior to the age of 18 years, which are strongly associated in a dose-response manner with lifelong negative physical and mental health consequences¹ including cardiovascular disease,² liver disease,³ depression,⁴ substance abuse,^5,6 and suicidality.⁷ Multiple studies have consistently reproduced these findings, and related associations have been expanded to include poor educational, social-emotional and employment outcomes.^1,8 ACEs are very common, with one half to two-thirds of the adult population experiencing at least one ACE.^9,10 ACEs occur at all income levels but there is a direct linear relationship between high ACE score (>=4) and lower incomes.^11,12 The ACEs in Felitti et al’s original work included psychological, physical, or sexual abuse; violence against the mother; or living with household members with substance use disorder, mental illness, suicidality, or history of imprisonment.¹ More recently, researchers have proposed expanding ACEs criteria to include witnessing violence, experiencing discrimination, lacking a safe neighborhood, being bullied, and living in foster care.¹³

Although we use the conventional term “parental ACEs” in this paper, we recognize that many children live with a non-parent primary caregiver. Thus, we ask the reader to keep in mind that the concepts and recommendations discussed below may be applied to any of a child’s caregivers.

Parental ACEs and Child Health Outcomes

More recent work expands our understanding of the impact of ACEs to include the negative impact of parental ACEs on child health broadly across multiple domains. A population-based study of Philadelphia parent-child dyads found that for each point increase in parental expanded ACE score the odds of poor overall child health increased by 19% and asthma by 17%.¹⁴ Maternal ACEs also predict impaired birth weight and missed child preventive care.^15,16 Multiple studies demonstrate a dose-response relationship between parental ACE score and risk for child developmental delay, with one study finding maternal ACE score of 3 or greater associated with 2.2 times greater likelihood of suspected child developmental delay and an increasing number of developmental domains affected.^17–19 Maternal ACEs are also associated with reduced child Ages and Stages Questionnaire Social-Emotional Score.¹⁵ Additionally, a dose-response relationship is seen with parental ACEs and child hyperactivity, emotional disturbance, and aggressive behavior.^20,21 Available studies primarily examine maternal data; much less is known about the impact of paternal ACEs but it is likely that they affect children’s health similarly.^16,20

Early Experiences and the Impact of Parental ACEs on Parenting Behaviors

Causal mechanisms for the relationship between parental ACEs and child health outcomes are not yet fully understood, but evidence to date suggests that multiple pathways are contributory. Chief among these is the impact of parental ACEs on parenting behaviors.²² The early years are a critical developmental period because experiences during this time embed themselves in the brain circuitry and provide scaffolding for behavior, emotionality, and physiology across the lifespan.²³ Safe, stable, nurturing relationships and growth through positive experiences form the roots of resilience, defined by Masten as the dynamic process of positive adaption to, or in spite of, significant adversity.²⁴ Forkey’s THREADS mnemonic was initially developed to identify factors critical to child resilience: Thinking and Learning Brain, Hope, Regulation or Self-control, Efficacy, Attachment, Developmental Skill Mastery, and Social Connectedness.²⁵ An adaptation of this mnemonic can aid in understanding the impact of the presence or absence of parental ACEs on parent resilience and parenting behaviors (Table 1).

Table 1:

Potential impact of Parental ACEs on the THREADS of Resilience and Parenting

Threads of Childhood25	Relevance to Parenting	How ACEs may disrupt THREADS, impairing parental resiliency
Thinking and Learning Brain	Parenting is a skill that can be developed, with opportunity for continued growth and cognitive development.	Reflexive behaviors and actions of brain may take over to manage a small and large threats; parents may have increased short-/long-term response to stimuli and increased reactivity to harsh environmental cues27
Hope	Belief, faith, and optimism in a future for oneself can motivate positive parenting behavior	Parents may have abandoned hope to deal with present challenges, experience negative emotions more strongly and have impaired coping77
Regulation and Self-Control	Executive function including working memory, problem-solving, inhibition control and attention control are critical to responsive parenting.	Parent may impulsively react to unpredictable events. This carries high risk of unhealthy behaviors (e.g. smoking during pregnancy, alcohol, marijuana, illicit drug use) which impair ability to parent positively.6,36
Efficacy	Parent has knowledge that they can impact their environment or situation.	Parent may not be able to maintain efficacy when reacting to situations rather than being in control of them. Mental illness, if present, and additional stressors and adversities such as poverty can compound already heightened parenting stress.23,78
Attachment and Attunement	Parent has secure attachment, marked by responsiveness and concern for their child.79	Attachment may be impaired. Depression, PTSD, or anxiety, if present, can lead to a parent having reduced emotional responsiveness to child’s needs and intrusive behavior toward80,81 children.
Developmental Skill Mastery Distance and Self-Care	Parent succeeds in building life skills alongside nurturing skills. Parent realizes self-worth without relying on child for sense of personal accomplishment.	In having to deal with the present threat, parents may lose ability to focus on future goals, nurturing their child, or both.
Social Connectedness (home, school, and community-based)	Parent can achieve the above within a network of positive, supportive social relationships.	Parent may have lost social connectedness due to past or present trauma.

A child’s capacity for resilient adaptation across the life course develops within the context of their relationships with primary caregivers. Individuals who experienced a positive family emotional climate, positive attachment with their parents, and less authoritarian parenting during their childhood are more likely to show warm, sensitive, stimulating maternal behavior in adulthood.²⁶ In the absence of a nurturing parental relationship, however, adults may develop a heightened stress response and altered capacity to respond effectively to life’s stressors, such as raising their own children.

The biological mechanism by which ACEs impair parenting is hypothesized to be multifold, correlating with the known impact of ACEs on child brain development. Parental emotionality and nurturing behavior are dependent on autonomic nervous system and hypothalamic-pituitary-adrenal axis (HPA) functioning, and ACEs negatively impact both.²⁷ Sustained activation of the stress response system in response to ACEs results in cell hypertrophy and proliferation as well as brain remodeling in the amygdala, hippocampus, and prefrontal cortex.²⁸ These architectural shifts impair the development of critical areas related to memory, learning, decision-making, and stress response.^28,29 They also increase parental risk of depression, post-traumatic stress disorder (PTSD), anxiety, and poor emotional regulation, which may decrease parental availability to respond to a child’s needs.^15,30,31

Intergenerational Transmission of ACEs

Parental ACEs may further impact child health through intergenerational transmission of ACEs. One hypothesized pathway for this transmission is epigenetic modification. Epigenetics refers to molecular-level changes in gene expression that occur as a result of environmental factors such as toxins and social-emotional factors such as manner of care and nurturing.³² ACEs have been found in human and animal studies to increase methylation of DNA in the promoter region of several genes including the glucocorticoid receptor gene, functionally reducing expression of those genes and leading to dysfunction of the HPA axis.²⁷ It is understood that some epigenetic changes are inherited,³³ and thus potentially affect the stress response and behaviors of future generations, but the inevitability of transmission and extent of impact are not known. Pregnant women with high ACEs have a greater risk of fetal demise, ³⁴ giving birth to a preterm infant,³⁵ and high-risk health behaviors during their pregnancy.³⁶ Research into the epigenetic mechanisms around ACEs and parenting abilities is still in its infancy, with further work needed to evaluate how the epigenetics of ACEs may impact other hormones and neurotransmitters, including dopamine, oxytocin, and other neuropeptides thought to be involved in nurturing.

These gaps notwithstanding, it is clear that parental ACEs may directly beget children’s ACEs. Children of parents with a high ACE score are themselves more likely to experience childhood adversity,³⁷ in part because ACE-related adult health outcomes, such as mental illness and substance use disorder, may themselves be ACEs for their children. Additionally, the conditions contributing to childhood adversity may continue to be present in adulthood, thus setting up potential for exposure of the next generation to the ACEs of poverty and violence. Further, parents who have experienced childhood adversity and poor modeling by their parents are more likely to take on suboptimal attitudes and parenting beliefs.^38,39 Mothers who experienced child physical abuse have been found to be 1.5 times more likely to use corporal punishment than those who had not been abused.³⁹ Fathers who experienced ACEs were more likely to be perpetrators of violence against their partners.⁴⁰

Framework for addressing parental ACEs in pediatric care settings

Trauma-informed care and healing-centered engagement provide a general framework for addressing parental ACEs. A trauma-informed approach to parental ACEs recognizes the high prevalence of ACEs, that any parent may have experienced childhood adversity, and that these experiences will influence parenting practices, the stresses of parenting, and interactions with the pediatric healthcare team.⁴¹ Central to trauma-informed care is a shift from the question of “What is wrong with you?” to the question of “What happened to you?” Healing-centered engagement adds the question, “What is right with you?” in recognition that all individuals, including those with a history of trauma, have strengths.⁴² Further, healing-centered engagement views healing as a collective experience, stresses culture as central to well-being, and empowers individuals to play an active role in their healing.⁴² Healthcare teams must keep in mind that although trauma has a significant impact, these experiences do not fully define any individual. Practicing healing-centered engagement can enable pediatricians to work with families from a perspective that focuses just as strongly on strengths and possibility as it does on trauma and its negative impacts. Above all, this approach frames ACEs as history and not destiny. It emphasizes resilience and success despite exposure to adversities.

Recognition of Parental ACEs in Clinical Settings

A trauma-informed perspective will enable pediatricians to recognize parent behaviors that may be a consequence of ACEs. Table 2 depicts the mnemonic “FRAYED,” based on the understanding that trauma may “fray” the fabric of healthy human development.²⁵ Initially developed to aid in identification of child symptoms related to trauma, the mnemonic may also be applied to parents. Considering how ACEs can fray the THREADS of parental resilience (Table 2) may aid pediatric health providers in identifying manifestations of parental ACEs. Notably, some behavioral consequences of parental ACEs may be a downstream consequence of multiple impacts of ACEs (e.g., decreased engagement may be due to attunement challenges, substance use disorder and/or depression). Although issues other than parental ACEs (e.g., current psychosocial stressors) may trigger these parental behaviors, pediatricians must consider that these behaviors may be indicative of past trauma. When these behaviors occur, pediatricians can use this as an opportunity to explore what may be driving the behavior and model safe and nurturing responses (Box 1).

Table 2:

Possible manifestations when parental resilience is FRAYED

Elements of FRAYED parenting 25	How parents may present in the pediatric setting
Fear, Fighting, and Fretting	• Interaction with the healthcare setting may trigger an emotional response related to past trauma
	• Missed or delayed appointments
	• Difficulty following through with treatment plans
	• Easy frustration with the healthcare team or child behaviors
Regulation Disorders	• Difficulty controlling emotions and temper
	• Quickness to anger
	• Disrespectful or demanding interactions
Attunement Challenges	• Difficulty perceiving child needs and responding appropriately
	• Challenges in supporting their child during painful medical procedures
	• Challenges recognizing urgency of child’s medical needs in relationship to more immediate needs
Alcohol and Substance Abuse	• Past or current substance abuse may:
	○ Impact engagement with healthcare system, such as aversion to medical procedures
	○ Decrease ability to parent effectively
Yelling	• Harsh, punitive parenting
	• Harsh interactions with child and/or healthcare team
Exhaustion	• Decreased engagement with the child’s healthcare team
	• Difficulty following through with treatment plans
Defeat/Detachment	• Depression and/or hopelessness
	• Lack of attachment with their child
	• Decreased engagement with the child’s healthcare team

Box 1:

Starting a conversation when THREADS may be FRAYED

In our practice we work to recognize that families may have trauma in the past, and that there are strengths that everyone can use and build on. Would you be open to discussing the strengths you rely on to be an effective parent?

Many families find it challenging to [make it to every appointment, get every medication dose, etc.]. What are some things that make this challenging for your family?

(In response to a parent’s frustration with a young child’s behavior in the moment) It’s so hard for kids to be cooped up in these small rooms, and for parents, too. Can we get your child [a snack, something to color, a book to look at]?

You’re frustrated with [how the school is handling a situation, your child’s behavior etc.]. You are worried about your child, and the process is not what you expected. [pause for parent response]

Being a parent is hard and can feel exhausting. Our own experiences as children might make parenting harder. How do you think your experiences while you were growing up might impact how you parent?

I notice you’re [checking the time, checking your phone]. I know the rest of your life doesn’t slow down just because you’re here for your child’s appointment. [pause for parent response]

• Follow up question: Tell me about your priorities today and how we can best meet your needs today.

What can we do to help you comfort your child today when we complete your child’s [visit, immunizations, blood testing]? What might help your child feel more comfortable during the procedure?

The Challenges of Screening

Research on incorporating ACEs screening, including parental ACE screening, as a routine component of healthcare, is in its infancy and no gold standard screening tool exists. Many experts have cautioned against universal ACE screening for both patients and their caregivers.^43–46 Concerns about adoption of ACEs screening include lack of standardized screening tools or criteria. It is also unclear at this point what should be assessed, i.e., individual ACEs and/or an ACE score. Currently available ACE screening tools do not capture duration, frequency, or magnitude of trauma. Further, providing resource information and service referral based solely on ACE score may overlook parents experiencing ongoing negative impacts of fewer ACEs. An algorithmic approach to parental ACEs based on ACE score may also limit appreciation of resilience factors and strengths and alienate or stigmatize parents without necessarily empowering them to address their past. ACE questionnaires are also population health tools and do not predict outcomes at the individual level.⁴⁷

Conversely, others advocate for universal ACE screening as a means to identify risk and guide treatment and resource allocation.⁴⁸ Some practices have implemented traditional ACEs screening tools with parents. Gillespie et al introduced universal parental ACE screening in their private, primary care practice with evidence of feasibility, including acceptability among parents and providers.⁴⁹ Components of this written screening include a framing statement that normalizes the screening, screening for ACE score, and assessment for resilience factors. Providers were given guidance for addressing positive screens, including verbal prompts from AAP Connected Kids to facilitate provider-parent discussions, developmental promotion activity handouts, and social services resource lists for parents.⁴⁹ Although the intervention has shown acceptability among parents and providers, the impact of this screening on parenting behaviors and child health outcomes is not yet known.

Screening for parental ACEs, if pursued, works best if conducted within the context of a nurturing clinician-family relationship, with acknowledgement and identification of resilience factors as well as provision of concrete resources.⁴⁶ Pediatricians must also keep in mind the need to address current psychosocial issues, including intimate partner violence, mental health issues, and substance use disorder, which have immediate consequences to the child and available interventions.⁴⁶ Identification of current psychosocial stressors for which there are evidence-based interventions (e.g. cognitive behavioral therapy for relapse prevention⁵⁰) should not be eschewed in favor of parental ACEs screening.⁵⁰

Implications for Practice

Pediatric health care providers have multiple options to support parents affected by ACEs. These may be viewed as a two-pronged approach, with universal interventions provided to all families and targeted interventions provided when risk and negative impacts are identified. The goal of both levels of intervention is to mitigate the potential impact of parental ACEs on child health and well-being and to strengthen parent and family resilience factors.

Recognizing the sensitive nature of such disclosures, documentation of parental ACEs in a child's medical record should be limited. This ensures confidentiality of a disclosure of experiences that other caregivers with access to the child’s chart may not know, or that the parent would not wish the child to learn of should the child eventually access the chart. Further, a caregiver who entrusts a particular member of the care team with this disclosure may not desire that it be known or accessible to the full team.⁵¹ Templated documentation denoting that the impact of parental ACEs was discussed and that appropriate resources were provided may be useful.

When past trauma or ongoing stressors are identified during a trusted provider-parent discussion, the disclosure should not be addressed as a diagnostic item to be scored. Rather it is an opportunity to validate the challenges created by trauma, recognize the caregiver’s resilience, and discuss how the caregiver sees their ACEs impacting their parenting and their child. Healthcare teams must recognize parents as the experts on their lives and empower parents to make informed choices on their own terms about use of available resources.^25,52

Pediatric providers should always put the child’s safety at the forefront. If parent behaviors put the child’s health at risk, referral to child protective services may be necessary as mandated by state law or to facilitate connection to more intensive services. Any such referrals should be carried out with transparency and with the provider showing consistent and reliable support to the parent.

Universal Interventions

At baseline, pediatricians and other healthcare team members can provide consistent, trusting relationships with both parent and child, modeling compassionate availability. Each encounter with a member of the healthcare team, from a phone call to make an appointment to the provider visit, is an opportunity to nurture the relationships which are key for disclosure and discussion of parental ACEs.^25,53 Further, social support and trusting relationships in parents’ lives may reduce intergenerational transmission of trauma and improve child health.^54,55 Just as importantly, members of the healthcare team can model safe, stable, and nurturing relationships through their interactions with one another.

Emerging evidence supports universal education to address psychosocial issues.^56–58 This approach is in line with the research finding that parents desire to learn more about ACEs and resilience.⁴⁹ Further, Vu et al found that key stakeholders, including adult patients, recommended conversations addressing psychosocial adversity rather than screening questionnaires.⁵¹ For parental ACEs, universal education may include conversations about the prevalence of ACEs, their impact on parent well-being, parenting practices, and child well-being, and resilience factors. Providers may also suggest additional resources for parenting and to address consequences of parental ACEs.⁵⁹ Universal education creates opportunity for caregivers to learn about the impact of parental ACEs and resources without a required disclosure and to access those resources at the time and place of their choosing. This approach signals to caregivers that the provider is open to conversations about trauma, while also minimizing pressure toward disclosure that may result from a screening approach. The Connected Parents, Connected Kids pocket card (Figure 1) is a universal education intervention that use the CUES framework.⁶⁰ CUES uses healing-centered engagement to empower parents to utilize resources for themselves and to serve as a resource for their community. Two pocket cards are provided to caregivers, using a script that includes 1) Confidentiality, 2) Universal Education and Empowerment, and 3) Support (Box 2).

Figure 1:

Stepwise approach to addressing Parental ACEs in pediatric healthcare settings. The interventions listed are examples; the list is not exhaustive.

Box 2:

Using CUES and the Connected Parents-Connected Kids Card to Support Parents^a

Confidentiality

• Share limits of confidentiality.

• Sometimes parents share challenges they are having, and I want to assure you that this information is confidential and doesn’t go in a child’s record unless you want it to be included, or we have concerns about a child’s safety.

Universal Education + Empowerment

• Give caregivers 2 pocket cards. Open the card and encourage them to take a look.

• Make sure they know you are a safe person to talk to.

• “I’m giving 2 of these cards to all parents/caregivers. They talk about how our past experiences may affect how we act as parents. It also shares some ways to take care of yourself and your kids. You can look through it, and I’m also including one for a friend or family member. On the back of the card are resources you can call or text, and you can always talk to me about how parenting is going.”

Support

• Know how to support someone who discloses their ACEs. Disclosure is not the goal of universal education, but it will happen.

• Offer parenting strategies and a care plan that take a history of ACEs into consideration.

• “Thank you for sharing this with me. I’m sorry this happened. A lot of parents have experienced things like this. There are resources that can help. [Share resources] We can help make the connection to any of these if you would like.”

^aData from Beyond Screenings: Easy Steps to Support Survivors in Health Settings Infographic. Available at: https://store.futureswithoutviolence.org/index.php/product/cues-poster/. Accessed 25 November, 2020.

Interventions promoting parenting skills can benefit all parents, but perhaps especially those with a history of ACEs who themselves did not experience positive parenting practices as children. Pediatricians can model positive parenting behaviors in their interactions with their patients, such as calling out good (or “good enough”) behavior and ignoring undesired behaviors. Programs such as Reach Out and Read and the Incredible Years also offer opportunities to model parenting skills, among a host of additional evidence-based interventions that have been introduced in the primary setting.^61–64 As part of routine anticipatory guidance, pediatricians can provide practical tips and concrete examples, such as scripts, for approaches to common parenting challenges. Additionally, they can normalize the frustrations of parenting and offer strategies for coping during these moments. BehaviorChecker.org is a free, evidence-based online resource that provides parents a structured approach to help address challenging behaviors in their children.⁶⁵ Promotion of mindfulness practices that aid in self-regulation may also be of benefit; there are multiple mindfulness apps to which parents may be directed. Parents can also be directed to resources such as Small Moments Big Impact, a free, pediatrician-developed app for parents of infants birth through 6 months that supports infant-parent relationships and addresses the challenges of early parenting.⁶⁶

Targeted Prevention Strategies for High Risk Families

More intensive and focused interventions are needed for families identified as higher risk for or acutely experiencing negative effects of parental ACEs. Multidisciplinary team-based approaches have been found effective in addressing parental ACEs and may be particularly useful in implementation of targeted interventions for families at risk. For example, family navigators on the primary care team can connect families to services, help parents develop problem-solving skills and address parenting stress, and provide emotional support.⁶⁷ Some pediatric practices have mental health providers embedded within their practice.⁶⁸ Some institutions have piloted two-generational programs that bridge the psychosocial, economic, and health sectors to assist parents affected by ACEs and their children, but further study is required to evaluate effects and scalability of these innovative models.^69,70 These approaches may counteract barriers families face when seeking services (e.g. difficulty obtaining timely appointments, transportation barriers, and reluctance to engage with mental health providers).⁷¹

High-risk parents showing evidence of FRAYED THREADS may benefit from intensive community-based social support services and parenting programs. Pediatricians should maintain an updated list of such services in their community and be equipped to facilitate referral to these services. There are multiple evidence-based interventions, including community programs, that may help build resilience capacity in families with parents who have experienced ACEs. Figure 1 provides examples of such interventions. Of note, these interventions were not designed solely for parents with histories of ACEs. This list is not exhaustive; a wide array of additional programming is being developed in primary care settings. Providers can also reference websites such as Aunt Bertha (findhelp.org) and The Children’s Advocacy Project of America (cap4Kids.org) to find services available in their localities.^64,72–74

Families may be reluctant to engage with a social services professional. This barrier may be addressed by using a “warm hand-off” approach when feasible, with a healthcare team member directly connecting the family and resource provider. Additionally, practices can consider implementing a closed-loop referral system to facilitate enrollment of families in such services.

Resources

Box 3 provides summarized points that can assist pediatricians to address parental ACEs routinely. Resources that can aid pediatric healthcare teams in promoting patient and family resilience after trauma include the American Academy of Pediatrics Trauma Toolbox for Primary Care and the Pediatric Approach to Trauma, Treatment, and Resilience Project. Further, Bair-Merritt et al developed measurable standards for addressing psychosocial adversity within the patient-centered medical home that provide practical and detailed actions, many of which may be translated to pediatric care provided in non-primary care settings.⁷⁵

Box 3:

Pearls and Pitfalls of Addressing Parental ACEs in Pediatric Healthcare Settings

Take a strengths-based approach:

• Focus on positive aspects of child-parent relationships/interactions.

• Emphasize that ACEs are history and not destiny.

• Acknowledge the parent’s resilience.

Engage with the parent as a true partner:

• Respect parent’s expertise in their lived experience.

• Allow parent to guide the discussion and establish boundaries.

• Respect parent’s choice for next steps.

Keep the child at the forefront of your relationship with the parent.

Keep in mind that trauma is not always the answer and may be accompanied by other issues. Trust parental report and do not jump to conclusions that the parent’s current situation or past history is the cause of the child’s health issues.

Be mindful of what is important to the parent as well as your relationship with the parent. It may put off a parent to raise issues around FRAYED THREADS at the wrong time or in the context of a new parent-provider relationship.

Do not ignore current factors, such as intimate partner violence, parental substance use disorder, or parental mental health concerns.

Be aware how your clinical setting may create or have undue barriers to care. Consider how your practice can improve its processes or offer additional needed services to increase parental success in navigating your setting, such as offering walk-in visits, telephone services, closed loop referral, or other services to improve engagement.

Create an environment that promotes open discussion about family challenges:

• Display information on resources for psychosocial needs.

• Implement universal education on parental ACEs and resilience.

Be aware of how your implicit biases may impact your relationship with families and management of child health issues to aid in equitable treatment.

Attending to self-care is critical.

• Be aware of and maintain your personal boundaries.

• Develop and maintain a self-care plan.

• Discuss with parents how they take care of themselves and what they think they can try.

Conclusion

All adults were once children – Dr. Bob Block

The existing evidence on the impact of parental ACEs on child health and development is significant and growing. The implications for the policy and practice of pediatric health care are numerous and present an abundance of opportunities to improve child well-being. Certainly, the gap between what we know and what we do is immense, and we have far to go to incorporate evidence into routine practice. Pediatrician and child mental health experts have called for a “two-generation” model of child health care which has at its center the parent-child relationship.⁷⁶ As more is learned about early childhood adversity, its impact on health outcomes across the life span, and its cross-generational effect, the more the potential of pediatrics is revealed.

KEY POINTS.

• A parent’s own adverse childhood experiences (ACEs) may impact the future health and well-being of their children.

• All parents can benefit from universal education on the impact of childhood trauma on parenting and the benefits of positive parenting techniques.

• Using a strengths-based approach when working with parents who have been affected by adverse childhood experiences allows parents to build on resilience factors.

SYNOPSIS.

Provide a brief summary of your article (100 to 150 words; no references or figures/tables). The synopsis appears only in the table of contents and is often used by indexing services such as PubMed