​“What My Bones Know” is a brand new, very poignant memoir written by a journalist who has built her career on sharing the stories of others, both on NPR’s This American Life and in podcasts. Stephanie Foo, the daughter of 1st generation immigrants from Southeast Asia, grew up in a community of Asian immigrant families where the American dream was prized. The outer veneer of stability, achievement, and accumulation of wealth hid the inner experience of families who had experienced untold traumas in their countries of origin and during the journey to a new life. Stephanie relates her experience of extreme physical and psychological abuse at the hands of her parents, which resulted in the manifestation of Complex Post-Traumatic Stress Disorder or C-PTSD. After becoming aware of her diagnosis, which is still somewhat controversial as a diagnosis among trauma experts, Stephanie embarks on her own research, as any good journalist and story-teller would. What I like about the book it that is describes the differences in complex or developmental trauma and PTSD that results from a single event or that begins in adulthood. These are vastly different experiences with effects on brain development, and treatments need to be targeted to the experience of the individual. The author also briefly describes her foray into a wide array of both evidence-based and more controversial interventions, from the alphabet soup of EMDR, IFS, and CBT, to yoga and psychedelics. This should not be taken as medical advice but is a good way to become more familiar with options that exist and for healthcare providers to hear the self-advocate point of view. I also appreciate the discussion of cultural and community factors as well as epigenetic and generational trauma. One of my personal takeaways is to recognize that individuals with C-PTSD should not just be encouraged to self-regulate when triggered but should go on to learn the social dance of repairing relationships after a perceived insult. It can be tempting to calm ones-self and move on to avoid the person who gave an insult in the future. However, the next level of maintaining healthy social relationships is to learn to express what has been hurtful and to navigate giving and receiving apologies or explanations, in order to preserve the relationship. We are made for connection and learning to remain connected is a great healing power. There is also a short discussion of the COVID-19 pandemic and how survivors of childhood trauma may fare better in stressful events, such as this, because they have been wired for survival. I will give warning that the author uses expletives in her vernacular, so take that as you will. Overall, a beautiful book and worth a read or listen! 

Laura Shamblin, MD FAAP
​www.TraumaInformedMD.com 

This is because many factors make up characteristics of resilience in each individual. One thing this book provides, which is probably the most unique, is quite a few real stories of families who have lived with RAD. Most of them are disturbing but necessarily honest. Not all of them have a happy ending. The author makes it known that she has tried to provide as many hopeful stories, where the child is doing well following therapy, as possible. She is attempting to provide hope and to emphasize the value of early diagnosis and intervention. What I felt was missing, was more description of the actual interventions that worked. I think the author may have left those descriptions out in order to not provide medical treatment advice without proper credentials. However, many of her pearls of wisdom may be helpful to parents in the trenches. I will include a few of those I thought were likely to be helpful. I apologize in advance to the author, as I will likely not be able to convey everything in the way that she would. These include the following:

1. Parents should attempt to see things from the child’s point of view. Children with RAD live in a state of fear. Having an emotional connection to a caregiver or sometimes a sibling is a fearful thing. Therefore, they do things to repel the caregiver. The caregiver is the “nurturing enemy.”
2. Those outside the home, and sometimes the father who is often gone to work are less of a threat and therefore behavior in front of them can be normal, which can seem manipulative.
3. A healing environment for a child with RAD is one where consequences are always predictable and the caregiver or household do not react in an emotionally charged way or allow the child to visibly alter the family’s plans. The child acts out in order to create chaos, get a negative response, and provoke a harsh reaction in a way they feel they have control over, because they were able to provoke it. The caregiver can counteract this by not showing how frustrated they are and providing consequences that are predictable but do not alter the caregiver’s plans.
4. Parents should practice keeping their facial expressions neutral in response to negative behaviors, and walk away to calm down when that is not possible. Parents of children with RAD have to become outwardly thick-skinned.
5. The child sees connection as something to be feared. The parent can help by reducing the amount of nurturing connection they try to provide the child. The parent should think of themselves as a “caregiver” rather than a parent for a period of time and withdraw from trying to force emotional bonding. The child must feel safe and that the home is predictable for a long time, possibly years, before they will then be ready to allow the parent to be a parent and display emotional connection. The parent can provide connection such as eye contact or touches at levels that they can tolerate or with permission.
6. Children with RAD usually need constant supervision. “Time outs” are a reward. “Time ins” are not desired and therefore may work as a consequence. But whether they are in trouble or not, a child with RAD should not be left unsupervised for any period of time. This gives them an opportunity to create chaos or misbehave in ways that push their caregiver away. They often need cameras and alarms on doors to monitor them at night as well.
7. Children with RAD lack an understanding of how their behaviors affect others. As a result, they may target siblings for physical or sexual abuse. This is another reason they need constant supervision.
8. The home environment should be as structured and supportive of the caregiver as possible. However, letting the child know what the schedule or plans are, gives them an opportunity to sabotage the plans.
9. Children with RAD often have a hard time with special plans or events such as holidays, birthdays, or vacations. They often sabotage special times. They may do this because they feel all good things end up bad, and they want to control the timing of the bad outcome. Or, they may do this when they can tell their caregiver or siblings care about something, as a way of pushing them away and creating chaos.
10. Parents should document daily activities, behaviors, and consequences as much as possible. This allows patterns to be seen by themselves and therapists, or other care team members, and used in the treatment plan. It also provides documentation if the child makes false accusations of abuse against the parent, which is common.
11. Parents should seek knowledgeable physicians, therapists, psychologists and other providers to create a treatment team. They should be prepared to help educate those who work with their child at school and family members and friends about RAD.
12. When a child poses a danger to other members of the family, they may have to receive out of home care for a period of time. Structured environments work best. Those that take RAD into account would be even better. instituteforattachment.org  in Colorado is one such place. 
13. Part of treatment usually involves relating consequences of the child’s actions to negative effects to them personally. They are not affected by general consequences or consequences to others. Negative consequences must relate to something they personally care about. Teaching them to make restitution can be helpful, meaning they have to repay those they have wronged with actions rather than just words. They may have to pay for something they broke, do chores to earn money to pay, write a letter of apology, clean up a mess, or some other action.
14. Small victories should be celebrated, but in a mild, non-threatening way. Children with RAD only understand and value tangible rewards, but they may easily use reward systems as an opportunity to manipulate, so behavioral intervention plans should be created with the help of a RAD informed therapist or psychologist. 
15. Marriages and family units are often strained by RAD. Caregivers often develop PTSD, anxiety/depression, or insomnia due to the physical and psychological targeting of the child toward the primary caregiver. The spouse often does not see these behaviors and struggles to deal with the aftermath of the effects on their spouse and family.
16. The caregiver and child can be supported by a good source of respite care. The respite caregiver should be consistently the same, be aware of RAD and the caregiver’s expectations for the child’s behavior, and ideally can provide respite at regular intervals in a predictable way.
17. Schools often struggle to work with children with RAD. The child could behave perfectly in school and only display negative behaviors at home. They could struggle academically due to the effects of neglect or prenatal substance exposure on the brain, but without a labeled disability, it may be hard to gain accommodations. Behaviors may also be explosive at school. Frequently, due to conflicts at school, parents will attempt to homeschool. This can create a downward spiral as this is forcing the child to be with the person who triggers their feelings of fear all the time and does not give the caregiver a break from constant structure, supervision, and negative behaviors either.
18. Early recognition, diagnosis, and development of a care plan can be vital to producing positive outcomes in the lives of children with RAD. As children are still developing, the sooner interventions can be made, the longer their brain will have to develop in positive ways.

In reading this book, I was hoping for a few more behavioral interventions or behavior management strategies. So, if that is what you are looking for, this may not be the resource which provides that. I feel it was helpful in providing a framework, or outline, of things to take into consideration for a parent of a child who is newly diagnosed with RAD, or suspects their child may have RAD. It provides a few websites and access to support groups related to RAD, as well. Unfortunately, this diagnosis does not have a large amount of evidence-based information available about it. Parents have had to form groups and nonprofits to support each other and pool collective knowledge. Some of these resources are out there, such as RADadvocates.org, and hopefully we can share this knowledge with parents who need it, and cannot wait for the science to catch up. 

Laura Shamblin MD 

The Connected Parent: Real Life Strategies for Building Trust and Attachment
by Karyn Purvis, Ph.D., and Lisa Qualls with Emmelie Pickett
I just finished reading The Connected Parent and I cannot recommend it highly enough! I think it would be most helpful to parents who are in the trenches of raising a child from a hard place. However, the principles and subjects discussed in it would be applicable to anyone who regularly comes in contact with children, including grandparents and extended family and friends, teachers, children and youth pastors, coaches, Sunday school teachers, pediatricians, daycare workers and owners, children’s camp workers, and more. You may be wondering what I mean by children from hard places. That term was coined to represent children who have survived early life adversity of various kinds. This could be a stressful pregnancy, extreme prematurity, adoption, foster care, neglect, abuse, prenatal or postnatal exposure to parents who used drugs or alcohol, domestic violence, or a chaotic home life due to poverty, community violence, family dysfunction, and various other stressors that affect children prenatally or in the first years of life. When these types of difficulties are present in the life of a child, without a healthy attachment to a primary caregiver who can act as a buffer to make the child feel safe and to meet the child’s needs, these difficulties can affect the growing brain of the child often causing developmental delays, behavior issues, and difficulties with social and emotional maturity. Parenting children from hard places is a very difficult undertaking that requires skills, coping mechanisms, and community support.
What I love about this book is that Lisa Qualls and Dr. Purvis focus on teaching a few very practical things that parents and caregivers can do to meet the needs of children from hard places. They teach parents how to be detectives in figuring out the needs of each specific child. Children from hard places have often developed survival skills that worked well in their early, difficult circumstances. When they continue to use these skills in a safe environment it often appears disrespectful or defiant. Sad feelings often look like mad feelings. Sensory avoidance can look like defiance or refusal. Fears can look like refusal to “act their age.” This book gives parents practical advice in how to meet needs, build attachment, allay fears, and encourage growth and maturity in our children. Lisa shares anecdotal stories from her large family and friends to help us see how these things play out in our day to day life, and to reinforce that none of us are perfect and there is always room for grace.
Lisa and Dr. Purvis also share some of the core strategies of the parenting method that Dr. Purvis and her colleague Dr. Cross developed, called Trust Based Relational Intervention (TBRI). These include redos, choices, time ins, and scripts among other things. I especially like the teaching on how to use scripts, as it has saved my sanity a few times. Scripts are short phrases that address behaviors in a way that is positive and easy to understand and remember in the midst of high emotion situations like melt downs. I don’t know about you, but I can get as flustered as my kids in these situations and it gets hard to think of what to say and then spit the words out. Similarly, when kids get upset the rational part of their brain is less accessible and they are responding from the emotional part of the brain. They cannot take in new information, or a lecture. If we learn scripts like “no hurts,” “gentle and kind,” “show respect,” “stick together,” and “listen and mind” when we are calm, we can use them in the middle of an upset and everyone knows what they mean without processing a lot of words. Families can make their own scripts that are culturally acceptable and more appropriate for different aged kids. Lisa gives the example of how teens have used terms like “be cool” instead of “no hurts”, and “check with me” instead of “ask permission.” This is just one example of the way TBRI principles have been helpful to me personally, but there are many more examples in the book along with the rationales for why these things work with kids and teens from hard places. They also spend some time translating how to meet the needs of older kids and teens and how to apply nurturing and correction principles in these challenging age groups.
Finally, something I haven’t seen in many other parenting books, Lisa spends a chapter discussing the importance of self-care for parents and gives lots of practical ideas that parents can use, even in the middle of the hardest times. She understands that telling parents to take better care of themselves is often a fruitless command and speaks from the point of view of a parent who has been there and understands the challenges.
Many of you may have already read The Connected Child by Karyn B. Purvis, Ph. D., David R. Cross, Ph.D., and Wendy Lyons Sunshine and you may be wondering how this book is different. I would say The Connected Child took a higher or more comprehensive view of children from hard places, with more explanation of prenatal growth, brain development, and meeting needs. It includes many of the same parenting techniques, so there is some overlap, but I felt The Connected Parent was a little easier to read, understand, and quickly apply for a parent who is currently in the process of parenting a child from a hard place. It has a lot of practical approaches with explanation of the rationale and then anecdotal stories that make it easier to remember and think about how these things play out in real life. I always like stories, as they keep books interesting. The Connected Parent is only 4 hours and 45 minutes on audiobook, so it’s a pretty quick read. Please check it out if you know and love a child from a hard place!
Laura Shamblin, MD
Fellow, Developmental Behavioral Pediatrics 

​I just wanted to write a quick check-in. I have been keeping to home with 4 children out of school and my husband working from home since mid-March. I've had thoughts of things I could be writing to put good information out there, but I really wanted to be sure I'm taking care of my own family first, sort of like making sure I don't have a rod in my eye while I point out the speck in others' as the Bible says. Thankfully, I can report we are doing okay. If this had happened a year ago when I had two children with pretty significant behavioral health concerns I would not be saying that. We have come a long way in a year with good therapies. I've written 2 articles which will be linked below about how to cope with stress and how to be the buffer for your child and others during this time and I'd love it if you'd share those with others. I am getting ready to start a fellowship in Development Behavioral Pediatrics this July 1st. I'm really excited to get started (and get out of the house!) but I am also mentally preparing that we are likely to see a major uptick in pediatric mental and behavioral health needs in the next few months and years. Unfortunately, some parents are not prepared to be the buffer for their child in a time of stress and we are likely to see an increase in child abuse going on. It may not be reported right now as kids aren't seeing the adults who normally report, but there will be the consequences to deal with for years to come. What can you do to help? There are a lot of nonprofits who work in this area that need continued funding during economic downturns. But closer to home, I want to encourage you all to be reaching out to family and friends who have kids at home, and if you have the ability to relieve some of their stress, do it. We are supposed to be social distancing, but in times of crisis especially, people should still be able to rely on their circle of support that includes extended family and friends who live close by. Don't be afraid to help those who need it. Get to know your neighbors from a distance and just look out for others. 

​During her exam he was able to disguise very inappropriate touch as a form of treatment and do it with her mom in the room, not realizing what was going on. This went on for over a year, escalating in nature. At the time, the reputation of Larry as the premier sports doctor for USA gymnastics, as well as a teacher of other physicians at Michigan State University, made it seem impossible to suggest he may be guilty of this evil. Due to the climate of victim-blaming, Rachael and her mother had to wait to see if an opportunity to speak out ever presented itself.
In the meantime, Rachael articulates so well the fallout of being a sexual assault survivor. She describes a heightened state of awareness and fear in public places. A fear of men standing behind her, even in a fast-food line. The inability to verbalize what had happened to her, making it impossible to consider going to see a mental health professional. With her family’s support she attempted to process her feelings through journaling and prayer. This part of the book is, I think, the most enlightening to readers who have not been a victim of abuse. The physiological changes, the emotions, and the way memories, nightmares, and fears resurface time after time for the rest of a survivor’s life is something we need to understand more in order to truly support those we come in contact with who are survivors. She explains every cultural bias against victims, point by point, making it easier to see how these biases are played out around us when we don’t even realize it.
For Rachael, as a person of strong Christian faith, her interactions with her church are also worth learning from. She describes sitting in Sunday School and discussing stories like Bathsheba and Dinah and the messages that can be transmitted to children about issues of sexual assault. If you grew up in church, like I did, it is easy to be desensitized to the horror of these stories. But when you think about them from the perspective of a survivor, it is easier to look at the messages we are often sending our children when we teach these stories, including when inappropriate comments are made by other students and not addressed by the teacher. They are a part of the Word of God and therefore have value in teaching. But it is so helpful to listen to the point of view of a survivor before discussing these issues, to help us avoid the pitfalls of our cultural biases.
Some of the messages of this book that translate to a better understanding of being trauma informed are these: Survivors need as many choices as possible as they deal with the aftermath or reporting of their abuse. Choice is a form of control and abuse always represents a loss of control for the victim. In order to recover, find their voice, and retake control of their lives, it is important to give them as many choices as possible when telling their story or seeking help. (I do want to be sure to say that when the victim is a minor at the time of disclosure, there is no choice in reporting for any adult who becomes aware of the abuse or the victim discloses to. Choices should be given when possible in who they talk to, the setting, who is present, etc. Whether or not it is reported to law enforcement or child protective services, is not a choice. It must be done.)
Something else it’s important to remember for being trauma informed is that a survivor’s perception of safety is more important than leadership’s perception of the safety of their organization. This can be called Felt Safety. If you are in leadership – a teacher, pastor, CEO – and you feel your organization is a safe place, both preventing abuse and open to receiving a disclosure of abuse about a leader or staff member and able to follow best practices in reporting and supporting the victim while investigating the claim, your opinion is secondary to whether a survivor feels safe enough to come forward in your organization. When we discuss outside instances of abuse whether in the news, books, movies, or religious texts, we are sending messages to survivors about how safe they would be discussing their abuse in our presence.
Another message that she grapples with and expresses so well is that God loves justice just as much as He loves forgiveness. The Bible teaches that vengeance belongs to Him, and there will be an eternal judgement for the evil we commit. Whether that justice is meted out in our lifetime or after life is not always in our control. But when it can be meted out by our courts, the message that sends to survivors is important. When considering the punishment for abuse, the sentence reflects the worth of the victim. That is the meaning of the book title, What is a girl worth? The answer should be everything. The punishment for victimizing the innocent should be the maximum the law allows. When we try to minimize or mitigate the evildoing of an abuser, we diminish the perfection and beauty of the goodness of God.
The story of Rachael Denhollander, to me, is an Esther story. Esther is told to use her position in a time of crisis, for "who knows but that you have come to your royal position for such a time as this?" Esther 4:14. Rachael developed the gifts God had given her which included an analytical mind and the ability to become an attorney, her supportive family, and her faith. With these three things she became the one person who could bring a police report against Larry Nassar in such a way that she could withstand the institutional push-back from Michigan State University, and get her story out into the public sector where other survivors could see it and join her in coming forward. Without the support from family and personal faith, as well as a few perfectly placed individuals who also sought truth, including a reporter, a detective, and a prosecutor, her story would not have been able to pierce the public arena and bring the judgement of our courts down on Larry Nassar.
I hope that others will take this opportunity to look at the institutions we are a part of, whether they be schools, churches, clubs, corporations or other spheres, for how we can make sure they are as prepared as they can be to both protect the innocent and to be a safe place for victims to disclose their abuse, seek help in reporting, and get support for healing. 
​One organization I've seen that provides this expertise is https://ministrysafe.com/ They have some great short videos about this issue on their site as well at https://ministrysafe.com/who-we-are/

​By Laura Shamblin, MD FAAP
Most of us have now heard of the Adverse Childhood Experiences Study published by Drs. Felitti and Anda in the American Journal of Preventative Medicine in May of 1998. The study and many follow up studies have shown a direct and dose dependent relationship between adverse childhood experiences, or abuse, neglect, and household dysfunction, and adult risky behaviors and health outcomes. As a Pediatrician and advocate for Trauma Informed Care, I’d like to take this opportunity to address some of the objections to screening for ACEs that I have come across. It is true that some areas of research are still emerging, such as protocols, but in other ways we are twenty years behind using the information we have to make a positive difference in our patients lives and in training new physicians to be more comfortable addressing social and experiential determinants of health.
Myth #1 People don’t want to talk about their personal or family traumas.
In several studies, the vast majority of patients did not mind answering a screening tool at a primary care visit. (1,2) Clinics who have adopted ACEs have found using a cover page with a short explanation of the relationship between childhood traumas and adult health outcomes to be helpful. It has also helped to have ACEs screening papers given to the patient to be filled out either at home before the visit, or in a private patient room before seeing the doctor rather than in the public waiting room. Any adoption of a new screening tool should ideally have input from a patient advisory group before implementation to account for concerns of different patient populations. (3)
Myth #2 Filling out a questionnaire may cause someone to remember suppressed memories of childhood abuse and have a sudden onset or worsening of mental health issues.
This concern has been brought up in a couple of published articles (4), however there are many more articles recording the use of ACEs screening tools in various outpatient settings without reference to this situation actually happening. The ACEs questionnaire has also been given and shown to many, many large audiences at conferences and trainings and again, there has never been a case brought to light of any major mental health consequences, to my knowledge. On the contrary, many people express appreciation and even relief to learn the associations between childhood experiences and adult behaviors and health outcomes. They know there is a problem, and it is helpful to put a name to it and therefore be able to get more information about treatment and recovery steps that can be taken. There is mention of patients being uncomfortable with the information on health outcomes being given without being accompanied by information on resilience, buffering, and positive and compensatory experiences. (5)
Myth #3 There aren’t any truly evidence-based interventions for childhood trauma. We shouldn’t make families aware of the negative health outcomes, because there is nothing proven to help them.
This assumes that all positive screens will need a behavioral health care referral. In a large study of 3 community pediatric clinics in the Chicago area, screening for ACEs only resulted in referral for mental health care in 2% of patients. (6) In a feasibility study in a family medicine practice including adults, no new referrals were made. (1) When those services are needed, there are several modalities of treatment that have good evidence for use in children and are recommended by the AAP. At the top of the list would be Trauma-Focused CBT followed by PCIT and CPP. TBRI is also a growing modality with good results among the adoption community and schools but less research funding nationally. More information about treatment modalities can be found here. https://www.traumainformedmd.com/treatments.html#/
For the many who do not need a referral, parenting resources such as local parenting classes (check with churches, hospitals, and pregnancy centers), as well as anticipatory guidance and education provided by the physician, is likely the most helpful resource and is the most asked for by parents. There is growing evidence that positive experiences in childhood as well as healthy attachment relationships with at least one adult both have a buffering effect on children who experience multiple ACEs. These positive experiences and relationships provide resilience as well as support for healing. (7,8)
Myth #4 There aren’t enough mental health professionals available to provide follow up for all of the positive screens we would get, so it’s better to just not ask the questions.
Behavioral health providers who use evidence-based methods of treatment for childhood trauma may be more available than most providers are aware. If you know the modality you would like to be used such as TF-CBT or CPP it is possible to use several search methods to find the nearest provider to your community. Links to these search sites are listed on the Treatments page of www.TraumaInformedMD.com here https://www.traumainformedmd.com/treatments.html#/. SAMHSA also has a search function you can find here https://findtreatment.samhsa.gov/ and most state Mental Health Departments also have search capabilities and resource lists. Another helpful search website is https://www.psychologytoday.com/us which has a way to filter for therapists that provide different modalities or types of therapy. By searching, you can quickly find what behavioral health resources may be near you, even in a rural location.
Myth #5 If we ask about abuse, we may uncover events that would fall under the mandatory reporting obligation. We may overwhelm the Child Protective Services and kids may be removed from the home who didn’t need to be, further traumatizing them.
First of all, if a child is in an unsafe situation there should be no problem with reporting it, despite the time and effort it may require from the provider. However, situations that are serious enough to involve your local Child Protective Services will be evaluated for safety and many of them will not require removal from the home, but they will give the family the opportunity to receive prevention services. The Family First Prevention Services Act is a federal law that was put into effect on October 1st, 2019. It allows state human services agencies to use federal matching money that was previously only used for out-of-home foster care to be used for preventions services given to the family with the child remaining in the home. This law requires some benchmarks in quality to be reached before using it and most states have not put it into effect yet, however, the national trend is changing toward keeping children in the home and providing services to the biological family when possible. (11)
Myth #6 I’d love to screen for ACEs but there is no way I have time during a patient visit to delve into those issues.
In most feasibility studies, practices have found that using a deidentified screening tool – one that just has the patient list the number of ACEs that are positive for them but not specify which ones – allows the physician to talk to them generally about being intermediate or high risk and what they can do to counteract those factors, rather than needing to hear the story of each one. Of course, if a patient wants to explain a positive answer, this may happen and opens the relationship to be a safe space for talking about these issues at this and future visits. When a deidentified screener was used, the time added to most visits was found to be 5 minutes or less in multiple studies. (1,9)
Myth #7 As a doctor, my focus is on my patients’ health, and knowing how many ACEs they have will not affect my diagnosis and treatment of current health issues.
The number of ACEs may not affect a specific diagnosis directly because there are other genetic and resilience factors that also play a role for each individual. However, universal screening makes it more likely that an environment or history of childhood trauma will come to your attention as you are treating chronic illnesses that have been shown to have direct correlations with childhood trauma and toxic stress, such as failure to thrive, asthma, obesity, ADHD, anxiety/depression, substance use, self-harm, and even things like syncope, headaches and chronic abdominal pain. ACEs are present in families of all socioeconomic backgrounds and you may fail to ask about such influences if the family appears to be well-functioning in your clinic.
I’d like to specifically point out the relationship between ACEs and ADHD diagnosis. Patients seem to have a dose dependent relationship between number of ACEs and likelihood of ADHD diagnosis. (10,12) It is also known that one symptom of PTSD is hypervigilance, which in a child includes behaviors such as inattention, inability to sit still, and other behaviors that mimic those of ADHD. Because the DSM-V does not allow for an ADHD diagnosis if another mental health disorder may explain the symptoms, it seems that a screening for ACEs and PTSD may be warranted in any person being screened for ADHD to further inform the diagnosis. As Guanfacine is an accepted treatment for both PTSD symptoms of hypervigilance and ADHD, it is logical that it may be a better first line treatment for a child with both ACEs and ADHD than a stimulant would be. Further research on this and elucidation of protocols are still being worked on.
Myth # 8 The ACEs screen was developed for adults and should not be used on children.
Depending on your purpose there may be value in screening both parents and children. In the case of parents there is some evidence that increased ACEs are related to developmental delays in their children. Surprisingly, there was even a stronger relationship between fathers’ ACEs and children’s developmental delays. (13) This would suggest that screening parents early on may be a way of knowing which to refer for more supports in parenting such as parenting classes or adult mental health services. Early adopters have suggested the 4-month well check visit as being a good time to screen as there are fewer other concerns at that visit. (3) Screening children, either having parents report for young children or having older children report for themselves, would be most helpful for reference when working up health and mental health conditions as stated above such as asthma, failure to thrive, ADHD, etc. These could be done either at well checks and referred back to during illness or could be done at times of work-up for these chronic conditions.

​Given the many demands on physicians’ time and paperwork requirements it can be easy to be so busy in our practices that we wait for government or professional organization mandates to dictate how we practice. I hope this helps to bring some resources and research to the forefront to help us use the information that ACEs screening would provide. We should NOT be screening if we are not comfortable with what we will do with the information. And what we will do is usually just have a conversation with the caregiver or patient about the results and things they can do to combat the effects of ACEs on their child, such as getting parenting support, keeping mom healthy, trying to have high quality, safe childcare, trying out things like mindfulness and exercise in the home, leaning on extended family and friends at times of stress, coordinating with teachers, etc. Of course, we will need to have mental health professionals in place that we can refer to when needed. For help with that look back at Myth #4.

References
 

1. Glowa PT, Olson AL, Johnson DJ. Screening for adverse childhood experiences in a family medicine setting: a feasibility study. J Am Board Fam Med. 2016;29(3):303-307.
2. Goldstein E. Patient preferences for discussing childhood trauma in primary care. Perm J. 2017;21:16-055. doi:10.7812/TPP/16-055.
3. Integrating ACEs science in pediatrics; Early adopters share lessons from the field. Oct 17, 2019. https://www.youtube.com/watch?v=KboAXj6HZm0&fbclid=IwAR33hjy9CflybhD3idcD81VjbYEaQUUq231FMjKeeSD3AqWXbqPKAQzwFNU&app=desktop
4. Finkeldor D. Screening for adverse childhood experiences (ACEs); Cautions and suggestions. Child Abuse and Neglect. 2018;vol85:174-179.
5. Gillespie RJ. Screening for Adverse Childhood Experiences in Pediatric Primary Care: Pitfalls and Possibilities. Pediatr Ann. 2019;48(7):e257-e261.
6. Selvaraj et al. Screening for Toxic Stress Risk Factors at Well-Child Visits: The Addressing Social Key Questions for Health Study. The Journal of Pediatrics. 2018;9,44:1-6e4.
7. Bethell C et.al. Positive Childhood Experiences and Adult Mental and Relational Health in a Statewide Sample. JAMA Pediatrics. 2019; Sep 9 : e193007.
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