Toxic Stress Screening

Toxic Stress

Toxic stress is the strong, unrelieved activation of the body's stress management system in the absences of protective adult support. Moderate, short-lived stress responses in the body can promote growth, but toxic stress can occur when a child experiences strong, frequent and/or prolonged adversity - adverse childhood events - without adequate support from adults to cope. This can derail healthy development and have damaging effects of learning, behavior, and health across the lifespan. (From Harvard University's Center for the Developing Child, Tackling Toxic Stress (Harvard University))

Adverse Childhood Events

Substantial, and growing, evidence (The Adverse Childhood Experiences (ACE) Study) details the negative impact of Adverse Childhood Events (ACE) on subsequent development, health, and well-being. Such events are common and may include loss of a parent or divorce, trauma or serious illness, mental illness or incarceration of a family member, exposure to domestic violence, abuse, or neglect, etc.
The ACE Study involved over 17,000 members of Kaiser Permanente HMO, from 1995 - 1997. The ACE Study asked respondents about 3 main types of ACE with 10 sub-types. Almost two-thirds of the study participants reported at least one ACE, and more than one in five reported three or more ACEs. The short- and long-term outcomes of these childhood exposures include a multitude of health and social problems.
The ACE score, which reflects the number of ACEs experienced, is strongly associated, in a graded fashion, with increased risk for:
  • Alcoholism and alcohol abuse
  • Chronic obstructive pulmonary disease
  • Depression
  • Fetal death
  • Poor health-related quality of life
  • Illicit drug use
  • Ischemic heart disease
  • Liver disease
  • Intimate partner violence
  • Multiple sexual partners
  • Sexually transmitted diseases
  • Smoking
  • Suicide attempts
  • Unintended pregnancies
  • Early initiation of smoking
  • Early initiation of sexual activity
  • Adolescent pregnancy

Screening for ACEs

Few tools are available to screen for exposures that could lead to toxic stress or for the symptoms that may result. We offer two: the SEEK Parent Screening Questionnaire (PSQ-R), and the Survey of Wellbeing of Young Children (SWYC) (PDF Document 4.2 MB). More are in development.
No widely-accepted guidelines exist for toxic stress/traumatic event screening. Some pediatricians present a screener at either all or selected well-child checkups, such as at the 2, 9 and 15 month, and the 2, 3, 4, and 5 year visits.


Information & Support

For Professionals

Adverse Childhood Experiences (CDC)
Extensive information and resources pertaining to ACEs, including the original CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study; Centers for Disease Control and Prevention.

The Adverse Childhood Experiences (ACE) Study
An ongoing collaboration between the Centers for Disease Control and Prevention and Kaiser Permanente; perhaps the largest study of its kind, analyzing the relationship between multiple categories of childhood trauma (ACEs), and health and behavioral outcomes later in life; site allows calculation of an individual's ACE score.

The National Child Traumatic Stress Network (NCTSN)
In-depth information about trauma-informed clinical interventions, screening and assessment practices, disaster behavioral health response and recovery, culture and trauma, and more.

What is Child Traumatic Stress? (NCTSN)
Education and questions and answers about child traumatic stress; National Child Traumatic Stress Network.

Trauma-Informed Patient Education (Children's Hospital of Philadelphia)
Downloadable patient education to help: parents help their children cope, children and teens cope with injury and pain or dealing with traumatic stress reminders, and siblings cope with their brother's or sister's hospitalization, illness, injury, and recovery. Also includes workbooks for coping with hospitalization.

Trauma Informed Care Network
A group of mental health and medical providers in Salt Lake City, Utah, who want to increase awareness and access to effective evidence-based trauma informed care. Includes listings of some of the trauma-trained providers in the area.

Helping Foster and Adoptive Families Cope with Trauma: A Guide for Pediatricians (AAP) (PDF Document 3.6 MB)
Designed to strengthen clinicians' abilities to identify traumatized children, educate families about toxic stress, and empower families to respond to children’s behavior in ways that acknowledge past traumas but promote the learning of adaptive reactions to stress; American Academy of Pediatrics.


Screeners and other tools to help clinicians identify patients and families with trauma.

Adversities – Beliefs - Consequences (ABC) Worksheet (PDF Document 115 KB)
Helps identify the impact of thoughts and feelings, as related to adversity, on the future; adapted from the Surviving Cancer Competently Intervention Program – Newly Diagnosed (SCCIP-ND) manual; site developed by The Center for Pediatric Traumatic Stress and The Children’s Hospital of Philadelphia.

SEEK Parent Screening Questionnaire (PSQ-R)
Parent questionnaire that screens for child maltreatment and toxic stress using 15 yes/no questions. Scroll to bottom of the page for links to free to download in English, Chinese, Spanish, Swedish, and Vietnamese; from the University of Maryland, School of Medicine Department of Pediatrics.

Survey of Wellbeing of Young Children (SWYC) (PDF Document 4.2 MB)
The Survey of Wellbeing of Young Children (SWYC) is a freely-available, comprehensive screening instrument for toxic stress and adverse events for children under 5 years of age. The SWYC was written to be simple to answer, short, and easy to read. The entire instrument requires 15 minutes or less to complete and is straightforward to score and interpret. There is a SWYC form for every age on the pediatric periodicity schedule. This is the complete set of forms.

Trauma Toolbox for Primary Care (AAP)
This 6-part series was designed with the primary care practice in mind – those who may or may not be familiar with adverse childhood experiences (ACEs), toxic stress, and the process of asking families about exposure to ACEs or other traumatic events; American Academy of Pediatrics.

Services for Patients & Families Nationwide (NW)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Helpful Articles

Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS.
Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.
Am J Prev Med. 1998;14(4):245-58. PubMed abstract
Describes the relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.

Authors & Reviewers

Initial publication: September 2015
Current Authors and Reviewers:
Author: Chuck Norlin, MD