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Roberta Waite, EdD, APRN, CNS-BC;

Patricia Gerrity, PhD, RN, FAAN;
and Roxana Arango

Abstract
Literature strongly suggests that early
exposure to adverse childhood expe-
riences (ACEs) disrupts crucial normal
stages of childhood development and
predisposes these individuals to sub-
sequent psychiatric sequelae. Even
with these data, little is found in nurs-
ing literature that discusses ACEs and
their impact on adult mental health.
Therefore, the purpose of this article is
to address how nurses approach com-
munication with clients about and as-
sess for traumatic life experiences. In
addition, screening measures for ACEs
will be presented, along with discus-
sion about ethical responsibilities of
health professionals and researchers
© 2010/shutterstock

in asking about abuse.

Journal of Psychosocial Nursing • Vol. 48, No. 12, 2010 51

 A
dverse childhood ex-
periences (ACEs) have
been consistently linked
to psychiatric difficulties in chil-
dren and adults (Timko, Sutkowi,
Pavao, & Kimerling, 2008). With
the exception of one landmark
ACE study (Felitti et al., 1998)
and several articles and books
(American Medical Association,
1995; Bohn & Holz, 1996) in the
professional and popular litera-
ture, there is a dearth of clinical
information that links an under-
standing of childhood abuse (and
the sequelae that contribute to
adult health care issues) with
the role of nurses in supporting
management and education of
this population. Moreover, why,
when, and how nurses go about
making inquiries concerning
child abuse is critical. The aims
of this article are to: (a) provide
a brief overview of the original
ACE study; (b) explore nurses’
role in evaluating for ACEs, in-
cluding their ethical responsibili-
ty to ask about ACEs; (c) identify
screening strategies and research
on screening; and (d) investigate
the role of nurses concerning best
practices related to prevention of
and mental health promotion re-
garding ACEs.
Examining individuals’ child
abuse history is important, given
that research has demonstrated
that the events people have ex-
perienced help shape their life
course, and some people are more
likely to be exposed to many neg-
ative and potentially traumatic
events (Felitti, 2002; Felitti et
al., 1998). Disparities in health
are prevalent, and exposure to
destructive events is not ran-
dom or based on chance alone;
social structures and processes
significantly predispose some in-
dividuals to confront traumatic
events with increased frequency
(Margolin et al., 2009; Melchior,
Moffitt, Milne, Poulton, & Cas-
pi, 2007). Life course researchers
52
have found that adverse experi-
ences are not without conse-
quence and may have an endur-
ing effect on health throughout
adulthood (Schilling, Aseltine,
& Gore, 2007).
Mental health and behavioral
concerns related to ACEs have
been reported by other research-
ers (Anda et al., 2007). Schilling
et al. (2007) and Rees (2007)
found that long-term conse-
quences of childhood trauma
include attachment problems,
eating disorders, depression, sui-
cidal behavior, anxiety, alcohol-
ism, violent behavior, mood dis-
orders, and posttraumatic stress
disorder (PTSD). All of these
chronic conditions are associated
with higher health care service
use (Havig, 2008). When left un-
treated, childhood trauma con-
tributes to a multitude of physi-
cal and mental health problems
throughout the life span. Trauma
causes lasting neuronal and hor-
monal changes that shape brain
structures and functioning, which
can lead to profound effects on
all dimensions of development—
social, cognitive, biological, and
emotional (van der Kolk, 2003).
Therefore, it is critical that nurs-
es engage their clients effectively
during assessment to become
more informed about any child-
hood abuse histories.
Advanced practice nurses are
in a unique position to readily
assess and understand the con-
stellation of risk factors that may
precipitate poor mental health
outcomes. Promoting mental
health using early assessment
and screening strategies can im-
prove outcomes for individuals,
families, and communities. This
is particularly relevant, as re-
search suggests that: (a) most cli-
ents with mood disorders in the
public mental health system are
likely to have been exposed to
serious ACEs; and (b) the social
and psychological consequences
of these early experiences in-
clude increased trauma expo-
sure in adulthood, followed by
PTSD, high-risk behavior, and
worse health, mental health, and
functional outcomes (Lu, Mue-
ser, Rosenberg, & Jankowski,
2008). Moreover, related inves-
tigation also reveals that ACEs
are highly interrelated and rarely
occur singly (Centers for Disease
Control and Prevention, 2005).
Thus, the presence of one ACE
should serve as a signal to clini-
cians (e.g., nurses) that other
ACEs likely occurred, requiring
timely assessment and potential
intervention to preclude their
sequelae. The following sections
will explore existing ACE litera-
ture; the nurse’s role; assessment,
screening, and prevention; and
mental health promotion.
Research Overview:
ACE Study
The ACE study conducted by
Felitti et al. (1998) originated as
a weight loss study in California
that examined the long-term ef-
fects of ACEs. While taking part
in this weight loss program, nu-
merous participants dropped out;
it was later discerned that many
of these participants had been
abused as children. These find-
ings led to the epidemiological
study that examined the effects of
stressful and traumatic childhood
experiences on behaviors related
to the leading causes of social
and health problems, disability,
and death in the United States.
The ACE study tracked more
than 17,000 largely White and
middle-class adults with a medi-
an age of 57. The study assessed
childhood exposure to multiple
kinds of abuse, neglect, domestic
violence, and other dysfunction-
al behaviors and examined par-
ticipants’ retrospective behaviors
from earlier childhood to adult-
hood. Findings identified that a
significant number of adults who
Copyright © SLACK Incorporated
went for medical screening had
experienced household abuse and
dysfunction during their child-
hoods. Moreover, compared with
those who had no ACEs, those
with significant adverse experi-
ences had major health concerns:
They were twice as likely to be-
come smokers, 12 times more
likely to have attempted suicide,
7 times more likely to abuse al-
cohol, and 10 times more likely
to have injected street drugs (Fe-
litti et al., 1998). Thus, the ACE
study shows that time alone does
not heal certain adverse experi-
ences; undeniably, time conceals
these adversities.
Putnam (1998) also report-
ed that childhood stressors are
known to produce changes in the
developing brain that affect emo-
tions, behavior, and cognition,
which in turn can impair health
and quality of life (e.g., prevalent
diseases, poor mental health, risk
factors for common diseases and
poor health, sexual reproduc-
tive health, general health, so-
cial problems). These traumatic
pathophysiological insults may be
“silent” until much later in life,
leading clinicians to prescribe
medications to treat symptoms
and illnesses without knowledge
of their potential origins from
the disruptive effects of ACEs
on neurodevelopment (Putnam,
1998). As progress in the treat-
ment of individuals affected by
traumatic stress evolves, under-
standing the need for more effec-
tive psychosocial evaluations for
adults will become increasingly
important in making decisions
about prognosis, diagnosis, and
treatment.
Nurses’ Role in ACEs
While Western health care
training tends to emphasize a re-
ductionistic biogenetic paradigm
relegating psychosocial causes
of mental health problems (e.g.,
poverty, discrimination, isolation,
Journal of Psychosocial Nursing • Vol. 48, No. 12, 2010
violence, dysfunctional families)
to the periphery, some research
has supported the resurgence of
interest in psychological and so-
cial factors (e.g., the ACE study)
(Sharfstein, 2005). Today, there
is also a better understanding of
the role of the pharmaceutical
industry in promulgating simplis-
tic, one-dimensional physiologi-
cal explanations and extremely
lucrative chemical solutions to
address mental health concerns.
Many health care professionals,
including nurses, have allowed
the biopsychosocial model to
turn into the “bio-bio-bio” mod-
el (Sharfstein, 2005). Not only
must researchers pay more atten-
Mounting literature connects
childhood abuse with adult
ADHD, highlighting the need
to take into account the role
of trauma in conceptualizing
individual cases.
tion to the psychosocial causes of
human suffering; nurses also need
to reflect on these issues in their
clinical practice—it is an ethical
imperative.
Ethical Imperative: Asking
about ACEs
Being asked about traumatic
events can be distressing, espe-
cially if it is handled in an insen-
sitive manner. Nurses may also
have concerns about and objec-
tions to asking questions about
childhood maltreatment. How-
ever, the ACE study provided
strong evidence of the associa-
tion between early traumatic ex-
periences and some of the major
public health problems facing
our nation, and at the same time,
investigators also generated an
important case study of the ac-
ceptability of asking about child-
hood abuse (Edwards, Dube,
Felitti, & Anda, 2007). Becker-
Blease and Freyd (2006) noted
that it is not disclosure by itself
that appears to result in harm,
but rather negative responses the
victim receives when disclosing
trauma. Mental health clinicians
and primary care providers must
therefore receive training in how
to ask about traumatic experi-
ences and respond to disclosures.
Not only do they need to be pre-
pared to provide referral sources
to clients, but also to respond
in a supportive manner to such
disclosures (i.e., with emotional
support, belief, validation, in-
formation, or tangible aid) and
to avoid negative exacerbations
in reactions to what the victim
shares (Read, Hammersley, &
Rudgeair, 2007).
Becker-Blease and Freyd
(2006) described that most com-
munication targeting the ethics
of self-report research on abuse
focuses on the risks of asking
participants about experiences
with violence and assumes par-
ticipants receive no direct ben-
efits. This perspective is based on
commonly held beliefs and sup-
positions that asking about abuse
is disconcerting, harmful, and
53
 stigmatizing. Further embedded sion when a psychologist asked
in these assertions are implicit me, “Have you been abused?” I
assumptions that survivors are think there was an assumption
not emotionally secure enough that I had a mental illness and
to assess risk or seek help, and you know because I wasn’t say-
that researchers have an respon- ing anything about my abuse
sibility to protect survivors from I’d suffered no-one knew. I just
questions about their experi- wish they would have said,
ences (Becker-Blease & Freyd, “What happened to you? What
2006). These researchers also happened?” But they didn’t. (p.
recognized that concern about 101)
the vulnerability of survivors Similarly, Read (2007) re-
and the desire to protect them ported that people seeking men-
from harmful questions about tal health care very often believe
their experiences is based chiefly there is a link between abuse and
on researchers’ personal beliefs. their mental health, yet they
Notably, individuals are grateful generally do not divulge their
to know that others care about abuse histories spontaneously.
Most individuals affected
by childhood maltreatment
are not affected by a single
mental health concern; rather,
they often have co-occurring
or multiple mental health
concerns.
these issues (Becker-Blease Abuse survivors’ silence may
& Freyd, 2006). For example, be interpreted to mean they do
Lothian and Read (2002) indi- not want to be reminded of the
cated that when mental health abuse or to discuss it. However,
service users were asked whether Read (2007) found that abuse
questions about sexual abuse survivors may be waiting for in-
should be included in mental dications that they will receive a
health assessments, the overall supportive response.
response from service users was: Asking about abuse can
There are so many doctors aid clinicians and researchers
and registrars and nurses and to gain a clear understanding
social workers and psychiatric of the origins of and effective
district nurses in your life ask- treatments for psychopathology.
ing you about the same thing, Many disorders are assumed to
mental, mental, mental, but not have a biological origin, mostly
asking you why. It took ten years, because researchers have not
many admissions, a lot of differ- studied the relationship of dis-
ent medication, ECTs [electro- orders with abuse. For instance,
convulsive therapies]. No-one the prevailing belief about at-
was able to draw out any abuse tention-deficit/hyperactivity
issues until my very last admis- disorder (ADHD) is that it is a
54
developmental neurobiological
disorder, and that the crux of ef-
fective treatments rests on the
role of medications in managing
the ADHD behaviors. While
researchers do not dismiss other
important psychosocial factors,
the emphasis is fundamentally
placed on a medical view. How-
ever, mounting literature con-
nects childhood abuse with adult
ADHD, highlighting the need
to take into account the role of
trauma in conceptualizing indi-
vidual cases (Rucklidge, Brown,
Crawford, & Kaplan, 2006;
Waite & Ivey, 2009). Weinstein,
Staffelbach, and Biaggio (2000)
reported that many practitioners
lack recognition of the high de-
gree of common characteristics
among the symptoms of ADHD
and PTSD, including inatten-
tion, irritability, impulsivity, and
restlessness. As reported in Ruck-
lidge et al. (2006), Weinstein re-
ported that inattention, one of
the core symptoms of ADHD,
may stem from re-experiencing
trauma, hypervigilance, and/or
avoidance of stimuli because of
trauma. Similarly, hyperarousal
could be misconstrued as hyper-
activity (Rucklidge et al., 2006).
If the trauma remains unidenti-
fied, these symptoms could possi-
bly become chronic. Also, given
increased awareness among re-
searchers that many individuals
with ADHD do not show neuro-
psychological impairments, it is
vital for clinicians and research-
ers to ponder other explanations
for these behaviors.
Given the research being
conducted on childhood mis-
treatment, society is confronted
with the reality and extent of
ACEs. With this knowledge, ac-
tion must be taken to prevent a
cycle of suppression or lack of
visibility. Students in nursing
and other health disciplines,
our successors in health care
practice and research, must be
Copyright © SLACK Incorporated
informed about this critical is-
sue. What educators teach their
students is critical—in the class-
room, clinic, and research labo-
ratory (Becker-Blease & Freyd,
2006). We support the system-
atic consideration of abuse and
praise Becker-Blease and Freyd
(2006) for imploring clinicians
to reflect on their scientific and
personal reasons for not inquir-
ing about abuse. How clinicians
talk (or do not talk) about abuse
with students affects the ques-
tions future researchers and cli-
nicians will ask (Becker-Blease
& Freyd, 2006).
Nursing Practice Assessment
In practice, nurses tend to
take a holistic approach to pa-
tient assessment and care. This
approach is critical to mitigate
the chances of missing relevant
information that can be cap-
tured in creating an individual’s
health story. Thus, a general
psychosocial evaluation con-
ducted with patients cannot be
considered complete until their
childhood exposure to multiple
kinds of abuse is assessed and
information is gathered about
their current health risks and
behaviors. Moreover, most in-
dividuals affected by childhood
maltreatment are not affected
by a single mental health con-
cern; rather, they often have
co-occurring or multiple mental
health concerns. Therefore, a
well-coordinated treatment ap-
proach may be a more appropri-
ate model than treatments that
address each disorder separately
(e.g., depression, PTSD, anxi-
ety).
For example, in a patient
with irritable bowel syndrome
or chronic somatic symptoms
(in the absence of identifiable
physical pathology), the clini-
cian might inquire, “We often
see these kinds of symptoms in
people who have experienced
Journal of Psychosocial Nursing • Vol. 48, No. 12, 2010
Please tell me about your childhood.
Follow through with precise questions about
abuse/neglect.
How was it living with your parents or the
person(s) who raised you?
What is your favorite
childhood memory?
What is your most awful
memory from childhood?
How were you
punished in
your home
during your
childhood?
Figure. Example of a focused inquiry about personal adverse childhood experiences.
some severe trauma. This trauma of abuse is already established, it
could be something like a major may be advantageous to suggest
car accident, serving in military an assessment that occurs in two
combat, having your life threat- stages: general psychiatric his-
ened in some way, being raped, tory and an account of the abuse
being physically harmed as a and posttraumatic events. This
child, or being touched in a sex- alerts patients and allows them
ual way as a child. Could any of to prepare themselves, which
these things have happened to can mitigate anticipatory anxi-
you?” If this does not yield a pos- ety.
itive response, some additional When nurses ask about child-
probing may help. For instance, hood abuse and the answer is
the clinician can ask when the “yes,” it is paramount they re-
symptoms began and whether spond fittingly. All patients
any specific traumatic event oc- need to be asked about abuse
curred around that time. Hav- because of the high prevalence
ing inquired about abuse, the of maltreatment across nearly
clinician must be ready to hear all mental diagnostic categories.
the patient’s explanation. This The temptation to query only
involves having sufficient time patients with select symptoms
for the patient to do this com- (e.g., PTSD) reflects a restricted,
fortably. In addition, if a history linear view of the impact of trau-
55
 rapport. When clinicians ask
Table patients questions about abuse,
Commonly Used Instruments to Screen for Trauma they should preferably avoid do-
ing so while initiating an assess-
Instrument Description
ment or bringing it up without
Stressful Life Events Screening A 26-question standardized instrument measuring a preface or clear context. An
Questionnaire (Goodman, exposure to all possible kinds of traumas, optimal time to ask can be when
Corcoran, Turner, Yuan, & including sexual and physical assault, witnessing taking a comprehensive psycho-
Green, 1998). violence, combat trauma, illness, accidents, social history, which naturally
traumatic deaths, and natural disasters; test- includes childhood. The Figure
retest reliability (median Cronbach’s alpha shows how a focused inquiry
coefficient = 0.73) and convergent validity about personal ACEs can be
(median Cronbach’s alpha coefficient = 0.64). approached.
Primary Care PTSD Screen A 4-question instrument measuring symptoms of This example of an approach
(Prins et al., 1999) trauma during the past month; sensitivity = 0.91 gives the patient some warning
and specificity = 0.72. of what is to come. Asking indi-
Impact of Event Scale–Revised A 22-item questionnaire developed and based viduals about their best memory
(Weiss & Marmar, 1997) on DSM-IV criteria; reported internal consistency can provide a foundation on
ranges from 0.79 to 0.92. which to moderate more de-
structive memories. In addition,
Life Stressor Checklist–Revised A 30-item instrument measuring lifetime exposure
clinicians may choose to pref-
(Wolfe & Kimmerling, 1997) to stressful events; Cronbach’s alpha coefficient =
ace an introduction to assess-
0.70.
ment questions with statements
Short Form of the PTSD A 6-item instrument empirically derived from such as “I’m going to ask you
Checklist-Civilian Version the 17-item PTSD Checklist-Civilian Version for about some unpleasant things
(Lang & Stein, 2005) use in primary care settings; Cronbach’s alpha that happen to some people
coefficient = 0.79. in childhood. We ask because
Childhood Trauma A 28-item retrospective self-report questionnaire sometimes it helps reveal why
Questionnaire-Short Form designed to assess five dimensions of childhood difficulties occur later in life.”
(Bernstein & Fink, 1998) maltreatment; reliability for each of the scales The clinician may also add, “It’s
across physical abuse = 0.83 to 0.86, emotional fine if you prefer not to answer
abuse = 0.84 to 0.89, sexual abuse = 0.92 to these questions.” When fram-
0.95, physical neglect = 0.61 to 0.78, and ing questions, asking “Were
emotional neglect = 0.85 to 0.91. you sexually (or physically)
abused?” is not an effective form
of inquiry. Many patients may
Note. DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, fourth edition.
not use these terms in relation
to their experiences. If asked
directly, some individuals may
ma. Also, spontaneous disclosure asked later. Delay of inquiry at report that they were not physi-
rates are low; hence, waiting for an initial assessment should be cally abused; however, if asked
patients to disclose abuse is not clearly recorded, including why, how discipline was managed in
useful (Havig, 2008). Nurses and the clinician needs to take their family, the patient may
must actively elicit each person’s responsibility for following up respond, “Oh, I was whipped
narrative and be ready with facts with the patient. Clinicians who often with a branch, extension
about what procedures need to wait for a “magic moment” or cord, anything my mom could
be in place to support patients if when rapport is on target should get her hands on.”
and when disclosure about abuse remember that, for many abused Dill, Chu, Grob, and Eisen
occurs. patients, asking may be a neces- (1991) found that framing ques-
Read and Fraser (1998) re- sary act that encourages rapport, tions in terms of general abuse
ported that asking about child- rather than creating a barrier revealed only approximately
hood abuse during the initial to it. Lothian and Read (2002) half of the abuse identified by
assessment process is critical reported that for some patients, questions about specific behav-
because—if the question is not asking about child abuse may ior. We propose that questions
posed then—it tends not to be even be a condition for gaining should therefore ask about ex-

56 Copyright © SLACK Incorporated

amples of specific events (e.g.,
“When you were a child, did an
adult ever hurt or punish you in
a way that left bruises, cuts, or
scratches? Did anyone ever do
something sexual that made
you feel uncomfortable?”) Spe-
cific questions covering adult-
hood—including the present—
should be asked.
Information obtained from
patients about child abuse of-
fers providers a reference point
for services from which patients
can benefit. A primary care pro-
vider may use referrals to assist
with interventions, while men-
tal health specialists will likely
intervene using their specialized
skills. Importantly, all providers
would benefit from integrating
a basic psychosocial assessment
that includes taking a child
abuse history. How this occurs
needs to be contextualized to
the specific setting and skill set
of the professional members.
Screening
Screening for ACEs can
have far-reaching implications
concerning mental health pro-
motion and mental illness pre-
vention. While it is important
to screen for ACEs, rigorous
standards used to evaluate men-
tal health screening measures
have not been applied for past
or current abuse, and large clin-
ical intervention trials are lack-
ing (Harris et al., 2001).
Screening Instruments
Screening instruments to
examine factors related to trau-
ma may be helpful; however,
if questionnaires are used, the
practitioner or collaborating
clinician should discuss the re-
sponses with the patient imme-
diately afterward. How these in-
struments are used can vary. In
some instances, patients com-
plete the questionnaires alone,
and then the nurse can discuss
Journal of Psychosocial Nursing • Vol. 48, No. 12, 2010
the findings one on one with
the patient, or the nurse can use
the questionnaire as a tool to
engage the patient. Commonly
used instruments to assess for
trauma include the Stressful
Life Events Screening Ques-
tionnaire (Goodman, Corcoran,
Turner, Yuan, & Green, 1998),
Primary Care PTSD Screen
(Prins et al., 1999), Impact of
Event Scale–Revised (Weiss &
Marmar, 1997), Life Stressor
Checklist–Revised (Wolfe &
Kimerling, 1997), Short Form
of the PTSD Checklist–Civil-
ian Version (Lang & Stein,
2005), and the Childhood Trau-
ma Questionnaire–Short Form
(Bernstein & Fink, 1998). The
Table contains details about
these questionnaires.
It is critical for health care
providers to practice screening
for ACEs. Too often there are
missed opportunities to identify
and intervene—either directly
or by providing information and
referral—with individuals who
have experienced abuse. The
instruments in the Table can be
used to assess for current or past
abuse at varied entry points
into the health services system
and should be used for both
men and women of all catego-
ries, regardless of demographic
or relational circumstances.
To progress in addressing
this public health concern,
frontline practitioners (e.g., ad-
vanced practice nurses; APNs)
serve a vital role in the assess-
ment of ACEs. The approaches
APNs use to manage their pa-
tients’ needs is determined by
the practitioners’ skill set and
model of care in which they
practice. That is, an integrated
model of care would benefit
from using a psychiatric APN
to address specific mental and
behavioral health concerns re-
lated to trauma. These integrat-
ed services limit use of referrals,
enable a seamless process of
communication among provid-
ers, and facilitate learning/edu-
cation among practitioners who
collaborate to meet patients’
needs. Through awareness of
adverse implications caused by
exposure to trauma, nurses can
equip themselves to address
these issues while providing
best practice to the individuals,
families, and communities they
serve.
Research on Screening
Springer, Sheridan, Kuo, and
Carnes (2003) called for prima-
ry and subspecialty care clini-
cians to screen adult patients
for a history of childhood abuse
as a health risk factor. Practice
guidelines and recommenda-
tions for a number of specific
psychiatric and nonpsychiat-
ric medical conditions include
an assessment of abuse history;
however, no published guide-
lines exist for how and under
what conditions adults should
be screened for childhood abuse
histories in primary care set-
tings. This is remarkable, con-
sidering Springer et al. (2003)
reported that 20% to 50% of
patients in adult primary care
settings have a history of physi-
cal or sexual abuse.
When conducting a history of
abuse in childhood, Thombs et
al. (2007) found that care must
be given to the words patients
use, as specific experiences may
have different implications and
consequences in a cross-cul-
tural context. Culturally sensi-
tive assessment of ACEs neces-
sitates that screening questions
and understanding patient re-
sponses accurately reflect their
experiences, without any bias
projected through the assess-
ment process. Responses to a
specific question will therefore
be independent of group mem-
bership among patients who
57
 not everyone will need or want
K E Y P O I N TS psychotherapy. Fowler (2000)
reported that, for some, making
1. Disparities in health are prevalent, and exposure to destructive events is not
a connection between their life
random or based on chance alone; social structures and processes significantly
predispose some individuals to confront traumatic events with increased history and their previously in-
frequency. comprehensible symptoms may
have a significant therapeutic
2. Trauma and adversity earlier in one’s life causes pathophysiological insults effect.
that may be “silent” until much later in life, leading clinicians to prescribe Although structured ques-
medications to treat symptoms and illnesses without knowledge of their tionnaires may be helpful, clini-
potential origins from the disruptive effects of adverse childhood experiences cians also need to discuss the re-
(ACEs) on neurodevelopment.
sponses provided by the patient.
3. It is an ethical imperative for nurses to ask clients about ACEs; not doing so It is important to respond effec-
further supports the social forces that perpetuate trauma and violence as tively instead of trying to gain
pervasive social and public health problems. the full narrative. Proceeding
in this manner can positively
4. It is important for society to acknowledge abuse of children not only as a influence the patient-provider
social issue, but also as a health and health care issue that demands immediate trust and rapport. While an in-
attention.
troduction of policies and guide-
Do you agree with this article? Disagree? Have a comment or questions?
lines that address the relevance
Send an e-mail to the Journal, at jpn@slackinc.com. of asking about abuse is vital to
We’re waiting to hear from you! establishing a supportive culture
for this challenging work, cli-
nician training is requisite for
have similar responses to a set clinicians should not feel pres- change to begin (Read, 2006).
of related questions concerning sured to gather all the details This training can equip clini-
ACEs. If this were not the case, about the incident(s) involving cians with the crucial skills and
a practical assumption would be the trauma and should not at- confidence to ask the right ques-
that the question is appraising tempt to “fix the problem” im- tions and respond appropriately.
factors associated with group mediately (Young et al., 2001).
membership, instead of with The first point is unnecessary Prevention and
abuse (Thombs et al., 2007). and undesirable, and the second Mental Health
is unrealistic. Foremost, it is im- Promotion
Responding to Abuse portant to focus more on the re- It is important to examine
Disclosures lationship with the client than evidence-based practice con-
Young, Read, Barker-Collo, on the abuse and to respond ap- cerning prevention and mental
and Harrison (2001) reported propriately to what the client health promotion strategies.
that general practitioners may disclosed (Young et al., 2001). Some components for success-
have concerns about how to Validation of the person’s ex- ful integrated treatment models
respond when traumatic life perience and reactions to disclo- include stages of change compo-
experiences are revealed; thus, sure will communicate both the nents, motivational interview-
they may not ask or examine understanding and the nonjudg- ing, and cognitive-behavioral
underlying causes for depres- mental stance of the clinician. It therapy (CBT) interventions
sion but merely treat symptoms is best not to imply that the per- (Barrowclough et al., 2001) in
with medication. When clini- son “should” have treatment of addition to screening for trauma
cians work with clients affected any kind; however, it is impor- and health problems. Moreover,
by trauma, it is critical to have tant that the clinician describe using an approach that builds on
appropriate mental and behav- what services are available. safety and empowerment in the
ioral health services (e.g., re- Familiarity with abuse-related community is critical. Positive
ferrals, integrated or co-located services in the provider’s own results have been reported with
services) in place before assess- organization and the broader both group and individual psy-
ing or screening individuals to community is critical. Pamphlets chotherapy for women survivors
support them through the re- summarizing this information of childhood sexual abuse (Price,
covery process. Two important can also be extremely helpful to Hilsenroth, Petretic-Jackson, &
points are that mental health both clinicians and patients. Yet Bonge, 2001). Controlled trials

58 Copyright © SLACK Incorporated

of women with PTSD associated
with childhood or adult sexual
abuse indicate that CBT can
reduce patient suffering (Price
et al., 2001). Several kinds of
CBT interventions significantly
decreased symptoms compared
with no treatment in women
with PTSD, half of whom had
experienced childhood sexual or
physical abuse (Foa et al., 1999).
In this study, exposure therapy
(systematic exposure to the trau-
matic memory in a safe environ-
ment) was also more effective
than supportive counseling.
Krakow et al. (2001) found
in a randomized controlled trial
that imagery rehearsal, another
kind of CBT, reduced chronic
nightmares and improved sleep
compared with a wait-listed con-
trol group of women with PTSD
related to sexual abuse in child-
hood. Many of these women had
been symptomatic for more than
a decade. Ballenger et al. (2000)
reported that CBT is usually
used in conjunction with phar-
macotherapy. Although not spe-
cific to adult survivors of child
abuse, in a review of controlled
trials using CBT, Kroenke and
Swindle (2000) found that sig-
nificant, measurable, and often
sustained improvement occurred
with this form of treatment in
clients with syndromes associ-
ated with childhood abuse.
Seng (2003) suggested that
“acknowledging the effects of
trauma can be an intervention
itself” (p. 36). By acknowledging
the trauma in clinical reasoning
and dialoguing with the patient
in planning care and interven-
tions, improvement occurred in
their lives (Seng, 2003). Fur-
ther, Olszewski and Varrasse
(2005) encouraged nurses to
educate the person about the
complex biological implications
about what trauma discussion
can do to empower traumatized
individuals. Instilling hope and
Journal of Psychosocial Nursing • Vol. 48, No. 12, 2010
facilitating recovery can be
transformative and a central
role of mental health nurses
who work with people who have
been traumatized. In addition,
clinicians should be aware of the
possible influences of cultural
factors (e.g., race) when imple-
menting interventions, as these
issues likely influence individual
coping strategies.
In summary, given the per-
nicious and disabling impact
of traumatic experiences, it is
requisite that collaborative ef-
forts take center stage. A call to
action is needed by clinicians,
researchers, policy makers, and
others to develop effective care
models for individuals affected
by trauma. Furthermore, these
care models must be consistent
with cultural preferences and
provide the best evidence, as a
one-size-fits-all intervention is
impracticable. A starting point
is to use screening instruments
and examine their validity
cross-culturally, to consistently
implement them as part of the
patient assessment process, and
to address other co-occurring
health-related issues effectively,
particularly those that affect
mental wellness.
Conclusion
Extant literature provided in
this article acknowledges that
associations between childhood
abuse and adverse adult health
outcomes are well established;
however, this link is infre-
quently acknowledged in the
general nursing literature. The
need for more visible research
and strategies that address ef-
fective approaches to practice
and that will reach nurses who
provide the bulk of frontline
health care is warranted. More-
over, we propose that it is an
ethical imperative for nurses
to ask about ACEs; not doing
so further supports the social
forces that perpetuate trauma
and violence as pervasive social
and public health problems.
Consideration should not focus
on whether to ask, but how to
ask about peoples’ experiences
with abuse, given the enormous
mental and physical health im-
plications from unrecognized
and untreated abuse. There is
a need for collaboration among
psychosocial and biomedical
researchers, clinicians, social
service agencies, criminal jus-
tice systems, insurance compa-
nies, and public policy makers,
all whom need to take a com-
prehensive approach to both
preventing and addressing the
sequelae of childhood abuse.
Like many social issues, factors
perpetuating ACEs and strate-
gies to intervene effectively
require collaboration for effec-
tive, comprehensive, and cre-
ative solutions. Society must
acknowledge abuse of children
not only as a social issue, but
also as a health and health care
issue that demands immediate
attention.
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Dr. Waite is Associate Professor, Col-
lege of Nursing and Health Professions,
Interdisciplinary Research Unit, Doctoral
Nursing Department, Dr. Gerrity is As-
sociate Dean for Community Programs,
and Ms. Arango is an undergraduate
psychology student, College of Arts and
Sciences, Drexel University, Philadel-
phia, Pennsylvania.
The authors disclose that they have
no significant financial interests in any
product or class of products discussed
directly or indirectly in this activity,
including research support. The authors
thank Dr. Barbara Granger for providing
editorial support for this article.
Address correspondence to Roberta
Waite, EdD, APRN, CNS-BC, Associate
Professor, College of Nursing and Health
Professions, Interdisciplinary Research
Unit, Doctoral Nursing Department,
Drexel University, 1505 Race Street,
Mail Stop 1030, Philadelphia, PA
19102; e-mail: rlw26@drexel.edu.
Received: January 21, 2010
Accepted: July 20, 2010
Posted: October 22, 2010
doi:10.3928/02793695-20100930-03
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