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For a pediatrician and former teacher ACEs awareness came from a punch in the face


Dr. Kavitha Selvaraj did not learn about adverse childhood experiences (ACEs) from a class in medical school. Her first awareness of ACEs came after a student slugged her in the face when she was a new teacher in a school in Los Angeles.

She had heard a chorus in the hallway urging her students she refers to as “J” and “N” to “Fight! Fight! Fight,” she writes in an essay in a recent issue of the journal Pediatrics.

The two were trading punches. When she stepped in the middle to break it up student “J,“ Selvaraj writes, “kept swinging with full force, and injured Selvaraj. His pupils were dilated, his face was sweaty, his respirations were fast and shallow,” she recalls.

When Selvaraj called the number listed for “J’s parent, it was a residential rehab program. When she told “J’s” mother about the fight, she wrote, her response was “So what.” His mother then hung up the phone. That gave her pause and she worried about who was caring for J.

That concern kept her from quitting her job. That she didn’t quit affected her students, she says, and she earned their trust.

Looking back at that incident now, says Selvaraj, who is a fellow in academic pediatrics and attending physician at Lurie Children’s Hospital in Chicago, “there were so many children on a daily basis dealing with these kinds of stressors and having it manifest in the classroom.  Dr. 

Dr. Kavitha Selvaraj

Selvaraj didn’t understand the deep links between her students’ trauma, their behavior and health outcomes until a decade later. And now that she does, she thinks that pediatricians, teachers and parents need to work together to create practices that build resilience in kids that are traumatized.It was at the end of her medical residency when she read the CDC-Kaiser Permanente Adverse Childhood Experiences Study (ACE Study). “I had never heard of the study, and I was completely floored.”

The ACE Study was groundbreaking research that looked at how 10 types of childhood trauma affect long-term health. They include physical, emotional and sexual abuse; physical and emotional neglect such as experiencing hunger; living with a family member who’s addicted to alcohol or other substances, or who’s depressed or has other mental illnesses; experiencing parental divorce or separation; having a family member who’s incarcerated, and witnessing a parent being abused.

Subsequent ACE surveys include racism, bullying, witnessing violence outside the home, losing a parent to deportation, living in an unsafe neighborhood, and involvement with the foster care system. Other types of childhood adversity can also include being homeless, living in a war zone, being an immigrant, moving many times, involvement with the criminal justice system, and attending a school that enforces a zero-tolerance discipline policy.

For Selvaraj, the ACE Study not only led her to refining her research focus to include trauma and resilience building as a framework for looking at children and obesity, but it also compelled her to think about how her experiences in both education and health care have given her a unique lens through which to look at children – a perspective she could share with her peers and former peers.

To start with, says Selvaraj, “Both [pediatricians and teachers] need to know the symptoms of toxic stress.”

And just as health care workers help children who have asthma develop an asthma action plan that’s shared among parents, pediatricians and teachers, Selvaraj suggests, there should be a “toxic stress plan” that’s also shared.

“What do you do when a child exhibits toxic stress? What do you do when they get up in a classroom and throw a chair across the room? What do you do when they’re in clinic and they’re not taking their insulin?”

“There are a lot of resilience building plans, and they’re specific to the child. Some may need quiet time. Some may need attention from adults. Some may need to squeeze a stress ball,” she continues. Older children, she said, should be included in helping to develop that toxic stress plan.

Selvaraj learned first hand as a new teacher how breaking down silos and building communication can help create a feeling of safety and trust for students with trauma and less burnout for teachers. ”Before I developed better class management skills, I thought my class was chaos and these students were crazy.”

She recalls peeking in at a veteran teacher’s history class and was shocked by what she saw. “There were my students and they were perfect angels! It was revelatory for me, “ she said.

The history teacher had seen her outside and that began more communication among them and other teachers. They shared tips about what works with certain students, such as “If you ask this one to collect papers at the end of class, she’ll be completely engaged in class,” explains Selvaraj.

In the same vein, says Selvaraj, “A teacher may notice inattention or slipping grades, but the pediatrician may notice that their asthma is getting much worse. You would never connect those things together, but in our world those things go hand in hand.”

As such, says Selvaraj parents, pediatricians and teachers see the children in different scenarios and each has information that the others don’t have. “If we don't’ speak up and have those root conversations together,” she says, “we’re never going to figure out what’s happening with our children.”

Selvaraj says that if there are more ways for parents, educators and pediatricians to connect, it will help inform the growing research in resilience. “I think for those getting into this field predictors of resilience in evidence-based medicine, in the medical setting, the education setting and the home setting is where the future is for all of this. We know toxic stress can have long lasting effects. On the flip side,” says Selvaraj, “if it’s identified early and we can give kids all the resources and love and tools that they need, we can mitigate those effects.”


Dr. Kavitha Selvaraj is participating in a webinar on March 30 entitled: Screening for Adverse Childhood Experiences in the Pediatric Primary Care Setting: Practical Considerations and Lessons Learned


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  • KavithaSelvaraj: Dr. Kavitha Selvaraj

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Comments (5)

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Martha, Thank you for your comments. If in your example, using an ACE tool found 75 of 100 kids with high ACE scores, wouldn't that make the tool suspect? I would think either the tool has a bar set too low, or we have extreme problems in our culture. Either way, I do understand the issue of why ask the question if there are no resources to deal with the answers. On the other hand, using the tool could be data that is used to get nurses back in schools, changing laws on getting treatment while at school, and a more holistic approach to the needs of children while the schools have them. Lastly, I understand your last point. I am reminded of my time observing teachers watch after students who appear to be "different" than the rest. They don't have to ask any questions or know everything in order to monitor for bullying, shaming, etc.

Daniel Parker posted:

Why don't schools have an ACE survey for students on the way in each school year?

In my experience, at least some of there reason is because to ask children those questions might be harmful to the children. Remember the average age in the original study was 40 something. If school personnel asked questions like these and a child became overwhelmed and dysregulated, what then? Which leads us to the next reason.

Another reason might be resources. If you asked a group of 100 kids about their ACEs and it turned out that 75 of them had high scores, who would then do something about that? Who would hold the responsibility that those kids would get the kinds of services they need? Schools generally do not have health workers - mental or physical - on hand to manage that kind of need.

Finally, asking children you might not get the full story. Children may have learned, explicitly or implicitly not to talk about things going badly at home. If they do tell, they may feel like they did something wrong, or feel afraid. Again, who will be responsible for those children now? What happens if they disclose something that warrants a call to Child Protective Services?

I think it's imperative for schools to know about the effects of ACEs/trauma and the ways they can respond, which I believe educators can do without ever knowing exactly what traumas/ACEs any particular student may have.

Really wish that I had such a caring teacher. After my mother died when I was 11 years, my grades just plummeted. Rather than asking what was happening in my life, my teachers began penalizing me for being lazy and slack.  Though one teacher did ask me if there was a problem at home. I couldn't confide in her. As a 13-year-old how do you tell your teacher your father hates you, your cousin is sexually abusing you, you are being accused of your uncle's sexual interest in you. It was all so confusing. I know I developed scoliosis because of all these traumatic events which I had to suppress.

I am 50 years now, and my life has been a struggle, depression, low self-esteem, back pain. Only now after taking a break from work and working on healing the past have I begun to feel like layers of muck is being cleared from my system.

Oh, how I wish I had the resources to work on myself in my 20s, life would definitely have been better.


Another great story and amazing writing! This former teacher now doctor is incredible.

I love this line:

"Selvaraj says that if there are more ways for parents, educators and pediatricians to connect, it will help inform the growing research in resilience."

YES! Yes! YES! That makes me hopeful!


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