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We are getting better and better at screening for ACEs. But it is not as encompassing as it should be. The ACEs questionnaire accounts for visible and measurable trauma. But what about the trauma that happens in the context of a relationship, that is not visible? I know, every trauma happens in the context of a relationship, but I am referring to the trauma that derives from parental unresponsiveness and emotional neglect.

So, what about the trauma that results from a parent who is unresponsive to a newborn or infant's cries? What about the trauma of a parent who leaves the newborn or infant home alone all day because they have to go to work, but when they are home and with the infant, they are loving, caring and responsive? How do we measure and address that? Asking the parent is not enough because most times they don't even know that they are traumatizing their kids. They are trying to survive.

I work at the CCTC in Philadelphia and I see a lot of parents who reports no trauma about the kids (the measurable ones we ask about, as per the questionnaire) who are clearly traumatized and showing behaviors.

I am not sure if anyone ever thought about this, but I have been going around with this question in my mind and I would love to hear if any of you has come up with something to address this kind of trauma?



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Please do not ever give up.  You have a passion so please keep asking questions like this because this is the type of question we need to answer and as we move to screening all peds patients, I really fear that many docs et al will think they’ve done their due as far as looking for  adversity that affects child development but much will be missed and generational cycles will not be broken.    

The ACE questions aren’t enough. I don’t know the answer to this question but if 40,000 people put their heads together to brainstorm, we could come up with something: 

Maybe this  won’t answer your question (perhaps, even confound it) but... for kids abused within the school system itself, how well do we actually police that system? I ask because I’ve become privy to a situation of staff misconduct and cover-up of sexual behavior and drugs.

1-Are ALL school employees REQUIRED to take ANNUAL training in both recognizing **and reporting** abuse? So EVERYONE is literally on the same page and knows what to look fir, what to do? ANNUALLY? 

2- Does the school district have a transparent method for β€œhanding off” reports that implicate their own staff?  Or do they tie local law enforcement up in their policies? 

3- What can happen to school staff who fail to report suspected abuse by staff member?

The child abuse reporting should be thorough... the end goal MUST be to reduce bullying/inappropriate behaviors/abuse by adults on kids. And it must not stop  there. School districts need anti-bullying policies that set β€œcivility” or β€œrespect” as the β€˜bottom line’, and have clear procedures on how to address any/all behavior that is not civil or respectful.

As a certified school nurse, I so often want to ask the ACE questions. There is  a nursing standard that directs you on how to ask question when you suspected abuse or neglect,  based on my nursing judge , sometimes I have ask some tough questions, being very sensitive to the wording of my questions to ensure that I don't retraumatize or cross any bondaries. But it would be interesting to read  research about  what has worked in other districts.

This a great question & something that I have thought about as well. I think relational trauma is challenging to quantify for a variety of reasons. The assessors personal views, societal pressures, religious & cultural differences, level of maturity of the parent, parental expectations, attachment style the parent received growing up, mental health issues, addiction problems, personality types of the child & parent clashing, & other concerns can influence how emotionally present a parent is. In addition, some children seem to respond differently to their parents not being emotionally present. I think the best indication is the child themselves. However, even this is tricky because sometimes when parents aren’t emotionally present children become parentified. These children may excel in school & other areas, so the emotional abuse concerns could be missed until they are much older. The kids who are often noticed are mainly the ones who fall below behavioral &/or educational norms. There are a couple of tools that I use to screen for relational trauma. Personal observations from meeting with the child & family, feedback from teachers & school staff, as well as school, DCS, & other records. Assessing how children get along with their siblings, peers, & adults in their lives is also important. I specialize in Play Therapy, specifically Sandtray Therapy. Having a child & parent(s) create a sandtray together provides a great opportunity to observe relational strengths & areas of concern.


This is so timely for me.  I have recently been looking at the SDQ Strengths and Difficulties Questionaire that is used by our social workers in schools as part of routine pre and post intervention tests to see if its scores, or particular indicators, might indicate where a stronger trauma informed approach should be employed. 

The information I have found so far indicate the SDQ is not good at identifying relational trauma and another tool is suggested.  See attached.


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