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I woke up in an ambulance.

The last thing I could remember was standing on a ledge in an auditorium and practicing for my school’s choir performance. I was in ninth grade, it was my first field trip in my new home here in the United States, and I was nervous. Then everything went black.

I had fainted. Although my front teeth bore the brunt of my fall and saved me from serious injury, I had broken them all. As the paramedic gently explained to me why there was blood gushing from my mouth, he asked, “Did you eat today?”

“Yes,” I responded. But I was lying. Shortly after moving to the United States, I developed almost debilitating anxiety. I worried about everything, especially my family’s safety. On that field trip, I  traveled in a bus with the choir and the whole time, I worried about making it home safely. Consumed with my stress, I had forgotten to eat.

At the hospital, doctor after doctor asked me about my surgical history, any medications I was taking and if I had ever fainted before. I had an entire work-up for fainting spells, and my pediatrician prescribed anti-anxiety medications. While everyone was trying to figure out what was wrong with me, though, no one asked what had happened to me.

My anxiety continued to hound me, remaining in the background as I went to college and medical school. Though it wasn’t as severe as the time that I fell, it became a part of me, like an extra appendage I just had to deal with. Then I had a child, and shortly after my daughter was born, I felt the anxiety rise to the surface again. I woke up several times a night to make sure she was breathing, and followed her around as she started to walk, constantly worrying about her safety. Although I don’t like to admit it, my anxiety made her anxious.

Then an encounter with a patient in my pediatric clinic changed the way I practice medicine, and my life.

Parents often bring children in for medication to treat attention-deficit/hyperactivity disorder. The children often have difficulty focusing at school and at home, and the symptoms can be distressing for parents and teachers. One young boy I saw looked quite withdrawn, so I put down the evaluation forms from his school and instead asked him about current or past stress. He told me that his dad had left their family six months ago, and shortly after that he started having trouble focusing in school. I didn’t know it at the time, but I had used one of the basic practices of trauma-informed care, where instead of asking “what’s wrong with this child,” we ask “what happened to this child.”

As I watched this young boy heal with therapy (and without medication), I took a look at the root of my own anxiety. I came to the United States after leaving a country under the threat of war. I was separated from my parents for a period of time, and I watched them worry about our safety. As we traveled under a cloud of uncertainty, the young child in me began to see the world as chaotic and sometimes unsafe. And shortly after that, my anxiety began. But none of my doctors had asked about this.

In 1998, the Centers for Disease Control and Prevention and Kaiser Permanente published a study in the American Journal of Preventive Medicine that surveyed more than 17,000 adults about their history of exposure to childhood traumas, including sexual and physical abuse, emotional and physical neglect and family dysfunction. They labeled these as Adverse Childhood Experiences, or ACEs, and developed a scoring system.

The results showed a clear connection between high ACE scores and poor adult health outcomes, meaning emotional traumas in childhood can translate into physical health ailments in adults. Compared to a person with an ACE score of 0 (with no exposure to trauma), someone who scored four or higher had more than twice the risk of developing liver and chronic lung disease. A score topping seven tripled your lifetime risk of having lung cancer and heart disease.

Several subsequent studies showed how different types of childhood traumas (or toxic stress) can rewire a child’s brain. Children who have experienced toxic stress live a majority of their lives in the body’s activated ‘fight or flight’ mode. Because of this, their brains are overloaded with stress hormones and they cannot focus on learning, causing them to fall behind in school.

As parents, it’s important to ask your pediatrician to screen your child for exposure to traumatic experiences. And it’s perhaps even more important to understand that a high score on this screening does not have to dictate their destiny. Just as chronic toxic stress can rewire a child’s brain, the exposure to interventions that promote resilience (including trauma-focused therapy, proper nutrition, yoga and mindfulness) can help the brain to form new connections, a phenomenon called neuroplasticity. With the right tools, children can thrive despite having experienced trauma.

Now in my work as a pediatrician, a child’s ACE score is as important to me as their pulse or respiratory rate. I understand that in my work-up for a child’s abdominal pain, I must also look at social and emotional determinants of health. I educate parents about tools to help build resilience, and the importance of having a compassionate and available adult in a child’s life. I counsel parents about how their own childhood experiences and traumas can affect their parenting, just as I offer advice about how to teach their kids dental hygiene skills.

When a child breaks their ankle or has a physical injury, we are quick to get them in for treatment. But emotional wounds, if left untreated, can scar quickly as well. And those scars can live with our children for a lifetime.

Smita Malhotra is a mother, pediatrician and writer. You can find her online on Twitter @DrSmita_MD and her website, mindfulpediatricgiblog.com.

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