Trauma-related terms like adverse childhood experiences (ACEs), post-traumatic stress disorder (PTSD), and trauma-informed care (TIC) frequently appear in guidelines and quality initiatives. However, clinicians often lack clarity on how to measure ACEs, how they differ from PTSD, and how to address trauma in patient care.
Alexander Nicholas Melinyshyn, MD, a neurologist based in Ontario, Canada, and board member for the Canadian Headache Society, shared guidance on ACEs and trauma-informed care at the 2025 Scottsdale Headache Symposium, held from December 3 to 7, 2025, in Scottsdale, Arizona.1
In an interview with The Clinical Advisor, Dr Melinyshyn suggested that the confusion around ACEs is in part due to how trauma is framed. “I think of ACEs as more of an epidemiological construct,” he said. “They’re meant to look for correlations and risk factors that anticipate problems later in life, not to function as a diagnosis.”
ACEs Are Risk Factors, Not Diagnoses
Headshot courtesy of Alexander Nicholas Melinyshyn, MD
The first study on ACEs was published in 1998. It demonstrated a link between experiencing adversity early in life and negative health outcomes in adulthood, including cardiovascular disease, mental illness, substance use disorders, and chronic pain.2
Following the landmark study, ACE screening tools grew in popularity. Items on ACE questionnaires range from emotional neglect and verbal abuse to parental incarceration or household substance use. Two patients with identical ACE scores may have vastly different experiences.
Dr Melinyshyn cautioned against conflating ACE scores with psychiatric diagnoses. For example, PTSD is a defined clinical diagnosis tied to a specific traumatic experience, such as sexual violence or life-threatening events, and includes clearly delineated symptom criteria.
“ACEs are much broader,” Dr Melinyshyn told The Clinical Advisor. “What’s traumatic to one person may not be traumatic to another.”
Furthermore, screening tools for ACE often miss protective factors, which can create “a huge hole in the research,” according to Dr Melinshyn. “We’re so focused on the negative that we don’t look at the positive experiences that buffer adversity,” he said. “Often, there was one protective relationship–a teacher, a grandparent, a mentor. That’s where the next step should be. How do we intervene early and create synthetic positive experiences?”
Consequences of ACEs
Although the brain continues to develop as patients enter their twenties, by definition, ACEs occur in the first 18 years of a patient’s life. Dr Melinyshyn said he believes that the most critical window for ACEs is infancy through early adolescence. Repeated trauma during this period may lock the body into a chronic fight-or-flight state driven by altered brain connectivity and sustained cortisol exposure, he explained.
“That adaptation might protect you in the moment, but over time, it has a cost,” Dr Melinyshyn said. Such costs of chronic stress include gastrointestinal dysfunction, weight gain, central nervous system changes, migraine, fibromyalgia, chronic fatigue, and functional neurological disorders.
“Each specialty is looking at one piece of the elephant,” Dr Melinyshyn explained, evoking the allegory of the blindfolded scientists, each specialist touching a different part of the animal and trying to explain what they are examining. “We’re missing the root cause, and early intervention could be relatively inexpensive compared with treating downstream disease.”
Why Clinicians Hesitate to Screen For Trauma
Despite growing awareness, many clinicians remain reluctant to screen for trauma, according to Dr Melinyshyn. Concerns like time constraints, lack of training, and fear of opening “Pandora’s box” may cause clinicians to avoid psychological trauma screenings.
“Our system is already strained to the limit,” Dr Melinyshyn acknowledged. “And many clinicians were trained with the mindset, ‘If it’s not limb- or life-threatening, it’s not my realm.’ ”
Dr Melinyshyn argued that by avoiding screening patients for trauma, clinicians can perpetuate strain on the health care system. Patients with unrecognized trauma frequently present with diffuse, multisystem symptoms and undergo extensive testing and treatment with a variety of specialists, he explained. Functional disorders like irritable bowel syndrome (IBS), migraine, fibromyalgia, and functional neurological disorder are especially prevalent in people who have experienced trauma.
“These are the patients doctors label as ‘difficult’ or ‘annoying,’ ” Dr Melinyshyn said. “But the truth is, we don’t have the skillset to manage the underlying problem. So, they keep coming back. The good news is they have a great prognosis if you put them on the right path.”
Trauma-Informed Care as “Universal Precautions”
Rather than advocating for universal, in-depth trauma screening, Dr Melinyshyn said he favors a pragmatic approach rooted in trauma-informed care. (Figure)
“At minimum, every clinician should behave in a way that’s trauma-informed, so you’re not retraumatizing people,” he said.
This can include offering validated questionnaires that patients complete independently, flagging high-risk individuals, such as those with refractory symptoms or pan-positive reviews of systems, and building brief trauma screening into routine care.
“It doesn’t have to take a lot of time,” Dr Melinyshyn said. “We’ve shown models that take 5 minutes. I think of it as a universal precaution, like handwashing.”
The key to adopting this “universal precaution,” Dr Melinyshyn added, is emotional intelligence among staff who will complete the screening. “That’s the elephant in the room. It’s hard to teach, and it’s often neglected in medical training,” he said.
Implementing Trauma-Informed Care
Implementing trauma-informed care requires special training. While advocating for greater awareness of trauma, Dr Melinyshyn warned that well-intentioned but undertrained providers can offer unconditional validation that reinforces maladaptive beliefs. According to Dr Melinyshyn, trauma-informed care requires appropriate training and clinical judgment, not unconditional affirmation.
“That’s not helpful therapy,” he said. “Patients may have distorted interpretations of events, and [a clinician] simply affirming everything can actually cause harm.”
Another common mistake that Dr Melinyshyn has noticed is when a clinician will label every symptom as trauma-related, potentially leading to missed diagnoses.
Taking time to identify trauma and treat its sequellae properly is an opportunity to help patients achieve their best outcomes and also save the system large costs.
While clinicians must be mindful not to unintentionally invalidate perceived traumas and threaten the clinical relationship, there is a delicate balance in helping patients with conditions causing negative thought distortions to recognize that not every adversity is truly traumatic – many negative experiences are a healthy part of life, Dr Melinyshyn explained. “This isn’t about abandoning medical rigor. That is where hard conversations, emotional intelligence, and clinical experience become paramount,” he said.
Restoring Patient Agency
Ultimately, according to Dr Melinyshyn, screening for trauma, providing trauma-informed care, and restoring patient agency are beneficial to both patients and health systems. He emphasized the importance of shared, but structured, decision-making with patients to help restore agency.
“I tell patients, ‘Here are the top recommendations. Go read, think about it, and call me when you’re ready,’ ” he said. “Making that decision is the first step toward becoming a survivor instead of a perpetual victim.”
This approach, he added, improves adherence and reduces nocebo effects. “Giving patients back their locus of control is part of the therapy,” Dr Melinyshyn said.
“We’re going to look back on this period and realize we could have saved billions of dollars and a lot of suffering by addressing trauma earlier.”
For additional resources on trauma-informed care, Dr. Melinyshyn has recommended the following:
- Purkey E, Patel R, Phillips SP. Trauma-informed care: better care for everyone. Can Fam Physician. 2018;64(3):170-172.
- Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. Substance Abuse and Mental Health Services Administration; 2014. HHS publication SMA 14-4884.
- Hunter J, Maunder R. How & why health professionals should ask about ACEs. http://www.acechange.ca/why-ask.html
