{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,23]],"date-time":"2026-10-23T20:58:50Z","timestamp":1792789130562,"version":"4.5.0"},"reference-count":66,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2026,9,17]],"date-time":"2026-09-17T00:00:00Z","timestamp":1789603200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"California Department of Health Care Services","id":[{"id":"https:\/\/ror.org\/02q70n095","id-type":"ROR","asserted-by":"crossref"}]},{"id":[{"id":"https:\/\/ror.org\/02q70n095","id-type":"ROR","asserted-by":"publisher"}]},{"name":"Office of the California Surgeon General"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Children"],"abstract":"<jats:p>Background: The Adverse Childhood Experiences (ACE) Pyramid has been widely used for more than two decades to illustrate pathways linking childhood adversity to health outcomes across the lifespan. Since its development, substantial advances in the science of toxic stress have expanded understanding of the biological mechanisms through which adversity influences lifelong health. Objective: To describe the development and scientific rationale for a revised ACE Pyramid that reflects contemporary evidence on toxic stress, the biological pathways linking childhood adversity to health, and opportunities for prevention and healing. Methods: A multidisciplinary revision process was conducted in collaboration with subject matter experts from government, academia, healthcare, professional associations, and community-based organizations. Iterative review and refinement were used to align the framework with current scientific evidence and practice. Results: A revised ACE Pyramid was developed that preserves the familiar structure of the existing framework while incorporating advances in the science of toxic stress, prevention, and healing. Compared with the ACE Pyramid featured on the CDC website during development of the revised framework, the revised framework more explicitly emphasizes prolonged or excessive activation of the stress response as a central mechanistic pathway linking childhood adversity to lifelong health, expands the biological layer to encompass multiple interacting biological systems beyond neurodevelopment alone, and integrates prevention and healing opportunities throughout the framework. Conclusions: The revised ACE Pyramid synthesizes more than two decades of advances in the science of toxic stress into an accessible conceptual framework. It explains how childhood adversity becomes biologically embedded to shape lifelong health while emphasizing that prevention is possible and healing can occur throughout the life course. By providing a shared framework for understanding toxic stress biology, it may help inform trauma-informed clinical care, public health action, research, and policy aimed at advancing health equity and improve outcomes for children and families.<\/jats:p>","DOI":"10.3390\/children13091261","type":"journal-article","created":{"date-parts":[[2026,9,17]],"date-time":"2026-09-17T08:03:17Z","timestamp":1789632197000},"page":"1261","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["The Revised ACE Pyramid: A Contemporary Framework for Understanding Childhood Adversity and Advancing Toxic Stress Prevention and Healing"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0009-0007-5528-3641","authenticated-orcid":false,"given":"Krista","family":"Kotz","sequence":"first","affiliation":[{"name":"University of California, Los Angeles-University of California, San Francisco (UCLA-UCSF) ACEs Aware Family Resilience Network (UCAAN), University of California, Los Angeles, CA 90024, USA"},{"name":"The D*Stress Foundation, San Francisco, CA 94105, USA"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"methodology","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"visualization","vocabulary":"credit"},{"role":"project-administration","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1265-2925","authenticated-orcid":false,"given":"Rachel","family":"Gilgoff","sequence":"additional","affiliation":[{"name":"University of California, Los Angeles-University of California, San Francisco (UCLA-UCSF) ACEs Aware Family Resilience Network (UCAAN), University of California, Los Angeles, CA 90024, USA"},{"name":"The D*Stress Foundation, San Francisco, CA 94105, USA"},{"name":"Sean N. Parker Center for Allergy and Asthma Research, Stanford University, Palo Alto, CA 94304, USA"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"visualization","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-6646-1187","authenticated-orcid":false,"given":"Andy","family":"Krackov","sequence":"additional","affiliation":[{"name":"University of California, Los Angeles-University of California, San Francisco (UCLA-UCSF) ACEs Aware Family Resilience Network (UCAAN), University of California, Los Angeles, CA 90024, USA"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"visualization","vocabulary":"credit"}]},{"given":"Bart","family":"Klika","sequence":"additional","affiliation":[{"name":"Prevent Child Abuse America, Chicago, IL 60602, USA"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"given":"Melissa","family":"Merrick","sequence":"additional","affiliation":[{"name":"Prevent Child Abuse America, Chicago, IL 60602, USA"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"}]}],"member":"1968","published-online":{"date-parts":[[2026,9,17]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"268","DOI":"10.1016\/S0091-7435(03)00123-3","article-title":"The impact of adverse childhood experiences on health problems: Evidence from four birth cohorts dating back to 1900","volume":"37","author":"Dube","year":"2003","journal-title":"Prev. Med."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1016\/S0749-3797(98)00017-8","article-title":"Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study","volume":"14","author":"Felitti","year":"1998","journal-title":"Am. J. Prev. Med."},{"key":"ref_3","unstructured":"Centers for Disease Control and Prevention (2026, May 15). About the CDC-Kaiser ACE Study, Available online: https:\/\/www.cdc.gov\/violenceprevention\/aces\/about.html."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Bhushan, D., Kotz, K., McCall, J., Wirtz, S., Gilgoff, R., Dube, S.R., Powers, C., Olson-Morgan, J., Galeste, M., and Patterson, K. (2020). The Roadmap for Resilience: The California Surgeon General\u2019s Report on Adverse Childhood Experiences, Toxic Stress, and Health, Office of the California Surgeon General.","DOI":"10.48019\/PEAM8812"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"e356","DOI":"10.1016\/S2468-2667(17)30118-4","article-title":"The effect of multiple adverse childhood experiences on health: A systematic review and meta-analysis","volume":"2","author":"Hughes","year":"2017","journal-title":"Lancet Public Health"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"999","DOI":"10.15585\/mmwr.mm6844e1","article-title":"Vital Signs: Estimated Proportion of Adult Health Problems Attributable to Adverse Childhood Experiences and Implications for Prevention\u201425 States, 2015\u20132017","volume":"68","author":"Merrick","year":"2019","journal-title":"MMWR Morb. Mortal. Wkly. Rep."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"104127","DOI":"10.1016\/j.chiabu.2019.104127","article-title":"Adverse childhood experiences and associated health outcomes: A systematic review and meta-analysis","volume":"97","author":"Petruccelli","year":"2019","journal-title":"Child Abus. Negl."},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Murphy, S.L., Kochanek, K.D., Xu, J., and Arias, E. (2024). Mortality in the United States, 2023. National Center Health Statistics (U.S.), CDC.","DOI":"10.15620\/cdc\/170564"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"141","DOI":"10.1016\/j.childyouth.2016.10.021","article-title":"Adverse childhood experiences and life opportunities: Shifting the narrative","volume":"72","author":"Metzler","year":"2017","journal-title":"Child. Youth Serv. Rev."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"e232","DOI":"10.1542\/peds.2011-2663","article-title":"The Lifelong Effects of Early Childhood Adversity and Toxic Stress","volume":"129","author":"Shonkoff","year":"2012","journal-title":"Pediatrics"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1418","DOI":"10.1017\/S095457941900138X","article-title":"Adverse childhood experiences: Mechanisms of risk and resilience in a longitudinal urban cohort","volume":"32","author":"Giovanelli","year":"2020","journal-title":"Dev. Psychopathol."},{"key":"ref_12","unstructured":"Centers for Disease Control and Prevention (2026, May 15). About the CDC-Kaiser ACE Study: The ACE Pyramid, Available online: https:\/\/www.cdc.gov\/violenceprevention\/aces\/about.html."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"m3048","DOI":"10.1136\/bmj.m3048","article-title":"Adversity in childhood is linked to mental and physical health throughout life","volume":"371","author":"Nelson","year":"2020","journal-title":"BMJ"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"403","DOI":"10.1016\/j.yapd.2016.04.002","article-title":"Toxic Stress in Children and Adolescents","volume":"63","author":"Bucci","year":"2016","journal-title":"Adv. Pediatr."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"2327333","DOI":"10.1080\/10253890.2024.2327333","article-title":"The Stress Phenotyping Framework: A multidisciplinary biobehavioral approach for assessing and therapeutically targeting maladaptive stress physiology","volume":"27","author":"Gilgoff","year":"2024","journal-title":"Stress."},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Bhushan, D., Kotz, K., McCall, J., Wirtz, S., Gilgoff, R., Dube, S.R., Powers, C., Olson-Morgan, J., Galeste, M., and Patterson, K. (2020). The Biology of Toxic Stress. The Roadmap for Resilience: The California Surgeon General\u2019s Report on Adverse Childhood Experiences, Toxic Stress, and Health, Office of the California Surgeon General.","DOI":"10.48019\/PEAM8812"},{"key":"ref_17","unstructured":"National Academies of Sciences, Engineering, and Medicine (2019). Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity, National Academies Press."},{"key":"ref_18","unstructured":"U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion (2026, February 01). Healthy People 2030: Social Determinants of Health, Available online: https:\/\/health.gov\/healthypeople\/objectives-and-data\/social-determinants-health."},{"key":"ref_19","unstructured":"Centers for Disease Control and Prevention, and Division of Violence Prevention (2026, September 02). Essentials for Childhood: Creating Safe, Stable, Nurturing Relationships and Environments for All Children, Available online: https:\/\/stacks.cdc.gov\/view\/cdc\/117721."},{"key":"ref_20","unstructured":"Pinderhughes, H., Davis, R.A., and Williams, M. (2015). Adverse Community Experiences and Resilience: A Framework for Addressing and Preventing Community Trauma, Prevention Institute. Available online: https:\/\/www.preventioninstitute.org\/sites\/default\/files\/publications\/Adverse%20Community%20Experiences%20and%20Resilience%20Executive%20Summary.pdf."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Bhushan, D., Kotz, K., McCall, J., Wirtz, S., Gilgoff, R., Dube, S.R., Powers, C., Olson-Morgan, J., Galeste, M., and Patterson, K. (2020). Tertiary Prevention Strategies in Healthcare. The Roadmap for Resilience: The California Surgeon General\u2019s Report on Adverse Childhood Experiences, Toxic Stress, and Health, Office of the California Surgeon General.","DOI":"10.48019\/PEAM8812"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1257","DOI":"10.1002\/jnr.23802","article-title":"Psychological stress in early life as a predisposing factor for the development of chronic pain: Clinical and preclinical evidence and neurobiological mechanisms","volume":"95","author":"Burke","year":"2017","journal-title":"J. Neurosci. Res."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"151","DOI":"10.1111\/nyas.13928","article-title":"Early life adversity and health-risk behaviors: Proposed psychological and neural mechanisms","volume":"1428","author":"Duffy","year":"2018","journal-title":"Ann. N. Y. Acad. Sci."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"669","DOI":"10.1038\/nn.3086","article-title":"Social neuroscience and health: Neurophysiological mechanisms linking social ties with physical health","volume":"15","author":"Eisenberger","year":"2012","journal-title":"Nat. Neurosci."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"118","DOI":"10.1007\/s11920-018-0983-y","article-title":"A Review of the Neurobiological Basis of Trauma-Related Dissociation and Its Relation to Cannabinoid- and Opioid-Mediated Stress Response: A Transdiagnostic, Translational Approach","volume":"20","author":"Lanius","year":"2018","journal-title":"Curr. Psychiatry Rep."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"80","DOI":"10.1016\/j.jpsychires.2018.02.002","article-title":"The effects of early life stress on reward processing","volume":"101","author":"Novick","year":"2018","journal-title":"J. Psychiatr. Res."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"265","DOI":"10.1146\/annurev-clinpsy-032816-045159","article-title":"Social Safety Theory: A Biologically Based Evolutionary Perspective on Life Stress, Health, and Behavior","volume":"16","author":"Slavich","year":"2020","journal-title":"Annu. Rev. Clin. Psychol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"241","DOI":"10.1111\/jcpp.12507","article-title":"Annual Research Review: Enduring neurobiological effects of childhood abuse and neglect","volume":"57","author":"Teicher","year":"2016","journal-title":"J. Child Psychol. Psychiatry"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"677","DOI":"10.1016\/j.yhbeh.2010.06.003","article-title":"Psychosocial stressor effects on cortisol and ghrelin in emotional and non-emotional eaters: Influence of anger and shame","volume":"58","author":"Raspopow","year":"2010","journal-title":"Horm. Behav."},{"key":"ref_30","first-page":"55","article-title":"How do glucocorticoids influence stress responses? Integrating permissive, suppressive, stimulatory, and preparative actions","volume":"21","author":"Sapolsky","year":"2000","journal-title":"Endocr. Rev."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"133","DOI":"10.1016\/j.tins.2020.01.002","article-title":"Early Adversity and Critical Periods: Neurodevelopmental Consequences of Violating the Expectable Environment","volume":"43","author":"Nelson","year":"2020","journal-title":"Trends Neurosci."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"703","DOI":"10.1146\/annurev-psych-010418-102936","article-title":"Stress and Obesity","volume":"70","author":"Tomiyama","year":"2019","journal-title":"Annu Rev. Psychol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"140","DOI":"10.1016\/j.psyneuen.2017.05.012","article-title":"The effects of early life adversity on the immune system","volume":"82","author":"Elwenspoek","year":"2017","journal-title":"Psychoneuroendocrinology"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1016\/j.bbi.2014.10.012","article-title":"Understanding inflammation, its regulation, and relevance for health: A top scientific and public priority","volume":"45","author":"Slavich","year":"2015","journal-title":"Brain Behav. Immun."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"e75","DOI":"10.1002\/lim2.75","article-title":"Human social genomics: Concepts, mechanisms, and implications for health","volume":"4","author":"Slavich","year":"2023","journal-title":"Lifestyle Med."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"331","DOI":"10.1177\/2167702613478594","article-title":"The Emerging Field of Human Social Genomics","volume":"1","author":"Slavich","year":"2013","journal-title":"Clin. Psychol. Sci."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"389","DOI":"10.1016\/j.amepre.2009.06.021","article-title":"Adverse Childhood Experiences and the Risk of Premature Mortality","volume":"37","author":"Brown","year":"2009","journal-title":"Am. J. Prev. Med."},{"key":"ref_38","unstructured":"Perry, B. (2026, May 15). The Neuroarcheology of Childhood Maltreatment the Neurodevelopmental Costs of Adverse Childhood Events. Available online: https:\/\/www.semanticscholar.org\/paper\/The-Neuroarcheology-of-Childhood-Maltreatment-The-Perry\/35bf24c5d43f42a3c8f5e91b81db933372b54c27."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"387","DOI":"10.1016\/j.tins.2015.04.004","article-title":"The adaptive human parental brain: Implications for children\u2019s social development","volume":"38","author":"Feldman","year":"2015","journal-title":"Trends Neurosci."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1103","DOI":"10.1037\/emo0000504","article-title":"Parent-child attachment and children\u2019s experience and regulation of emotion: A meta-analytic review","volume":"19","author":"Cooke","year":"2019","journal-title":"Emotion"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"39","DOI":"10.15585\/mmwr.su7304a5","article-title":"Adverse Childhood Experiences and Health Conditions and Risk Behaviors Among High School Students\u2014Youth Risk Behavior Survey, United States, 2023","volume":"73","author":"Swedo","year":"2024","journal-title":"MMWR Suppl."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"723","DOI":"10.1111\/tsq.12107","article-title":"Long-Term Physical Health Consequences of Adverse Childhood Experiences","volume":"56","author":"Monnat","year":"2015","journal-title":"Sociol. Q."},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"Waehrer, G.M., Miller, T.R., Silverio Marques, S.C., Oh, D.L., and Burke Harris, N. (2020). Disease burden of adverse childhood experiences across 14 states. PLoS ONE, 15.","DOI":"10.1371\/journal.pone.0226134"},{"key":"ref_44","unstructured":"Loudermilk, E., Obure, R., Obenauer, J., Quinn, M., and Stinson, J. (2016, January 6\u20137). The Role of Adverse Childhood Experiences in Adult Divorce and Separation. Proceedings of the Appalachian Student Research Forum, Johnson City, TN, USA. Available online: https:\/\/dc.etsu.edu\/etsu-works\/7952\/."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"828","DOI":"10.1016\/S2215-0366(22)00202-4","article-title":"Social thinning and stress generation after childhood maltreatment: A neurocognitive social transactional model of psychiatric vulnerability","volume":"9","author":"McCrory","year":"2022","journal-title":"Lancet Psychiatry"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"30","DOI":"10.7812\/TPP\/03-089","article-title":"Childhood Abuse, Household Dysfunction, and Indicators of Impaired Adult Worker Performance","volume":"8","author":"Anda","year":"2004","journal-title":"Perm. J."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"390","DOI":"10.1016\/j.chiabu.2015.05.013","article-title":"Pathways from childhood abuse and other adversities to adult health risks: The role of adult socioeconomic conditions","volume":"51","author":"Font","year":"2016","journal-title":"Child Abus. Negl."},{"key":"ref_48","first-page":"100349","article-title":"Adverse childhood experiences and premature mortality through mid-adulthood: A five-decade prospective study","volume":"15","author":"Yu","year":"2022","journal-title":"Lancet Reg. Health-Am."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"105821","DOI":"10.1016\/j.psyneuen.2022.105821","article-title":"Associations between exposure to adverse childhood experiences and biological aging: Evidence from the Canadian Longitudinal Study on Aging","volume":"142","author":"Mian","year":"2022","journal-title":"Psychoneuroendocrinology"},{"key":"ref_50","unstructured":"(2010). A Conceptual Framework for Action on the Social Determinants of Health: Debates, Policy & Practice, Case Studies, World Health Organization."},{"key":"ref_51","unstructured":"(2024). Blueprint for Change Impact Report Prevent Child Abuse America, Prevent Child Abuse America. Available online: https:\/\/preventchildabuse.org\/wp-content\/uploads\/2025\/05\/PCAA-2024-Impact-Report-Digital-1.pdf."},{"key":"ref_52","unstructured":"(2026, March 02). Prevent Child Abuse America. Available online: https:\/\/preventchildabuse.org."},{"key":"ref_53","unstructured":"National Center for Injury Prevention and Control, Division of Violence Prevention, Centers for Disease Control and Prevention (2026, February 01). Essentials for Childhood: Steps to Create Safe, Stable, Nurturing Relationships and Environments. Available online: https:\/\/americanspcc.org\/wp-content\/uploads\/2017\/03\/Adverse-Childhood-Experiences-ACEs-CDC-essentials_for_childhood_framework.pdf."},{"key":"ref_54","unstructured":"(2026, March 02). Primary Prevention National Messaging Toolkit. Available online: https:\/\/preventchildabuse.org\/wp-content\/uploads\/2026\/01\/PCAA_Digital-Toolkit_final.pdf."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1542\/peds.2021-055591","article-title":"Opportunities to Treat Toxic Stress","volume":"151","author":"Gilgoff","year":"2023","journal-title":"Pediatrics"},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1111\/nyas.12998","article-title":"Mindfulness meditation and the immune system: A systematic review of randomized controlled trials","volume":"1373","author":"Black","year":"2016","journal-title":"Ann. N. Y. Acad. Sci."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"56","DOI":"10.1080\/17437199.2020.1760727","article-title":"Meditation interventions efficiently reduce cortisol levels of at-risk samples: A meta-analysis","volume":"15","author":"Koncz","year":"2021","journal-title":"Health Psychol. Rev."},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"156","DOI":"10.1016\/j.jpsychires.2017.08.004","article-title":"Mindfulness mediates the physiological markers of stress: Systematic review and meta-analysis","volume":"95","author":"Pascoe","year":"2017","journal-title":"J. Psychiatr. Res."},{"key":"ref_59","doi-asserted-by":"crossref","unstructured":"Jones, R., Tarter, R., and Ross, A.M. (2021). Greenspace Interventions, Stress and Cortisol: A Scoping Review. Int. J. Environ. Res. Public Health, 18.","DOI":"10.3390\/ijerph18062802"},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"136","DOI":"10.1016\/j.healthplace.2018.03.001","article-title":"Does spending time outdoors reduce stress? A review of real-time stress response to outdoor environments","volume":"51","author":"Kondo","year":"2018","journal-title":"Health Place"},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"21501319241306302","DOI":"10.1177\/21501319241306302","article-title":"Parenting Education to Improve Relational Health Through Pediatric Primary Care: A Scoping Review","volume":"15","author":"Delgado","year":"2024","journal-title":"J. Prim. Care Community Health"},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"913","DOI":"10.1097\/01.chi.0000222784.03735.92","article-title":"Child-parent psychotherapy: 6-month follow-up of a randomized controlled trial","volume":"45","author":"Lieberman","year":"2006","journal-title":"J. Am. Acad. Child Adolesc. Psychiatry"},{"key":"ref_63","doi-asserted-by":"crossref","first-page":"1241","DOI":"10.1097\/01.chi.0000181047.59702.58","article-title":"Toward evidence-based treatment: Child-parent psychotherapy with preschoolers exposed to marital violence","volume":"44","author":"Lieberman","year":"2005","journal-title":"J. Am. Acad. Child Adolesc. Psychiatry"},{"key":"ref_64","doi-asserted-by":"crossref","first-page":"71","DOI":"10.7812\/TPP\/13-098","article-title":"The role of eye movement desensitization and reprocessing (EMDR) therapy in medicine: Addressing the psychological and physical symptoms stemming from adverse life experiences","volume":"18","author":"Shapiro","year":"2014","journal-title":"Perm. J."},{"key":"ref_65","doi-asserted-by":"crossref","unstructured":"Wilson, G., Farrell, D., Barron, I., Hutchins, J., Whybrow, D., and Kiernan, M.D. (2018). The Use of Eye-Movement Desensitization Reprocessing (EMDR) Therapy in Treating Post-traumatic Stress Disorder\u2014A Systematic Narrative Review. Front Psychol., 9.","DOI":"10.3389\/fpsyg.2018.00923"},{"key":"ref_66","doi-asserted-by":"crossref","first-page":"167","DOI":"10.2147\/NDT.S10389","article-title":"Cognitive behavioral therapy for the treatment of post-traumatic stress disorder: A review","volume":"7","author":"Kar","year":"2011","journal-title":"Neuropsychiatr. Dis. 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