Children who have suffered early abuse or neglect may later present with significant behavior problems including emotional instability, depression, and a tendency to be aggressive or violent with others. Troublesome behaviors may persist long after the abusive or neglectful environment has changed or the child has been in foster care placement. Neurobiological research has shown that early abuse results in an altered physiological response to stressful stimuli, a response that deleteriously affects the child’s subsequent socialization. Pediatricians can assist caregivers by helping them recognize the abused or neglected child’s altered responses, formulate more effective coping strategies, and mobilize available community resources. Pediatrics 2008;122:667–673 INTRODUCTION Early maltreatment can significantly alter a child’s normal developmental arc and leave the victim with significant long-term impairments. Health care professionals who provide care for maltreated children must consider the consequences of previous abuse for the child’s ongoing development and adaptation when faced with a variety of long-term behavior problems regardless of whether children reside with their birth families, foster families, or adoptive families. An increasing body of evidence documents the robust relationship between adverse experiences in early childhood and a host of complications, both medical and psychological, that manifest throughout childhood and later in adult life. The Adverse Childhood Events Studies have demonstrated that child abuse, neglect, and other circumstances that disrupt the parent-child relationship are significantly associated with many leading causes of adult death, such as stroke, cancer, and heart disease, and with heavy health service utilization. These disparate consequences, including depression and suicide, hypertension and diabetes, cigarette smoking, alcohol and other substance abuse, and fractured bones, bear compelling testimony to the vulnerability of children to stressful experience.1 Pediatricians see children before, during, and after adverse events. In the office, clinicians deal daily with children who are suffering the effects of trauma, including separation and loss, physical and sexual abuse, parental neglect, and witnessing violence. Many of these children, especially those for whom the stress is particularly severe, chronic, or pervasive, will have difficulty overcoming their persistent physiological and psychological responses to their earlier stress. Lingering symptoms of posttraumatic stress disorder (PTSD) or disrupted attachment can present as difficulties with sleep, anxiety, oppositional behavior, violent behaviors, and school failure.2,3 The child’s problematic behavior may continue long after abuse or neglect have ceased, despite consistent and attentive parenting by foster or adoptive parents or birth parents who have successfully changed their own behaviors. Desperate caregivers may seek the pediatrician’s help in diagnosing and treating a suspected “medical condition” or “chemical imbalance.” Unless health care professionals recognize the relationships of these common behavior problems to their remote antecedents, their interventions will be at best inefficient and at worst ineffective or even counterproductive. The primary health care professional holds the first, perhaps most critical link for caregivers and www.pediatrics.org/cgi/doi/10.1542/ peds.2008-1885 doi:10.1542/peds.2008-1885 All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.