CYW ACE-Q User Guide

ACE-Q

USER GUIDE FOR

HEALTH

PROFESSIONALS

Center for Youth Wellness ACE-Questionnaire

(CYW ACE-Q Child, Teen, Teen SR)

Lead Authors

Nadine Burke Harris, MD, MPH

Todd Renschler, PsyD

Acknowledgements to

Center for Youth Wellness (CYW)

Clinical, Research, Strategic Initiatives, Data and

Organizational Learning teams, (2012-2015)

Bayview Child Health Center (BCHC) staff

including Medical Assistants and Pediatricians

Leadership High School students

and instructor Tiffani Johnson

CYW Community Advisory Council (CAC)

CYW Community Research Board (CRB)

Suggested Citation

Burke Harris, N. and Renschler, T.

(version 7/2015).

Center for Youth Wellness ACE-Questionnaire

(CYW ACE-Q Child, Teen, Teen SR). Center for

Youth Wellness. San Francisco, CA.

CYW ACE-Q User Guide

Lead Authors

Monica Bucci, MD

Lisa Gutiérrez Wang, PhD

Kadiatou Koita, MS

Sukhdip Purewal, MPH

Sara Silvério Marques, DrPH, MPH

Nadine Burke Harris, MD, MPH

Acknowledgements to

BCHC-CYW Learning Collaborative

CYW Communications team

Suggested Citation

Bucci M, Gutiérrez Wang L, Koita K, Purewal

S, Silvério Marques S, Burke Harris N. Center

for Youth Wellness ACE-Questionnaire User

Guide. San Francisco, CA: Center for Youth

Wellness; 2015

CYW ACE-Q USER GUIDE

INTRODUCTION

Over the past several decades emerging research has revealed

early adversity as a major threat to health and well-being across

the life course. Adverse Childhood Experiences, or ACEs, have

been linked to poor health outcomes in adulthood, and there is

growing literature indicating that toxic stress caused by ACEs

can profoundly alter child and adolescent development.

The Center for Youth Wellness (CYW) was created to

respond to the new medical understanding of how early

life adversity harms the developing brains and bodies of

children. In partnership, the Bayview Child Health Center

(BCHC), a primary care pediatric home serving children

and families in the Bayview Hunters Point neighborhood

in San Francisco, and CYW provide an integrated pediatric

care model aimed at addressing both the physical and

behavioral health needs of families exposed to ACEs.

The CYW Adverse Childhood Experiences Questionnaire

(CYW ACE-Q) was developed through the BCHC-CYW

partnership with input from community and youth

stakeholders. The User Guide provides a brief review of

the research literature and outlines how the CYW ACE-Q

is used at BCHC-CYW.

The CYW ACE-Q and User Guide have been made available

to primary care providers for the purpose of information

sharing. The CYW ACE-Q is free and is intended to be used

solely for informational or educational purposes. The

CYW ACE-Q is not a validated diagnostic tool, and is not

intended to be used in the diagnosis or cure of any disease.

CYW ACE-Q USER GUIDE

TABLE OF CONTENTS

Background 4

Rationale for Screening for ACEs 8

The Center for Youth Wellness Adverse

Childhood Experiences Questionnaire (CYW ACE-Q) 9

CYW ACE-Q Implementation Considerations 16

BCHC-CYW Integrated Pediatric Care Model 17

References 19

CYW ACE-Q USER GUIDE

BACKGROUND

ADVERSE CHILDHOOD EXPERIENCES

Adverse Childhood Experiences (ACEs) are stressful or traumatic events experienced before age 18. They

are grouped into three categories: abuse, neglect, and household dysfunction

1,2

The three types of ACEs include

Emotional

Sexual

Physical

Emotional

Physical

Divorce

Mother treated violently

Mental Illness

Substance Abuse

Incarcerated Relativ

ABUSE NEGLECT HOUSEHOLD DYSFUNCTION

The term, “ACEs,” was coined in 1998 following the publication of the Adverse Childhood Experiences

Study (ACE Study). The study was groundbreaking in that it found that ACEs were not only common within

the population, but were strongly related to the development and prevalence of numerous health prob-

lems

. The ACE Study was the rst to assess physical health outcomes related to these particular adver-

sities in a large study population.

FIGURE 1. CATEGORIES OF ADVERSE CHILDHOOD EXPERIENCES (ACEs)

s o u r c e : Robert Wood Johnson Foundation, 2013

CYW ACE-Q USER GUIDE

The ACE Study. Over 17,000 California adults who

were patients of Kaiser Permanente in San Diego

were interviewed about their medical history and

exposure to ACEs. Almost two-thirds (63.5%) of par-

ticipants reported having at least one ACE, and 12%

reported having four or more

. A dose-response

relationship was revealed between the number of

ACEs experienced by an individual and negative

health outcomes, such that with increasing num-

bers of ACEs, the odds of reporting an illness or

health risk behavior also increased

ACEs and Negative Health Outcomes. Subsequent

research with diverse populations of adults, and

with children and adolescents, continue to support

the conclusion that a relationship exists between

ACEs and health outcomes. In adults, ACEs have

been found to have a strong, dose-response asso-

ciation with cardiovascular disease, chronic lung

disease, headaches, autoimmune disease, sleep

disturbances, early death, obesity, smoking, gen-

eral poor health, depression, posttraumatic stress

disorder, anxiety, substance abuse, and binge

drinking

. In children and adolescents, ACEs have

been correlated with fair or poor general health

5,6

, illness requiring a doctor 6, fair or poor dental

health

, lifetime asthma

5,8

, ADHD 5, autism

, being

overweight or obese,

5,9

and learning diculties

In addition, studies on ACEs during childhood and

adolescence have found an association between

ACEs and violent behavior (delinquent behavior, bully-

ing, physical ghting, dating violence, weapon-carrying)

National Prevalence Rates. A nationally represen-

tative study found that approximately two-thirds

of adults reported at least one ACE

. In children,

the prevalence of at least one ACE has ranged from

one-third to nearly one-half of the population in na-

tionally representative samples

5,7,8

; among popula-

tions at high-risk for maltreatment, the rate reach-

es as high as 91%

TABLE 1. ACE STUDY FINDINGS

In the ACE Study, in comparisonto those reporting no

ACEs, individuals with 4+ ACEs had signicantly greater

odds of reporting...

Ischemic heart disease 2.2

Any Cancer 1.9

Chronic Bronchitis or emphysema (COPD) 3.9

Stroke 2.4

Diabetes 1.6

Ever attempted suicide 12.2

Severe obesisty 1.6

Two or more weeks of

depressed mood in the past year 4.6

Ever used illicit drugs 4.7

Ever injected drugs 10.3

Current smoker 2.2

Ever had a sexually transmitted disease 2.5

so ur ce : Felitti, 1998

CYW ACE-Q USER GUIDE

TOXIC STRESS

Although the causal mechanisms linking childhood adversity to poor health outcomes are still being

explored, scientists now understand that a maladaptation of the physiological stress response system

plays an important role in negative long-term health outcomes.

Physiological Stress Response. Stress is the phys-

iological and behavioral response elicited by selec-

tive pressure from the physical and social environ-

ment that challenges and disrupts homeostasis

— the self-regulating process biological systems

have in place to maintain the internal stability for

survival

12,13

. While the experience of stress is inu-

enced by many factors - including the intensity and

severity of the stressor, the individual’s perception

of the stressor, physical and mental health, and

genetic makeup - the physiology of the response

involves the activation of the neuro-endocrine-im-

mune (NEI) network. This NEI network is comprised

of the autonomic nervous system (sympathetic and

parasympathetic), the hypothalamic-pituitary-adrenal

(HPA) axis, and the immune system.

In the face of an acute stressor, the neurons in the

amygdala— the part of the brain responsible for

emotions, especially fear, regulation of attention

and modulation of memory—are activated. The

amygdala receives and interprets the present situa-

tion as a threat and sends signals to the hypothal-

amus, which in turn activates the HPA axis

14,15

. The

hypothalamus activates the sympathetic nervous

system response by sending signals through sym-

pathetic nerves to the adrenal medulla and trigger-

ing the secretion of catecholamines (epinephrine and

norepinephrine also known as adrenaline and noradrena-

line) into circulation. This results in a constriction

of the blood vessels, increase in blood pressure,

increase in heart rate and force of cardiac contrac-

tion, increased muscle tone, and bronchial dilation

with increase in the respiratory rate

16,17

. The circu-

lating adrenaline also triggers the release of stored

glucose and fat to be used as an energy source.

These changes prepare the body for a “ght” or

“ight” response.

The activation of the HPA axis results in a cascade

of hormonal release. Once activated, the neurons

in the hypothalamus synthesize and release a

hormone called the corticotropin-releasing factor

(CRF). This hormone travels to the pituitary gland

through hypophysial portal vessels. The binding of

CRF to its receptors induces the release of the ad-

reno-corticotropic hormone (ACTH) in the systemic

circulation. ACTH, then, targets the adrenal glands

and induces the secretion of glucocorticoids (cor-

tisol) from the adrenal cortex

. Cortisol release is

responsible for many of the changes occurring in

the body, a phenomenon that appears to be par-

ticularly pronounced during experiences of chron-

ic stress

. Some of the effects of cortisol include

activation of the natural immune response through

the granulocytes (neutrophils, macrophages, mast cell,

and eosinophils), the natural killer cells, and the com-

plement proteins. Their actions are inammation,

destruction of the invaders with oxygen radicals,

and phagocytosis. The macrophages also produce

pro-inammatory cytokines (messenger molecules)

such as the interleukin 1 and 6 (IL-1, IL-6), and tumor

necrosis factor (TNF) that produce inammation

and promote wound healing

Once the exposure to the stressor is discontinued,

a negative feedback inhibition shuts down the

stress response. The body’s continuous actions

to maintain homeostasis through these changing

conditions, has been termed as allostasis

CYW ACE-Q USER GUIDE

The American Academy of Pediatrics (AAP) has described three general categories of stress response:

POSITIVE STRESS RESPONSE A normal and essential part of healthy development. It is characterized

by brief increases in heart rate and blood pressure, as well as mild eleva-

tions in hormonal levels. When children are exposed to a stressor as part

of their development, such as the rst day of school or a school test, in

the presence of a caring relationship with an adult who provides protec-

tive effect to cope with the stressor, after the initial activation, the physio-

logical stress response shuts down through negative feedback, once the

child is no longer exposed to the stressor

TOLERABLE STRESS RESPONSE The body’s alert systems are elevated to a greater degree. The activation

is time-limited and buffered by a caring adult relationship. This allows the

brain and organs to recover

TOXIC STRESS RESPONSE Occurs with strong, frequent or prolonged adversity. It is characterized

by disruption of brain architecture and other organ systems. Toxic stress

is associated with increased risk of stress related disease and cognitive

impairment

CYW ACE-Q USER GUIDE

RATIONALE FOR SCREENING FOR ACES

EARLY DETECTION CAN PREVENT NEGATIVE HEALTH OUTCOMES

Many of the foundations of health in adulthood are laid during childhood and adolescence. Though there

are children who experience multiple ACEs in their rst few years of life, most children accumulate ACEs

over the course of their childhood. In a multisite study of children exposed to or at risk for maltreatment,

it was found that by age 6 children had an average ACE score of 1.94. Between ages 6 and 12, on average

they accumulated an additional 1.53 ACE, and then between ages 12 to 16 another 1.15

. The gradual

accumulation of ACEs suggests that there is an opportunity to identify children at risk for accumulating

ACEs and the negative health outcomes associated with them. By doing so, we can raise awareness of the

importance of preventing further exposure to ACEs, identify needed specialized treatment for children who

have been exposed, and better tailor health care measures based on an understanding of the child’s odds

of illness or disease. In addition, while the plasticity in the brain during early childhood and adolescence is

a source of vulnerability to ACEs, it is also an opportunity for intervention and treatment

THE PRIMARY CARE SETTING IS AN IDEAL SETTING FOR UNIVERSAL SCREENING,

HEALTH PROMOTION AND DISEASE PREVENTION

The primary care medical home is uniquely positioned to be the site for routine universal screening for

ACEs. Primary care physicians are trained in disease prevention and to understand the important role of

parents and communities in determining a child’s well-being

. Interacting with children and their families

at regular intervals can allow patients and providers to develop a trusting relationship which can facilitate

the disclosure of ACEs.

Universal screening for ACEs is critical. For some children the effects of toxic stress are seen in externaliz-

ing behaviors, such as poor impulse control and behavioral dysregulation. In these children, externalizing

behaviors may be symptoms of the neurodevelopmental impacts of toxic stress. Routine screening offers

the opportunity to identify individuals at high risk and offer Anticipatory Guidance before the child be-

comes symptomatic. In addition, there are also individuals who do not exhibit any externalizing behaviors,

and are still at increased risk of developing poor health outcomes.

THE AMERICAN ACADEMY OF PEDIATRICS (AAP) RECOMMENDS ROUTINE SCREENING

The American Academy of Pediatrics (AAP) describes the basic science of pediatrics as falling at the inter-

section of understanding individual biology, ecology, and development. The clinical report “The Pediatrician’s

Role in Child Maltreatment Prevention” published by the AAP provides recommendations for implementing a

comprehensive program to identify maltreatment in order to better support positive child development

. In the AAP policy statement, “Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating

Developmental Science into Lifelong Health, ” the AAP explicitly calls on pediatricians to “actively screen for

precipitants of toxic stress that are common in their particular practices”

CYW ACE-Q USER GUIDE

INSTRUMENT DESCRIPTION

Based on the instrument created by Vincent Felitti and Robert Anda for use with adults

, the CYW Ad-

verse Childhood Experiences Questionnaire (CYW ACE-Q) is a clinical screening tool that calculates cumu-

lative exposure to Adverse Childhood Experiences (ACEs) in patients age 0 to 19. Respondents are asked

to report how many experience types (or categories) apply to them or their child, not which experiences

apply (i.e. it is de-identied). The CYW ACE-Q is intended for use in pediatric and family practice settings to

identify patients at increased risk for chronic health problems, learning diculties, mental and behavioral

health problems and developmental issues due to changes in brain architecture and developing organ

systems brought on by exposure to extreme and prolonged stress. The tool is available in three age-spe-

cic versions, and in English and Spanish. It takes approximately two to ve minutes to complete.

CYW ACE-Q VERSIONS

1. CYW Adverse Childhood Experiences Questionnaire for Children (CYW ACE-Q Child)

17 item instrument completed by the parent/caregiver for children age 0 to 12

2. CYW Adverse Childhood Experiences Questionnaire for Adolescents (CYW ACE-Q Teen)

19 item instrument completed by the parent/caregiver for youth age 13 to 19

3. CYW Adverse Childhood Experiences Questionnaire for Adolescents : Self Report (CYW ACE-Q Teen SR)

19 item instrument completed by youth age 13 to 19

THE CENTER FOR YOUTH WELLNESS

ADVERSE

CHILDHOOD

EXPERIENCES

QUESTIONNAIRE

CYW ACE-Q

CYW ACE-Q USER GUIDE

INSTRUMENT STRUCTURE

The instrument is comprised of two sections: Section 1 of the CYW ACE-Q (i.e. items #1-10) consists of

the traditional ten ACEs for which we have population-level data for disease risk in adults. Section 2 in-

cludes seven (CYW ACE-Q Child) or nine (CYW ACE-Q Teen and CYW ACE-Q Teen SR) items assessing for exposure

to additional early life stressors identied by experts and community stakeholders. These items are hy-

pothesized to also lead to disruption of the neuro-endocrine-immune axis, but are not yet correlated with

population level data about risk of disease. They include involvement in the Foster Care system, bullying,

loss of parent or guardian due to death, deportation or migration, medical trauma, exposure to community

violence, and discrimination.

SECTION 1 Ten items assessing exposure to the original ten ACEs

SECTION 2 Seven or nine items assessing for exposure to additional early life stressors

relevant to children/youth served in community clinics

SCORING

As an instrument calculating cumulative exposure to categories of adversity, the respondent is asked to

report how many categories apply to them or their child. Respondents tally the number for each section

and write the total in the box provided. Each completed CYW ACE-Q generates a two number score, for

example, a score of 3+2 (three categories endorsed in Section 1 and two endorsed in Section 2) or 4 + 4 (four categories

endorsed in each section).

PLEASE NOTE: As a clinical tool, BCHC-CYW uses the CYW ACE-Q total score (Section 1+ Section 2) to identify

which patients are at high risk of health and developmental concerns. The traditional ACEs (Section 1) and

additional items (Section 2) are kept separate in the CYW ACE-Q for purposes of research and evaluation.

Specically, BCHC-CYW is collecting traditional ACE data to assess whether the integrated pediatric care

model results in a decreased risk of adverse health and developmental outcomes.

ADMINISTRATION

The CYW ACE-Q is either an informant (CYW ACE-Q Child and CYW ACE-Q Teen) or self-report (CYW ACE-Q Teen

SR) instrument. It is presented to the parent/caregiver and/or youth upon check-in for standard medical

appointments. It is administered to all new patients, 9 months and older, prior their rst appointment, at

the 9- and 24-month Well Child Check, and yearly thereafter (see Table 2. Administration Schedule).

TABLE 2. ADMINISTRATION SCHEDULES

REGISTRATION 1ST APPOINTMENT AT CLINIC

9 MONTH WELL CHILD CHECK

24 MONTH WELL CHILD CHECK

YEARLY FOR AGES 3-12

YEARLY FOR AGES 13-19

CYW ACE-Q CHILD CYW ACE-Q TEEN SR CYW ACE-Q TEEN

CYW ACE-Q USER GUIDE

The instrument is introduced by the Medical Assis-

tant. The following steps are taken to administer

the CYW ACE-Q Child (for patients 0-12 years of age):

1. Medical Assistant greets and welcomes the care-

giver and patient.

2. Medical Assistant informs the caregiver that

they will need to ll out several forms prior to

the child/youth’s appointment. The packet is

provided on a clipboard. We recommend that the

CYW ACE-Q be included earlier in the packet to

increase completion rate and reinforce the clini-

cal model (screen-counsel-refer).

3. The Medical Assistant provides a general de-

scription of each form in the packet, providing

context. S/he informs the caregiver that the Pri-

mary Care Provider will review the results with

her/him and the child/youth.

4. The caregiver completes the packet and returns

it to the Medical Assistant.

5. The packet is provided to the Primary Care Pro-

vider for review prior to the appointment. The Pri-

mary Care Provider reviews the information prior

to meeting with the patient.

The following steps are taken to administer the

CYW ACE-Q Teen and CYW ACE-Q Teen SR (for pa-

tients 13-19 years of age):

1. Medical Assistant greets and welcomes the pa-

tient and caregiver.

2. Medical Assistant informs them that they will

need to ll out several forms prior to the appoint-

ment. The patient and caregiver each receive a

separate packet on a clipboard. They are asked

to complete the forms separately. As with the

CYW ACE-Q Child, we recommend that the CYW

ACE-Q Teen and CYW ACE-Q Teen SR be included

earlier in the packet to increase completion rate

and reinforce the clinical model (screen-counsel-re-

fer).

3. The Medical Assistant provides a general de-

scription of each form in the packet, providing

context. S/he explains that the Primary Care Pro-

vider is interested in obtaining information from

both their perspectives. S/he also informs them

that the Primary Care Provider will review the re-

sults with them during the appointment.

4. The packets are returned separately to the Medi-

cal Assistant upon completion.

5. Both packets are provided to the Primary Care

Provider for review prior to the appointment. The

Primary Care Provider reviews the information

prior to meeting with the patient.

CYW ACE-Q USER GUIDE

TABLE 4. MEDICAL ASSISTANT SAMPLE SCRIPTS

Point of Contact with Patient/Caregiver Sample Script

INTRODUCTION OF THE PACKET

We have some forms that we’d like for you to complete so that the

doctor understands how Child’s Name is doing. The doctor will an-

swer any questions you have about the forms, and I’m here if you need

clarication on the instructions.

There are X forms in this packet and we give these forms to all of our

patients. (Present other forms as routinely done.)

The second piece of paper is the CYW Adverse Childhood Experiences

Questionnaire. This is something we give to each patient. This form

asks some personal questions and screens for health risks due to ex-

posure to stress. Review the statements and write down the number

of statements that apply to your child, not which ones.

When you have nished, return the forms to me. I will place everything

in a folder and give it to the doctor before you and Child’s Name go in

for your visit.

PLEASE NOTE: If the patient is a teen (age 13-19), the Medical Assistant will ask

both the parent/caregiver and the teen to complete their respective forms (i.e.

CYW ACE-Q Teen and CYW ACE-Q Teen SR) separately so the doctor can under-

stand both perspectives.

CYW ACE-Q USER GUIDE

REVIEWING THE CYW ACE-Q RESULTS WITH THE PATIENT

The Primary Care Provider should integrate the CYW ACE-Q results with other relevant patient information.

Through conversation with the patient and her/his caregiver, the Primary Care Provider may identify relevant

symptoms that should be considered in determining whether a referral for services is clinically indicated.

INTERPRETATION OF RESULTS

The completed CYW ACE-Q will have two scores: one for Section 1 (original ten ACEs), and another for Section

2 (supplementary items). If the patient’s CYW ACE-Q score from both Section 1 and Section 2 equals zero to

three (0-3) and the patient does not present with additional symptomatology (see Relevant Symptomatology

listed below), the Primary Care Provider should provide Anticipatory Guidance. If the patient’s score is one to

three (1-3) with symptomatology, or four or higher, an appropriate referral to care should be made.

FIGURE 2. CYW ACE-Q SCORING

CYW ACE-Q SCORE 0-3

WITHOUT SYMPTOMATOLOGY

CYW ACE-Q SCORE 1-3

WITH SYMPTOMATOLOGY OR

4 ACE SCORE

ANTICIPATORY GUIDANCE REFER TO TREATMENT

TABLE 4. RELEVANT SYMPTOMATOLOGY

Sleep disturbance

Weight gain or loss

Failure to thrive

Enuresis, encopresis

Constipation

Hair loss

Poor control of chronic disease

(such as asthma or diabetes)

Developmental regression

School failure or absenteeism

Aggression

Poor impulse control

Frequent crying

Restricted affect or numbing

High risk behavior in adolescents

Unexplained somatic complaints

(such as HA or abdominal pain)

Depression

Anxiety

Interpersonal conict

CYW ACE-Q USER GUIDE

TABLE 6. PRIMARY CARE PROVIDER SAMPLE SCRIPTS

Screening Result Sample Script

GENERAL INTRODUCTION

TO THE CYW ACE-Q RESULTS

CYW ACE-Q SCORE OF 0

CYW ACE-Q SCORE 1-3

WITHOUT SYMPTOMATOLOGY

New research has shown that children’s exposure to stressful or trau-

matic events can lead to increased risk of health and developmental

problems, like asthma and learning diculties. As a result, at this

clinic we now screen all of our patients for Adverse Childhood Expe-

riences. Once again, you don’t have to tell us which ones your child

experienced, only how many. I’d like to take a moment to review your

responses.

Based on your responses, I don’t see any cause for concern. We now

understand that exposure to stressful or traumatic experiences like

the ones listed here may increase the amount the stress hormones

that a child’s body makes and this can increase their risk for health

and developmental problems. If, in the future, [Child’s Name] experienc-

es any of these issues, please let us know because early intervention

can lead to better outcomes.

I see that [Child’s Name] has experienced [CYW ACE-Q Score] of these

items, is that correct? Based on your responses, I want to ask a few

more questions about her/his health and development. Has [Child’s

Name] experienced any signicant weight gain or loss since these ex-

periences occurred? How is [Child’s Name] doing in school? Has the

teacher or school staff expressed any concerns? How’s [Child’s Name]

sleep? Have you noticed any worsening of your [Child’s Name]asthma/

eczema/diabetes since these events occurred?

(Caregiver answers no and that the patient is doing ne)

We now understand that exposure to stressful or traumatic experi-

ences like the ones listed here may increase the amount the stress

hormones that a child’s body makes and this can increase their risk

for health and developmental problems. At this time, it doesn’t seem

like [Child’s Name] is experiencing those issues, but if, in the future, s/

he does start showing symptoms, please let us know because early

intervention can lead to better outcomes.

CYW ACE-Q USER GUIDE

CYW ACE-Q SCORE 1-3

WITH SYMPTOMATOLOGY or

CYW ACE-Q SCORE 4 or MORE

I see that [Child’s Name] has experienced [CYW ACE-Q Score] of these

items, is that correct? Based on your responses, I want to ask a few

more questions about her health and development. Has [Child’s Name]

experienced any signicant weight gain or loss since these experienc-

es occurred? How is [Child’s Name] doing in school? Has the teacher

or school staff expressed any concerns? How’s [Child’s Name] sleep?

Have you noticed any worsening of [Child’s Name] asthma, eczema, di-

abetes since these events occurred?

(Caregiver responds yes)

We now understand that exposure to stressful or traumatic experi-

ences like the ones listed here may increase the amount the stress

hormones that a child’s body makes and this can increase their risk

for health and developmental problems.

Because of what [Child’s Name] has experienced, I am concerned that

this may be contributing to her problems in school/worsening asth-

ma/weight gain.

Some of the things that have been shown to help the body recover

from adversity and normalize those stress hormones include good nu-

trition, healthy sleep, regular exercise, therapy, mindfulness- like med-

itation, and healthy relationships.

I’d like to refer [Child’s Name] to some services that could be helpful.

(Describe referral and resources available at your setting. This may include a “warm

hand-off” or formal referral to an internal mental health or behavioral health pro-

vider integrated into the clinic, or may be a referral to a partner agency.)

We also know that a healthy caregiver is one of the most important

ingredients for healthy children so the same applies to you mom/dad/

grandma/auntie. Reducing or managing your stress level is one of the

best things that you can do for [Child’s Name] to improve his/her health

and development.

TABLE 6. PRIMARY CARE PROVIDER SAMPLE SCRIPTS (continued)

Screening Result Sample Script

CYW ACE-Q USER GUIDE

CYW ACE-Q IMPLEMENTATION CONSIDERATIONS

The American Academy of Pediatrics (AAP) recommends that clinicians who are preparing to begin

screening use the following four questions to guide their process

• Why are we looking at this issue?

• What are we looking for?

• How do we nd it?

• What do we do once we have found it?

Given this framework, Primary Care Providers and/or Clinic Managers planning to integrate the CYW

ACE-Q into clinical practice may consider the following steps:

1. Gain an understanding of the background and rationale for screening for ACEs

A. Review additional resources on ACEs and Toxic Stress, for example, literature cited throughout

this document to better understand the relationship between exposure to Adverse Childhood

Experiences (ACEs) and negative health outcomes.

B. Review the benets of screening for ACEs in your particular setting.

2. Understand the context and feasibility for integrating the CYW ACE-Q into your practice setting

A. Vision

I. Initiate discussions with supervisors/managers and senior leadership to gauge interest and possible concerns.

II. Determine how the integration would work within your existing model and how it would connect to the mis-

sion and goals of your organization.

III. Set short, medium and long-term goals for integration.

IV. Evaluate existing systems and processes to ensure compliance with state and other regulatory bodies.

V. Develop plans for collecting and evaluating data to assess implementation success.

B. Resources

I. Evaluate what stafng support is needed to integrate the CYW ACE-Q. For example, from an administrative

perspective, the CYW ACE-Q will increase workload of staff collecting and managing the health data.

II. Identify internal or external resources for patients requiring behavioral health services or other supports.

Understand what community partnerships exist and/or must be developed to support in planning, implemen-

tation and response to the integration of screening for ACEs is essential. Warm handoffs have been known

to be effective in linking primary health care and specialized services; a relatively quick turnaround time is

preferred for patients to engage in special services.

III. Understand what training and professional development needs are required for staff. For example, trainings

on trauma-informed care, vicarious trauma, conict resolution, and mandated reporting should be incorpo-

rated, along with consistent supervision.

CYW ACE-Q USER GUIDE

TABLE 6. PROMISING INTERVENTIONS

Research indicates that the following

interventions may mitigate dysregulation

of the neuro-endocrine-immune network

associated with exposure to ACEs.

30–35

Regular Exercise

Good Nutrition

Sleep

Mental Health

Mindfulness Practices

(e.g., meditation)

Supportive Relationships

The BCHC-CYW model was created to recognize

the impact of Adverse Childhood Experiences

(ACEs) on health and seeks to treat toxic stress in

children. We do this by routine screening, which

allows for early detection and intervention, paired

with a multidisciplinary approach focused on ad-

dressing the neuro-endocrine-immune dysregula-

tion of toxic stress.

Our model integrates primary health care, mental

health and wellness, research, policy, education,

and community and family support services to

meet children and families where they are to sup-

port them in leading healthier lives.

Children/youth are screened for exposure to ACEs

during routine visits to the Bayview Child Health

Center (BCHC). Based on the CYW Adverse Child-

hood Experiences Questionnaire (CYW ACE-Q)

results and information collected during the ap-

pointment, pediatricians determine whether a re-

ferral to the Center for Youth Wellness (CYW) for

integrated care is indicated.

FIGURE 3. CYW ACEs SCREENING PROCESS

SCREEN COUNSEL REFER

BCHC-CYW INTEGRATED PEDIATRIC CARE MODEL

CYW ACE-Q USER GUIDE

CYW CLINICAL MODEL

CYW treats children/youth (referred by BCHC pediatricians) who exhibit signs and symptoms of neuro-endo-

crine-immune dysregulation and their caregivers.

Care Coordination is at the heart of the CYW clinical model. Our approach is distinct from traditional case

management in that each of our Care Coordinators is trained to interact and respond to patients using an

ACEs-informed lens. This means educating families and other providers about the impacts of ACEs and

toxic stress on health, engaging families at home and school, providing consistent guidance, modeling

self-care, and making referrals as needed. Care Coordinators are responsible for the families’ care and

they coordinate care within BCHC-CYW programs and with outside resources.

We provide a variety of carefully coordinated mental health and wellness interventions to address the

impact of ACEs and toxic stress. These interventions are guided by a multidisciplinary, two-generation

approach and include:

ASSESSMENT We screen children for exposure to adversity and assess symptoms of toxic stress

in the pediatric setting.

HOME VISITS We engage families at home and school, as many families lack access to child-

care and transportation.

EDUCATION We offer targeted education that helps families better understand the causes and

symptoms of chronic stress and provide ways to mitigate the kind of stress that

can hurt children’s health and well-being.

PSYCHOTHERAPY We provide a variety of evidence-supported treatments and promising practices

that share core principles of culturally competent, trauma-informed therapy that

are appropriate for children and families from diverse cultural backgrounds, includ-

ing Child Parent Psychotherapy and Cue-Centered Therapy. We do this in partner-

ship with the Child Trauma Research Program at the University of California San

Francisco, led by Dr. Alicia Lieberman, and the Early Life Stress and Pediatric Anxi-

ety Program at Lucile Packard Children’s Hospital, led by Dr. Victor Carrion.

WELLNESS NURSING Nurses provide education to families about the impacts of ACEs and toxic stress

on health and wellness. They coordinate Specialty Care appointments, often ac-

companying patients/families to see specialists. Provide consultation on strate-

gies for attaining, maintaining, or recovering optimal health.

PSYCHIATRY Psychiatrists are provided through a partnership with Department of Psychiatry

at University of California San Francisco. They provide medication evaluations of

children and caregivers and offer consultation to BCHC physicians and CYW staff.

BIOFEEDBACK We provide biofeedback services to build awareness and control over body pro-

cesses such as muscle tension, blood pressure, and heart rate to help patients

recognize and better regulate their ght or ight response.

REFERRALS In addition to making appropriate referrals for our clinical services, we also co-

ordinate referrals to high-quality institutional partners who also use an ACEs-in-

formed lens in their work.

CYW ACE-Q USER GUIDE

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