Assessing for Adversity

Buy-in and Design

Considerations and Resources


  • Make sure your clinic has a workflow in place for how ACEs will be administered, scored, discussed with the patient, and responded to appropriately, with clear roles defined across clinic staff members

    • Consider how the tool is explained to youth before administration, confidentiality (and limits, such as when mandated reporting is required), who will be involved in appointments, how connections to support resources are made, etc.​

  • Ensure resources and referral networks to support identified needs from screenings are already in place

    • Establish connections to resources (clinical and non-clinical) and who will support patients/families in accessing these

  • Provide training on using the screening tool(s) as well as on trauma-informed practices inclusive of healing centered engagement and HOPE frameworks

    • Check for organizational and individual staff comfort and buy-in on screening and address concerns and needs

Kids Doctor Checkup

​​​Screening for ACEs: Rational

In her TED talk, “How childhood trauma affects health across a lifetime,” Dr. Nadine Burke Harris gives a call to action for the use of Adverse Childhood Experiences (ACEs) screening in pediatric primary care. Exposure to ACEs increases the risk of health problems across an individual’s lifetime. This is a dose-gradient response, meaning the more ACEs a person experiences, the greater that risk. Experiencing four or more ACEs is associated with significantly increased risk for 7 out of 10 of the leading adult causes of death, including heart disease, stroke, cancer, COPD, diabetes, Alzheimer's, and suicide. Prolonged exposure to toxic stress leads to changes in brain structures as well as hormone levels in the body and can negatively impact the immune system. These changes can impact all areas of health, from food cravings and metabolism to emotional regulation and decision-making to sleep. understanding what a person has been through can provide greater understanding for risk factors as well as care plan needs. Recognizing ACEs through screening provides an opportunity to support the developing brain, immune, and hormonal systems of the body. Additionally, screening presents an opportunity to support families and communities in addressing concerns that contribute to ACEs and with an aim of decreasing the likelihood of more ACEs occurring over time. 

Young Man in Therapy

Creating Workflows 


1. Identifying Barriers and Establishing Buy-in 

  • Workflows for implementing ACEs screening begin with the establishment of larger organizational attention to all workflows to include trauma-informed and Healing Centered Engagement practices. ACEs screening is an extension of this work.

    • Prior to adding ACEs screening to the workflow, educate ALL SBHC staff on the purpose of adding it and address any hesitance.


  • SBHCs are limited on the time they have with patients and staff capacity to meet multiple needs. When, how, and why should the clinic take on more are some of the most common questions asked when a practice considers ACES screening. Begin discussing ACEs screening by establishing the value and purpose of adding the ACEs screening to your clinic workflow. 

    • Responding to patients with upfront knowledge of ACEs can informed more effective care plans and save time in the long run!

    • Ask staff members “how will ACEs screening improve patient care?” and note barriers and resistance and identify what is needed to resolve these. 

2. Designing the Workflow: from administration to follow-up 

The Center for Youth Wellness provides a useful template (see Appendix A: ACEs Screening Decision Making Inputs Worksheet) for creating ACEs screening workflows and more resources can be found through ACEs Aware’s ACE Screening Clinical Workflows, ACEs and Toxic Stress Risk Assessment Algorithm, and ACE-Associated Health Conditions: For Pediatrics and Adults. When designing a workflow, consider the following elements.


  • Determine appointment types when screening will be administered, such as annual well visits, and process for staff to know when to have screening ready for a visit

    • Who will  track when screenings are needed and when they have been completed

    • What system will be used for tracking and reminders (EHR, spreadsheet, etc)

  • Establish appointment-specific workflows

    • Who administers the screening

      • How do they preface it – including purpose and limits of confidentiality/mandated reporting

    • Where does the patient complete the screening

      • consider confidentiality and trauma-informed space)

    • Who reviews it (may be multiple staff)

      • This may very depending on patient responses and needs. See the Tiered Response section of Responding to Adversity while Building for more information. ​

    • What is the plan for responding to ACEs?

      • Screenings require a review and response, including those that score 0. ​

      • Ensure SBHC procedures for responding to mandatory reporting are included

    • Who is consulted (what determines this, is there a base standard?)

    • What are the expectations, how are needed referrals/follow-ups handled? 

  • After the appointment

    • Design workflows for internal and external referrals and resources

      • Include connections to non-clinical supports and resources to foster agency, hope and resilience 

      • Who will follow-up with patients on referrals/connections suggested? 

  • Mandatory reporting and ACEs workflows

    • Ensure patients and clinic staff are aware of mandatory reporting as it relates to ACEs disclosures and how this process works at your SBHC prior to administering screenings

      • For identified screenings, a report may be necessary for a ‘yes’ response to any adverse experiences indicating possible maltreatment.

      • For de-identified, a report may be necessary if the score reflects the patient responded ‘yes’ to a certain number of statements, which indicate possible maltreatment occurred (Ex: 8/10 of the PEARLS, because at least 3 experiences indicate possible reportable maltreatment, therefore if a patient reports 8 or more as a score, it indicates at least one of those is reportable)

      • Patients may disclose experiencing maltreatment that requires a report in conversation, independent of ACEs screening or as part of the screening review

People: (see Sample Staff Roles in Responding to ACEs - also found under General Resources)

  • Consider the role of each SBHC staff member in the ACEs screening process

    • Who is responsible for what, when, and how  

    • How might these roles/responses change based on the level of concern identified

  • Identify outside stakeholders and resources who will likely be involved

    • Create relationships and plans for connecting patients 

    • Consider what resources are needed for outside referrals (creating referral lists, building community partnerships, vouchers for patients, etc.) and have them prepared and on hand.  

  • Ensure staff have the resources and training they need to fulfill their role, prior to implementing ACEs screening

    • Provide ongoing training opportunities and avenues for input from staff on the process and adapt as needed. 

Boy Playing with Abacus

Screening Tools 

There are a variety of screening tools available for screening youth and adults for ACEs. Remember, ACEs screenings indicate number of experiences, not impact of these experiences. ACEs screening is not the same as trauma screening. Individuals with ACEs may or may not report their experiences as traumatic. When selecting a screening tool, consider the following: 

Who is being screened (parent or patient)? 

  • In addition to (or instead of) screening children for ACEs, some pediatric practices screen parents for ACEs since the presence of these may impact outcomes for their own children (similar to the reasoning for routine maternal depression screening in pediatric settings) 


Who is filing out the ACEs screening (parent or patient)? 

  • A self-report version may be used for youth who are old enough to complete other screenings, such as depression, anxiety, and substance use, on their own. 

    • Parents are most likely to fill out the ACEs by selecting the answers that apply for experiences their child has had, until the child reaches adolescence. ​


What languages is the tool available in? 

  • Some have been translated already.  


Is the screening tool ”identified” or “deidentified”?  

  • “De-identified” means that only the patient’s total ACEs score will be seen by the appropriate clinic staff. Staff will not know which questions a patient responded “yes” to, only how many. This may increase likelihood of accurate ACEs disclosure / screening tool completion. Clinic staff will not have knowledge of which ACEs a patient has experienced unless the patients responds “yes” to all.


Screening for Resilience 

If using ACEs screening tools provided by Apex Evaluation, patients will receive four open-ended questions to assess resilience at the end of the ACEs screening. If you are using a a different screening tool consider how you can assess resilience.

Consider how you respond to resilience screenings using a similar process to designing the workflow for ACEs screening.

  • Ideally this is embedded in your ACEs screening and follow-up practices. 

  • The core principles of Healing Centered Engagement and HOPE framework naturally support resilience building efforts

Remember, screening for ACEs is only one part of addressing adversity.

Screening for ACEs without planning and training to establish appropriate responses and resources could cause harm. Be sure to check out Responding to Adversity while Building Resilience to learn more about trauma-informed care that includes Healing Centered Engagement and HOPE frameworks to support youth and their families. 

Happy Kids with Books