Adverse Childhood Experiences (ACEs)
Adverse Childhood Experiences or ACEs are categorized as abuse, neglect, and household challenges experienced during childhood.
These include:
- Emotional, physical, and sexual abuse;
- Emotional and physical neglect; and
- Household challenges that include exposure to domestic violence, a family member with household substance abuse, a family member with mental illness, an incarcerated household member, or parental separation or divorce.
Screening for ACEs with evidence-based tools helps clinical teams move toward prevention and also identify individuals at high risk who may benefit from additional assessment and interventions. On a population level, the higher the ACEs score, the greater the likelihood of poor health outcomes or high-risk behavior as an adult. ACEs scores do not predict individual outcomes, but screening provides the opportunity to intervene earlier to foster resiliency.
Positive Childhood Experiences (PCEs) are protective factors and can mitigate the adverse effect of ACEs . A critically important component of screening includes promoting resiliency through conversations with youth and caregivers in identifying PCEs and referrals to resources that foster resiliency. Safe, stable, and nurturing relationships build resiliency. Understanding the context and lived experiences of patients and their families is an important step toward providing trauma-informed care.
"Understanding Adverse Childhood Experiences (ACEs)" was published by NYS and has been translated into multiple languages. Also available is the ACEs webpage, which can be found here.
The original ACE study by Dr. Vincent Felitti and others in 1998 was the first epidemiologic study of adults to demonstrate that reported exposures to childhood abuse, neglect, and family dysfunction are common, and highly interrelated. They also noted that the effects of the ACEs were cumulative. See graph with examples of higher ACE scores associated with greater prevalence of poor health outcomes or high-risk behavior as an adult.
Dose Response - Exposure to Abuse/Household Dysfunction in Childhood and Risk for Leading Causes Death in Adults - Felitti et al, 1998
Information for Pediatric Primary Care Providers
Basics of Trauma-Informed Care and ACEs Screening:
ACEs screening should ideally take place in the context of trauma-informed care to ensure a safe, empowering environment for the child and family. Trauma-informed care is an approach that health care teams take to acknowledge a patient's life situation, both past and present. ACEs screening enables the team to be responsive to the adverse experiences of a child, be increasingly aware of the signs and symptoms of trauma, and actively avoid re-traumatization. The enhanced relationship between the health care team, patients and their families are guided by a set of core principles in a trauma-informed approach that includes: Safety; Trustworthiness and Transparency; Peer Support; Collaboration; Empowerment; and Humility and Responsiveness. To learn more visit: Trauma-Informed Care Implementation Resource Center by the Center Health Care Strategies site. Screening for ACEs is always voluntary and identifying individual ACEs is not required. Parents/caregivers should complete the ACEs screening on behalf of children who are unable to complete it on their own.
Toolkits
- Toolkit from Coordinated Care Services, Inc. - Trauma-Informed Organizations Implementation Roadmap, 2023.
- Toolkit from ACEs Aware and Center for Health Care Strategies - Integrating Adverse Childhood Experiences Screening into Clinical Practice: Insights from California Providers, March 2022
Resiliency Building and Pediatric Provider Role in Anticipatory Guidance:
- The most important protective factor for children to help them thrive is having at least one consistent, supportive relationship with a parent, caregiver or other adult.
- Safe, stable and nurturing relationships are the building blocks of positive childhood experiences and contribute to the skills needed for children to thrive and flourish, and offset the potential health harms of childhood adversity.
- Involving caregivers, including those who may be struggling, is a critical part of the solution and can be an empowering experience. There is no benefit to blame or shame.
- Building resilience buffers against exposures to stress and trauma.
- Other Positive Childhood Experiences that predict support of children's lifelong health include:
- Feeling safe talking about their feelings,
- Having a sense of belonging at school; and
- Feeling supported when things are tough.
Project TEACH Referral Resources:
- Project TEACH is a statewide program that supports reproductive, primary care, and pediatric clinicians to deliver quality mental health care in NYS.
- Project TEACH services are available at no cost.
- The program strives to strengthen and support the delivery of care to children, families, and individuals who experience mental health concerns.
- Education, resources, and primary care provider consultations with child, adolescent, and maternal psychiatrists are available.
- For consultations with a child, adolescent, or perinatal psychiatrist, contact (855) 227-7272.
- Visit the Project TEACH website.
- Websites and Articles:
- Project TEACH Provider Resources website;
- Medicaid Update articles:
- Project TEACH Maternal Mental Health Services article published in the January 2023 issue of the Medicaid Update.
- Understanding How Adverse Childhood Experiences Affect Patients' Health Across the Lifespan article published in November 2022 issue of the Medicaid Update.
Medicaid Benefit for ACEs Screening
NYS Medicaid provides reimbursement for Adverse Childhood Experiences (ACEs) screening conducted in primary care settings for children and adolescents up to 21 years of age. An annual ACEs screening will be covered, as determined appropriate and medically necessary.
Medicaid Update Article: Reimbursement for Adverse Childhood Experiences Screening.
ACEs Screening Tool Examples
Use of a research-based tool is required when screening for ACEs to be eligible for NYS Medicaid reimbursement. Health care practices should adopt the tool that meets the needs of their population and clinical workflow. Examples of recommended screening tools include:
- modified ACEs questionnaire based on the original Centers for Disease Control and Prevention (CDC)-Kaiser Permanente ACEs study (providers should refer to 1 and 2 of the "References" section below);
- part 1 of thePediatric ACEs and Related Life Events Screener (PEARLS) - Childtool, for individuals zero to 19 years of age, to be completed by the parent/caregiver or by the youth based on the age of the patient (providers should refer to 2 of the "References" section below); and
- Adverse Childhood Experiences Questionnaire for Adults, for individuals 18 to 21 years of age, to be completed by the patient (providers should refer to 2 of the "References" section below).
References:
- Screening for Adverse Childhood Experiences and Traumadocument
- ACEs Aware "Screening Tools" web page
Additional Resources
- Directory of NYS practices:
- For any behavioral health crisis, call 988, or go here.
- CDC Violence Prevention website: "Adverse Childhood Experiences".
- CDC 2022 BRFSS Questionnaire (see module 15, pages 95 through 98).
- ACEs Aware "Screening Tools" web page.
- The New York State Trauma-Informed Network & Resource Center aims to support and share the principles of trauma-informed across NYS through knowledge sharing, connection to resources and events that support trauma-informed work and wellness practices.
- American Academy of Pediatrics supports trauma-informed care as a model of relational health care. See resources for child-serving practices to support caregiver-child relationships and promote resilience.
- Adults interested in looking at the ACEs questionnaire for themselves can access the form.
- Resources for parents through Project TEACH.
We Can Prevent Childhood Adversity Infographic
