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.

2
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

3
 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 dysfunction1,2.

FIGURE 1. CATEGORIES OF ADVERSE CHILDHOOD EXPERIENCES (ACEs)

The three types of ACEs include

ABUSE NEGLECT HOUSEHOLD DYSFUNCTION

Physical Physical Mental Illness Incarcerated Relative

Emotional Emotional Mother treated violently Substance Abuse

Sexual Divorce

source: Robert Wood Johnson Foundation, 2013

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-
lems1. The ACE Study was the first to assess physical health outcomes related to these particular adver-
sities in a large study population.

4
 CYW ACE-Q USER GUIDE

The ACE Study. Over 17,000 California adults who

were patients of Kaiser Permanente in San Diego TABLE 1. ACE STUDY FINDINGS
were interviewed about their medical history and
exposure to ACEs. Almost two-thirds (63.5%) of par- In the ACE Study, in comparisonto those reporting no
ticipants reported having at least one ACE, and 12% ACEs, individuals with 4+ ACEs had significantly greater
odds of reporting...
reported having four or more 3. A dose-response
relationship was revealed between the number of Ischemic heart disease 2.2
ACEs experienced by an individual and negative Any Cancer 1.9
health outcomes, such that with increasing num- Chronic Bronchitis or emphysema (COPD) 3.9
bers of ACEs, the odds of reporting an illness or Stroke 2.4
health risk behavior also increased 1. Diabetes 1.6
Ever attempted suicide 12.2
ACEs and Negative Health Outcomes. Subsequent
research with diverse populations of adults, and Severe obesisty 1.6

with children and adolescents, continue to support Two or more weeks of

depressed mood in the past year 4.6
the conclusion that a relationship exists between
Ever used illicit drugs 4.7
ACEs and health outcomes. In adults, ACEs have
been found to have a strong, dose-response asso- Ever injected drugs 10.3

ciation with cardiovascular disease, chronic lung Current smoker 2.2

disease, headaches, autoimmune disease, sleep Ever had a sexually transmitted disease 2.5
disturbances, early death, obesity, smoking, gen-
source : Felitti, 1998
eral poor health, depression, posttraumatic stress
disorder, anxiety, substance abuse, and binge
drinking 4. 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 7, lifetime asthma 5,8, ADHD 5, autism 5, being
overweight or obese, 5,9 and learning difficulties 9.
In addition, studies on ACEs during childhood and
adolescence have found an association between
ACEs and violent behavior (delinquent behavior, bully-
ing, physical fighting, dating violence, weapon-carrying) 10.

National Prevalence Rates. A nationally represen-

tative study found that approximately two-thirds
of adults reported at least one ACE 11. 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% 6.

5
 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- glucose and fat to be used as an energy source.
iological and behavioral response elicited by selec- These changes prepare the body for a “fight” or
tive pressure from the physical and social environ- “flight” response.
ment that challenges and disrupts homeostasis
— the self-regulating process biological systems The activation of the HPA axis results in a cascade
have in place to maintain the internal stability for of hormonal release. Once activated, the neurons
survival 12,13. While the experience of stress is influ- in the hypothalamus synthesize and release a
enced by many factors - including the intensity and hormone called the corticotropin-releasing factor
severity of the stressor, the individual’s perception (CRF). This hormone travels to the pituitary gland
of the stressor, physical and mental health, and through hypophysial portal vessels. The binding of
genetic makeup - the physiology of the response CRF to its receptors induces the release of the ad-
involves the activation of the neuro-endocrine-im- reno-corticotropic hormone (ACTH) in the systemic
mune (NEI) network. This NEI network is comprised circulation. ACTH, then, targets the adrenal glands
of the autonomic nervous system (sympathetic and and induces the secretion of glucocorticoids (cor-
parasympathetic), the hypothalamic-pituitary-adrenal tisol) from the adrenal cortex18. Cortisol release is
(HPA) axis, and the immune system. responsible for many of the changes occurring in
the body, a phenomenon that appears to be par-
In the face of an acute stressor, the neurons in the ticularly pronounced during experiences of chron-
amygdala— the part of the brain responsible for ic stress19. Some of the effects of cortisol include
emotions, especially fear, regulation of attention activation of the natural immune response through
and modulation of memory—are activated. The the granulocytes (neutrophils, macrophages, mast cell,
amygdala receives and interprets the present situa- and eosinophils), the natural killer cells, and the com-
tion as a threat and sends signals to the hypothal- plement proteins. Their actions are inflammation,
amus, which in turn activates the HPA axis 14,15. The destruction of the invaders with oxygen radicals,
hypothalamus activates the sympathetic nervous and phagocytosis. The macrophages also produce
system response by sending signals through sym- pro-inflammatory cytokines (messenger molecules)
pathetic nerves to the adrenal medulla and trigger- such as the interleukin 1 and 6 (IL-1, IL-6), and tumor
ing the secretion of catecholamines (epinephrine and necrosis factor (TNF) that produce inflammation
norepinephrine also known as adrenaline and noradrena- and promote wound healing20.
line) into circulation. This results in a constriction
of the blood vessels, increase in blood pressure, Once the exposure to the stressor is discontinued,
increase in heart rate and force of cardiac contrac- a negative feedback inhibition shuts down the
tion, increased muscle tone, and bronchial dilation stress response. The body’s continuous actions
with increase in the respiratory rate16,17. The circu- to maintain homeostasis through these changing
lating adrenaline also triggers the release of stored conditions, has been termed as allostasis21.

6
 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 first 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 stressor22.

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 recover22.

Occurs with
TOXIC STRESS RESPONSE  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
impairment23.

7
 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 first 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 24. 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 25.

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 26. 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
27
. 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” 26.

8
 CYW ACE-Q USER GUIDE

THE CENTER FOR YOUTH WELLNESS

ADVERSE
CHILDHOOD
EXPERIENCES
QUESTIONNAIRE
CYW ACE-Q

INSTRUMENT DESCRIPTION
Based on the instrument created by Vincent Felitti and Robert Anda for use with adults28, 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-identified). 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 difficulties, 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-
cific versions, and in English and Spanish. It takes approximately two to five minutes to complete.

CYW ACE-Q VERSIONS

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

C
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

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

TABLE 2. ADMINISTRATION SCHEDULES

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

10
 CYW ACE-Q USER GUIDE

The instrument is introduced by the Medical Assis- The following steps are taken to administer the
tant. The following steps are taken to administer CYW ACE-Q Teen and CYW ACE-Q Teen SR (for pa-
the CYW ACE-Q Child (for patients 0-12 years of age): tients 13-19 years of age):

1. Medical Assistant greets and welcomes the care- 1. MedicalAssistant greets and welcomes the pa-
giver and patient. tient and caregiver.

2. Medical Assistant informs the caregiver that 2. Medical Assistant informs them that they will
they will need to fill out several forms prior to need to fill out several forms prior to the appoint-
the child/youth’s appointment. The packet is ment. The patient and caregiver each receive a
provided on a clipboard. We recommend that the separate packet on a clipboard. They are asked
CYW ACE-Q be included earlier in the packet to to complete the forms separately. As with the
increase completion rate and reinforce the clini- CYW ACE-Q Child, we recommend that the CYW
cal model (screen-counsel-refer). ACE-Q Teen and CYW ACE-Q Teen SR be included
earlier in the packet to increase completion rate
3. TheMedical Assistant provides a general de- and reinforce the clinical model (screen-counsel-re-
scription of each form in the packet, providing fer).
context. S/he informs the caregiver that the Pri-
mary Care Provider will review the results with 3. TheMedical Assistant provides a general de-
her/him and the child/youth. scription of each form in the packet, providing
context. S/he explains that the Primary Care Pro-
4. The caregiver completes the packet and returns vider is interested in obtaining information from
it to the Medical Assistant. both their perspectives. S/he also informs them
that the Primary Care Provider will review the re-
5. The
packet is provided to the Primary Care Pro-
sults with them during the appointment.
vider for review prior to the appointment. The Pri-
mary Care Provider reviews the information prior 4. Thepackets are returned separately to the Medi-
to meeting with the patient. 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.

11
 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
clarification 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 finished, 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.

12
 CYW ACE-Q USER GUIDE

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 CYW ACE-Q SCORE 1-3

WITHOUT SYMPTOMATOLOGY WITH SYMPTOMATOLOGY OR > 4 ACE SCORE

ANTICIPATORY GUIDANCE REFER TO TREATMENT

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.

TABLE 4. RELEVANT SYMPTOMATOLOGY

Sleep disturbance Poor control of chronic disease Restricted affect or numbing

(such as asthma or diabetes)
Weight gain or loss High risk behavior in adolescents
Developmental regression
Failure to thrive Unexplained somatic complaints
School failure or absenteeism (such as HA or abdominal pain)
Enuresis, encopresis
Aggression Depression
Constipation
Poor impulse control Anxiety
Hair loss
Frequent crying Interpersonal conflict

13
 CYW ACE-Q USER GUIDE

TABLE 6. PRIMARY CARE PROVIDER SAMPLE SCRIPTS

Screening Result Sample Script

GENERAL INTRODUCTION New research has shown that children’s exposure to stressful or trau-
TO THE CYW ACE-Q RESULTS matic events can lead to increased risk of health and developmental
problems, like asthma and learning difficulties. 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.

CYW ACE-Q SCORE OF 0 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.

CYW ACE-Q SCORE 1-3 I see that [Child’s Name] has experienced [CYW ACE-Q Score] of these
WITHOUT SYMPTOMATOLOGY 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 significant 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 fine)

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.

14
 CYW ACE-Q USER GUIDE

TABLE 6. PRIMARY CARE PROVIDER SAMPLE SCRIPTS (continued)

Screening Result Sample Script

CYW ACE-Q SCORE 1-3 I see that [Child’s Name] has experienced [CYW ACE-Q Score] of these
WITH SYMPTOMATOLOGY or items, is that correct? Based on your responses, I want to ask a few
CYW ACE-Q SCORE 4 or MORE
more questions about her health and development. Has [Child’s Name]
experienced any significant 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.

15
 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 process29:

• Why are we looking at this issue?

• What are we looking for?

• How do we find 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 benefits 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 staffing 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, conflict resolution, and mandated reporting should be incorpo-
rated, along with consistent supervision.

16
 CYW ACE-Q USER GUIDE

BCHC-CYW INTEGRATED PEDIATRIC CARE MODEL

The BCHC-CYW model was created to recognize
the impact of Adverse Childhood Experiences TABLE 6. PROMISING INTERVENTIONS
(ACEs) on health and seeks to treat toxic stress in
children. We do this by routine screening, which Research indicates that the following
allows for early detection and intervention, paired interventions may mitigate dysregulation
with a multidisciplinary approach focused on ad- of the neuro-endocrine-immune network
dressing the neuro-endocrine-immune dysregula-
associated with exposure to ACEs. 30–35
tion of toxic stress.

Our model integrates primary health care, mental Regular Exercise

health and wellness, research, policy, education, Good Nutrition
and community and family support services to Sleep
meet children and families where they are to sup-
Mental Health
port them in leading healthier lives.
Mindfulness Practices (e.g., meditation)
Children/youth are screened for exposure to ACEs
Supportive Relationships
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

17
 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 fight or flight 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.

18
 CYW ACE-Q USER GUIDE

REFERENCES
1. FelittiVJ, Anda RF, Nordenberg D, et al. Relationship of child- 13.  cEwen BS. Stressed or stressed out: What is the differ-
M
hood abuse and household dysfunction to many of the lead- ence? J Psychiatry Neurosci JPN. 2005;30(5):315-318.
ing causes of death in adults: The Adverse Childhood Experi-
ences (ACE) Study. Am J Prev Med. 1998;14(4):245-258. 14.  erman JP, Ostrander MM, Mueller NK, Figueiredo H. Lim-
H
bic system mechanisms of stress regulation: hypothal-
2. Robert Wood Johnson Foundation. The truth about ACEs. May amo-pituitary-adrenocortical axis. Prog Neuropsychophar-
2013. http://www.rwjf.org/en/library/infographics/the-truth-about- macol Biol Psychiatry. 2005;29(8):1201-1213. doi:10.1016/j.
aces.html. pnpbp.2005.08.006.

3.  nda RF, Dong M, Brown DW, et al. The relationship of adverse

A 15.  ampbell S, MacQueen G. The role of the hippocampus in
C
childhood experiences to a history of premature death of fam- the pathophysiology of major depression. J Psychiatry Neurosci.
ily members. BMC Public Health. 2009;9(1):106. 2004;29(6):417-426.

4. Kalmakis KA, Chandler GE. Health consequences of adverse 16.  aggerty RJ. Stress, Risk, and Resilience in Children and Adoles-
H
childhood experiences: A systematic review. J Am Assoc Nurse cents: Processes, Mechanisms, and Interventions. Cambridge Uni-
Pract. March 2015. doi:10.1002/2327-6924.12215. versity Press; 1996.

5. Bethell CD, Newacheck P, Hawes E, Halfon N. Adverse child- 17. Herd JA. Cardiovascular response to stress. Physiol Rev.

hood experiences: Assessing the impact on health and 1991;71(1):305-330.
school engagement and the mitigating role of resilience.
Health Aff (Millwood). 2014;33(12):2106-2115. doi:10.1377/ 18. Smith SM, Vale WW. The role of the hypothalamic-pitu-

hlthaff.2014.0914. itary-adrenal axis in neuroendocrine responses to stress.
Dialogues Clin Neurosci. 2006;8(4):383-395.
6. Flaherty EG, Thompson R, Dubowitz H, et al. Adverse child-
hood experiences and child health in early adolescence. JAMA 19. O’Connor TM, O’Halloran DJ, Shanahan F. The stress response

Pediatr. 2013;167(7):622-629. and the hypothalamic-pituitary-adrenal axis: From mole-

cule to melancholia. QJM. 2000;93(6):323-333. doi:10.1093/
7. Bright MA, Alford SM, Hinojosa MS, Knapp C, Fernandez-Ba- qjmed/93.6.323.
ca DE. Adverse childhood experiences and dental health
in children and adolescents. Community Dent Oral Epidemiol. 20.  egerstrom SC, Miller GE. Psychological stress and the hu-
S
2015;43(3):193-199. doi:10.1111/cdoe.12137. man immune system: A meta-analytic study of 30 years of
inquiry. Psychol Bull. 2004;130(4):601-630. doi:10.1037/0033-
8.  ing R, Gjelsvik A, Nocera M, McQuaid EL. Association be-
W 2909.130.4.601.
tween adverse childhood experiences in the home and pedi-
atric asthma. Ann Allergy Asthma Immunol. 2015;114(5):379-384. 21. McEwen BS. Physiology and neurobiology of stress and ad-
aptation: Central role of the brain. Physiol Rev. 2007;87(3):873-
9.  urke NJ, Hellman JL, Scott BG, Weems CF, Carrion VG. The
B 904. doi:10.1152/physrev.00041.2006.
impact of adverse childhood experiences on an urban pediat-
ric population. Child Abuse Negl. 2011;35(6):408-413. 22.  honkoff JP, Boyce WT, McEwen BS. Neuroscience, molec-
S
ular biology, and the childhood roots of health disparities:
10. Duke NN, Pettingell SL, McMorris BJ, Borowsky IW. Ad-
 Building a new framework for health promotion and disease
olescent violence perpetration: Associations with mul- prevention. JAMA. 2009;301(21):2252-2259.
tiple types of adverse childhood experiences. Pediatrics.
2010;125(4):e778-e786. doi:10.1542/peds.2009-0597. 23.Shonkoff JP, Levitt P. Neuroscience and the future of early
childhood policy: Moving from why to what and how. Neuron.
11.  ilbert LK, Breiding MJ, Merrick MT, et al. Childhood adversity
G 2010;67(5):689-691. doi:10.1016/j.neuron.2010.08.032.
and adult chronic disease: An update from ten states and the
District of Columbia, 2010. Am J Prev Med. 2015. http://www.sci- 24. Thompson R, Flaherty EG, English DJ, et al. Trajectories of
encedirect.com/science/article/pii/S0749379714005121. Accessed adverse childhood experiences and self-reported health at
May 14, 2015. age 18. Acad Pediatr. 2014. http://www.sciencedirect.com/science/
article/pii/S1876285914003349. Accessed May 21, 2015.
12. McEwen BS. The neurobiology of stress: From serendipi-
ty to clinical relevance. Brain Res. 2000;886(1–2):172-189.
doi:10.1016/S0006-8993(00)02950-4.

19
 CYW ACE-Q USER GUIDE

25. 
Knudsen E. Sensitive periods in the development of the 31.  opresti AL, Drummond PD. Obesity and psychiatric disor-
L
brain and behavior. J Cogn Neurosci. 2004;16(8):1412-1425. ders: Commonalities in dysregulated biological pathways and
doi:10.1162/0898929042304796. their implications for treatment. Prog Neuropsychopharmacol Biol
Psychiatry. 2013;45:92-99. doi:10.1016/j.pnpbp.2013.05.005.
26. Garner AS, Shonkoff JP, Siegel BS, et al. Early childhood ad-
versity, toxic stress, and the role of the pediatrician: Trans- 32. Macdonald G, Higgins JP, Ramchandani P, et al. Cogni-

lating developmental science into lifelong health. Pediatrics. tive-behavioural interventions for children who have been
2011;129(1):e224-e231. sexually abused. Cochrane Database Syst Rev. May 2012.
doi:10.1002/14651858.CD001930.pub2.
27. Flaherty EG, Stirling J. The pediatrician’s role in child mal-
treatment prevention. Pediatrics. 2010;126(4):833-841. 33. Miller, Gregory E., Brod, Gene H., Yu, Tianyi, Chen, Edith. A
doi:10.1542/peds.2010-2087. family-oriented psychosocial intervention reduces inflamma-
tion in low-SES African American. PNAS. June 2014:1-6.
28.  elitti VJ, Anda RF. Family health history questionnaire.
F
1998. http://www.cdc.gov/violenceprevention/acestudy/question- 34.  imkin DR, Black NB. Meditation and mindfulness in clinical
S
naires.html. practice. Child Adolesc Psychiatr Clin N Am. 2014;23(3):487-534.
doi:10.1016/j.chc.2014.03.002.
29.  merican Academy of Pediatrics. Addressing adverse child-
A
hood experiences and other types of trauma in the primary 35.  lopen N, McLaughlin KA, Shonkoff JP. Interventions to im-
S
care setting. 2014. https://www.aap.org/en-us/Documents/ttb_ad- prove cortisol regulation in children: A systematic review. Pe-
dressing_aces.pdf. Accessed July 27, 2015. diatrics. 2014;133(2):312-326.

30.  houry B, Sharma M, Rush SE, Fournier C. Mindfulness-based

K
stress reduction for healthy individuals: A meta-analysis.
J Psychosom Res. 2015;78(6):519-528. doi:10.1016/j.jpsy-
chores.2015.03.009.

20