Screening for adverse childhood experiences increases visits to behavioral health services

New adverse childhood experience (ACE) screenings increase the rate of positive screenings and receipt of behavioral health services among children and adolescents, according to a recent study.

ACEs have been associated with physical and mental health complications, but there have been challenges in attempting to implement large-scale screening and appropriate action following positive screenings. The lack of referral guidelines and the slow uptake of ACE screening in pediatric primary care have led to these challenges.

Most states prioritize trauma-related education programs rather than considering how to identify the need for these services in children. There are also few studies on how the implementation of ACE screening affects treatment response among pediatric patients in primary care.

To determine the association between ACE screening and completed visits to behavioral health services, the researchers conducted a study in an integrated health system. Approximately 1.5 million children were served in the system, and data for the study was collected from pediatric electronic patient records from July 1, 2018 to November 30, 2021.

Participants were members of the health care system who had completed ACE screening at the pilot clinic. Data were divided into preintervention and postintervention periods to determine outcome, with the assumption that no intervention would lead to a continuation of preintervention trends.

A questionnaire was completed by the participants before the intervention, with participants 13 years of age and older responding on their own while participants aged 2 to 12 filled out the questionnaires from their parents. Baseline scores were consistent with ACE screening results.

Changes implemented during the intervention include screener switching, referral from a pediatrician to a medical social worker if screens are positive, and direct referral from a social worker to behavioral health services after assessment. These changes were based on screening progress, feedback from parents and professionals, and policy changes.

The new screening tool was the Pediatric ACEs and Related Life-Events Screener (PEARLS). PEARLS contained 10 common screening questions, along with 7 questions on community violence exposure, housing incapacity, discrimination, food insecurity, parental separation, death of parent or guardian, and serious physical illness or parental disabilities.

The primary outcome of the study was the rate of visits to behavioral health services completed within 90 days of a positive health screening. Covariates included age at screening, race and ethnicity, and Medicaid status.

There were 4030 ACE-positive screened children, with a mean age of 9.94 years. Participants’ gender was narrowly split, with 73% being Hispanic and 33% having Medicaid status. Of the positive screenings, 1383 occurred in the preintervention period and 2949 in the postintervention period.

Positive screened children were 7.5 times more likely to complete a behavioral health visit, with health visits more likely among girls and older participants. The investigators concluded that changes to health systems should be implemented to screen children for ACEs and provide them with care.


Negriff S, DiGangi MJ, Sidell M, Liu J, Coleman KJ. Evaluation of screening for adverse childhood experiences and receiving behavioral health services among children and adolescents. JAMA network open. 2022;5(12):e2247421. doi:10.1001/jamannetworkopen.2022.47421

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