Screening for Adverse Childhood Experiences

Screening for ACEs and toxic stress and providing targeted, evidence-based interventions for toxic stress can improve efficacy and efficiency of health care, better support individual and family health and well-being, and reduce long-term health costs.

serious male doctor speaking with child patient

What are ACEs?

The term Adverse Childhood Experiences (ACEs) comes from the landmark 1998 study by the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente. ACEs describe 10 categories of adversities in three domains experienced by age 18 years: abuse, neglect, and/or household dysfunction. (1)

A child or adolescent who experiences ACEs without the buffering protections of trusted, nurturing caregivers and safe, stable environments can develop a toxic stress response, which can impact brain development, hormone and immune systems, and genetic regulatory systems.

ACEs are strongly associated, in a dose-response fashion, with some of the most common and serious health conditions facing our society today, including at least 9 of the 10 leading causes of death in the United States. (2) (3) Identifying a history of trauma in children and adults and responding with trauma-informed care, can improve the health and well-being of individuals and families and lower long-term health costs.

An ACE screening evaluates children and adults for ACEs experienced by age 18:

  • Abuse: physical, emotional, and sexual abuse
  • Neglect: physical and emotional neglect
  • Household dysfunction: growing up with household incarceration, mental illness, substance dependence, parental separation or divorce, or intimate partner violence

How do you screen for ACEs?

The following screening tools must be used to obtain Medi-Cal payment – find the tools on the screening tools page:

For Children & Adolescents (Ages 0 – 19) – Pediatric ACEs Screening and Related Life-events Screener (PEARLS), developed by the Bay Area Consortium on Toxic Stress and Health (BARC), a partnership between the Center for Youth Wellness, University of California, San Francisco (UCSF), and UCSF Benioff Children’s Hospital Oakland.

Providers receive a single Medi-Cal payment if the adolescent or their caregiver completes the tool. However, the best practice is for both the adolescent and the caregiver to each complete a tool.

There are three versions of the tool based on age, reporter, and format:

    • PEARLS for children, for ages 0-11, to be completed by a caregiver
    • PEARLS for adolescents, for ages 12-19, to be completed by a caregiver
    • PEARLS for adolescents self-report tool, for ages 12-19, to be completed by the adolescent

For Adults – ACE Questionnaire for Adults adapted from the work of CDC and Kaiser Permanente.

If an alternative version of the ACE Questionnaire for Adults is used, it must contain questions on the 10 original categories of ACEs to qualify. Visit the Screening Tools page to find the ACE Questionnaire for Adults compiled by the Office of the California Surgeon General and the Department of Health Care Services, in consultation with the ACEs Aware Clinical Advisory Subcommittee.

For 18- and 19-year olds, either tool may be used. For patients 20 years and older, the adolescent self-report version of the PEARLS tool is also acceptable.

Medi-Cal payment is available for ACE screenings based on the following schedule:

  • Children and adolescents under age 21: Permitted for periodic ACE screening as determined appropriate and medically necessary, not more than once per year, per provider (per managed care plan).
  • Adults age 21 through age 64: Permitted once in their adult lifetime (through age 64), per provider (per managed care plan). Screenings completed while the person is under age 21 years do not count toward the one screening allowed in their adult lifetime.

At the beginning of an appointment, the age-appropriate screening tool should be given directly to adult patients, caregivers for children and adolescents, and adolescent patients for completion in a private setting when possible.

ACE screening tools that qualify for Medi-Cal payment are available in both identified and de-identified formats.

  • De-identified. Respondents count the number of ACE categories on the screening tools that they or their child has experienced, and indicate only the total score – without identifying which ACE(s) they or their child experienced.
  • Identified. Respondents count the number of ACEs categories on the screening tool that they or their child has experienced and specify which ACE(s) they or their child experienced.

The ACE score refers to the total reported exposure to the 10 ACE categories indicated in Part 1 of the PEARLS and in the ACE Questionnaire for Adults. ACE scores range from 0 to 10.

The ACE score refers to the total number of ACE categories experienced, not the severity or frequency of any one category. The higher a patient’s ACE score, the greater the risk for ACE-Associated Health Condition(s).

Each patient’s individual health outcomes will be based on a combination of cumulative adversity (including ACEs and other stressors), protective factors, and differential biological susceptibility. Therefore, ACE screening should be used in a probabilistic, not a deterministic, manner to alert providers to which patients are at a greater health risk based on population-level data.

If the ACE score is different on the adolescent self-report than the caregiver report, the higher of the two ACE scores should be used for treatment and billing.

Visit TREAT: Science & Clinical Practice for information and resources on how to incorporate ACE screenings into your clinical practice, create treatment plans, and deliver trauma-informed care.

Visit SCREEN: Certification & Payment for information on how to bill Medi-Cal for ACE screenings.

Providers bill Medi-Cal using Healthcare Common Procedure Coding System (HCPCS) codes based on the results of the screening. Code G9919 is used for screens that have a score of 4 or greater (high risk) and code G9920 is used for screens that have a score of 0 to 3 (lower risk).

References

1: Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. American Journal of Preventive Medicine 1998; 14: 245–58.
2: Centers for Disease Control and Prevention. Leading causes of death by age group 2017. https://www.cdc.gov/injury/images/lc-charts/leading_causes_of_death_by_age_group_2017_1100w850h.jpg (accessed May 8, 2019).
3: Merrick MT, Ford DC, Ports KA, Guinn AS. Prevalence of adverse childhood experiences from the 2011-2014 Behavioral Risk Factor Surveillance System in 23 states. JAMA Pediatrics 2018; 172: 1038.