The authors assessed models of care developed by clinics to integrate Adverse Childhood Experiences (ACE) education, screening, and response, and present evidence of the effects of pediatric ACE screening on health care utilization and quality. Findings support continued efforts to strengthen and sustain integrated ACE care models and a better understanding of the longer-term implications of the models for pediatric patients and their families.

Examining the Implementation and Impact of Pediatric ACE Screening

Results from a Cohort of California Clinics

Peggy G. Chen, Graham DiGuiseppi, Kandice A. Kapinos, Rachel M. Burns, Dana Schultz, Avah Mousavi-Raad, Gabriela Alvarado, Stacey Yi, Priya Gandhi, Joshua Breslau, et al.

ResearchPublished Jul 30, 2026

Adverse Childhood Experiences (ACEs)—including abuse, neglect, and household challenges—are associated with increased risk of lifelong physical, behavioral, and mental health problems. In 2019, California launched the ACEs Aware initiative to support screening for and response to ACEs and the delivery of trauma-informed care.

The authors assessed implementation processes used by clinics that developed models of care to integrate ACE education, screening, and response. They present evidence for improvements in health care utilization and quality of care outcomes between patients who received pediatric ACE screening and a matched sample of patients who did not receive pediatric ACE screening. Clinics demonstrated that integrating ACE education, screening, and response into primary care is feasible when supported by intentional training, dedicated staff, and a culture of trauma-informed care. Furthermore, compared with unscreened patients, ACE screened patients had more positive health care utilization and quality of care outcomes over a 12-month follow-up period. Evidence supports continued efforts to strengthen and sustain integrated ACE care models and better understand longer-term implications of these models for pediatric patients and their families.

Key Takeaways

  • Compared with unscreened patients, ACE screened patients were more likely to achieve the following health care utilization outcomes: an increased likelihood of referral to and receipt of supportive services, including psychotherapy and/or psychiatry services, dyadic or family therapy (Healthy Steps), and CalAIM services (community supports and enhanced care management); and a lower likelihood of utilizing ED services.
  • ACE screened patients were also more likely to achieve the following quality of care outcomes: the receipt of the recommended number of well-child visits for children ages 15–30 months, the receipt of recommended immunizations by age 2, the receipt of anemia screening, the receipt of developmental screening (e.g., motor, language, cognitive, and social-emotional screening), and the receipt of physical activity counseling and body mass index measurement.
  • Clinicians and staff perceived that ACE education, screening, and response helped validate patients’ lived experiences, supported understanding of the relationship between adversity and health, and promoted a whole-person, trauma-informed approach to care.
  • Health care leaders, providers, and staff revealed that implementing an integrated ACE education, screening, and response process requires intentional training, dedicated linkage staff, and sustained organizational support.

Recommendations

  • Policymakers should sustain and expand implementation of ACE screening and education while continuing to build supports for ACE response. Given that ACE screening is associated with increased utilization of routine outpatient care and reductions in ED utilization, policymakers should continue to support programs to implement, expand, and sustain ACE screening and response efforts.
  • Policymakers should support improvements in data-sharing infrastructure. Grantee organizations were often unable to effectively monitor referrals or report data in a way that allows for impactful analyses of the effects of ACE screening. Future grant-making efforts in this area should consider specifying data reporting requirements as part of any efforts to study the impact of ACE education, screening, and response on downstream outcomes.
  • Organizations should approach training as a component of culture change and take an inclusive approach. Grantee organizations repeatedly stressed the importance of building a shared language within their organizations around trauma, stress, and supportive responses.
  • Organizations should build in dedicated linkage staff. Dedicated staff whose role was to link patients with services helped simplify the referral workflow for patients and clinicians.

Topics

Document Details

Citation

Chicago Manual of Style

Chen, Peggy G., Graham DiGuiseppi, Kandice A. Kapinos, Rachel M. Burns, Dana Schultz, Avah Mousavi-Raad, Gabriela Alvarado, Stacey Yi, Priya Gandhi, Joshua Breslau, Jeff Sheehy, Mikah Owens, Edward L. Machtinger, Shannon Thyne, and Nicole K. Eberhart, Examining the Implementation and Impact of Pediatric ACE Screening: Results from a Cohort of California Clinics. Santa Monica, CA: RAND Corporation, 2026. https://www.rand.org/pubs/research_reports/RRA4408-2.html.
BibTeX RIS

Research conducted by

This evaluation was funded by the UCLA/UCSF ACEs Aware Family Resilience Network (UCAAN) and conducted in the Health Services and Outcomes Program of RAND Health.

This publication is part of the RAND research report series. Research reports present research findings and objective analysis that address the challenges facing the public and private sectors. All RAND research reports undergo rigorous peer review to ensure high standards for research quality and objectivity.

This document and trademark(s) contained herein are protected by law. This representation of RAND intellectual property is provided for noncommercial use only. Unauthorized posting of this publication online is prohibited; linking directly to this product page is encouraged. Permission is required from RAND to reproduce, or reuse in another form, any of its research documents for commercial purposes. For information on reprint and reuse permissions, please visit www.rand.org/pubs/permissions.

RAND is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors.