The Center for Youth Wellness Adverse Childhood Experiences Questionnaire, 2015
Description: The CYW Adverse Childhood Experiences Questionnaire (CYW ACE-Q) was developed through the Bayview Child Health Center partnership. The Questionnaire is free, but you must complete a quick, online form to gain access.
Section 2 of the Questionnaire includes seven (CYW ACE-Q Child) or nine (CYW ACE-Q Teen and CYW ACE-Q Teen SR) additional ACEs assessing for exposure to additional early life stressors that were identified by experts and community stakeholders. These items are hypothesized 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 due to race, sexual orientation, place of birth, disability or religion.
The Children's Clinic ACE and Resilience Survey, 2015
Description: Pediatricians at the Children’s Clinic in Portland, OR, ask parents about their own childhood adversity in an effort to prevent their children from experiencing childhood trauma. They also include a resilience survey; they are using one of the Connor-Davidson surveys. Their 14-question ACE survey is attached at the bottom of this list.
Elsie Allen Health Center ACE Survey, 2015
Description: Students answer 6 additional questions, plus the original ACE Study 10-question survey. The questionnaire was designed by the clinic staff to address the kinds of experiences – such as homelessness and pregnancy – that are common in their students.
Loma Linda University Whole Child Assessment, 2016
Description: Attached to this blog post is the Whole Child Assessment, which is being used by pediatricians to screen for ACEs at Loma Linda University. It is available in English and Spanish. Dr. Ariane Marie-Mitchell led the development of this survey at Loma Linda University (firstname.lastname@example.org).
The Montefiore Medical Group Team Patient Screening Tool
Description: The Montefioire Medical Group Team uses an optional patient screening tool to identify the number of stressful events to which a child is exposed and help prevent or lower the risk for health problems in child patients. The same questions as those in the CDC-Kaiser assessment are asked, though the question stem language is adapted to read, "Since your child was born..."