Frequently Asked Questions (FAQs)

The Pediatric ACEs and Related Life-event Screener (PEARLS)

The PEdiatric ACEs and Related Life-events Screener (PEARLS) was developed by the Bay Area Research Consortium on Toxic Stress and Health (BARC), a partnership between the Center for Youth Wellness, UCSF Benioff Children’s Oakland, and the Adversity Bio-Core (ABC) Bank at the UCSF School of Medicine and Pharmacy. The tool was designed to identify exposure to childhood adversity and events that may increase a child’s risk for toxic stress and negative health outcomes. The tool is currently available, free of charge, and is recommended for use in all child-serving medical practice settings.

PEARLS Child (Parent/Caregiver Report)
PEARLS Teen (Self Report)
PEARLS Teen (Parent/Caregiver Report)

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To download the PEARLS tool, please join NPPC or log in to the NPPC member site

What does the PEARLS tool screen for?

The PEARLS screens for a child’s exposure to Adverse Childhood Experiences (ACEs) and other potential risk factors for toxic stress (bullying, community violence, food or housing insecurity, etc.) that may increase a child’s risk for negative health outcomes. These exposures were selected because they have been linked with poor physical, developmental, and behavioral health outcomes in childhood and throughout life.

The PEARLS has two sections: Section 1 screens for the ACEs tied to lifelong health and wellness challenges in the original Felitti and Anda research on ACEs1. Section 2 includes other risk factors for toxic stress not in the original ACE Study, but which have also been found to impact child and adult health. Their potential pathways to affecting health are being investigated in an ongoing BARC study, which actually shares the name PEARLS (although the study’s R stands for Resilience because of the study’s interventions). The tool’s name thus pays homage to its ground-breaking origins.

The PEARLS asks whether an individual has ever experienced:

Section 1. Original ACEs Section

  • Abuse (physical, emotional, sexual)
  • Neglect (physical, emotional)
  • Dysfunction in the household among parents/caregivers (caregiver separation/divorce, domestic violence, substance misuse, incarceration, mental illness)

Section 2. Other Adversities that are risk factors for toxic stress or negative health outcomes

  • Hardship (food insecurity, housing instability)
  • Others significant life events (caregiver’s serious physical illness or death, community violence, bullying, discrimination)

1 Felitti and Anda (1998) ACE Study

How was the PEARLS developed?

The PEARLS tool was developed as part of the BARC Pediatric ACEs Screening and Resilience Study, a partnership between the Center for Youth Wellness, UCSF Benioff Children’s Oakland, and the Adversity Bio-Core (ABC) Bank at the UCSF School of Medicine and Pharmacy. The tool’s questions were selected through a rigorous scientific process involving a literature review and scan for existing ACEs and trauma screening tools, and expert opinion and analysis. These included foundational work done at the Center for Youth Wellness on the CYW Adverse Childhood Experiences Questionnaire (CYW ACE-Q). The PEARLS tool adapted the CYW ACE-Q, then piloted and iteratively changed it based on pediatrician, parent, and caregiver input. A detailed description of the process of this initial level of validation can be found in this peer-reviewed article.

Given the BARC’s intentional, rigorous, and evolutionary validation process, CYW now recommends that all clinicians use the PEARLS in place of the CYW ACE-Q.

Where can I find the PEARLS tool and what versions are available?

The PEARLS can be downloaded from the National Pediatric Practice Community on ACEs (NPPC) website. To download PEARLS, you will need to become an NPPC member (click “Join” on the website). There are multiple versions based on the child’s age, including  parent/caregiver versions for children and adolescents and teen self-reporting, the primary language needed, and whether the person answering is asked to specify which experience(s) happened or simply share a total number.

Age and Reporter

  • Child Parent/Caregiver Report (Child P/C): Parent or caregiver reports on a child’s (ages 0-11) experience; includes 17 questions
  • Teen Parent/Caregiver Report (Child P/C): Parent or caregiver reports on a teen’s (ages 12-19) experience; includes 19 questions
  • Teen Self-report (Teen SR): Teen (ages 12-19) self-reports on his or her own experiences; includes 19 questions

Formats

  • “De-identified”: Respondents simply count the number of experiences from a list of what could have happened to their child or themselves, and write down the total number that happened (they do not specify which adverse experience happened). This version is a quick assessment of risk for toxic stress intended for use in a busy pediatric practice and with the assumption that further assessment or identification of the items will occur with follow up or referral
  • “Identified”: Respondents specify which experience(s) happened to their child or themselves (if using the self-report version) by choosing “yes” or “no” for each question. It provides the provider with specific information about which experiences their patient has encountered.  

Practices seeking information about which version(s) and format(s) may best fit their providers and patients can read more on the NPPC website or contact the NPPC team.

Is the PEARLS validated?

The PEARLS Child P/C has been found to have high face validity. This means it’s highly likely the items on the tool are measuring actual exposure to ACEs and related life-events among children, even though humans (as opposed to other information sources) are reporting. This phase of validation included cognitive interview and item wording refinement with parents/caregivers, physicians and clinic staff, as outlined in the BARC manuscript published in December 2018 on PLOS One.  

The tool continues to be understood as part of an ongoing randomized, controlled trial (of the same name). The study’s investigators believe they will soon be able to further validate the PEARLS based on children’s health outcomes and biological markers of toxic stress.

PEARLS Teen P/C and PEARLS Teen SR are not currently part of the ongoing study and are therefore not currently receiving the same level of validation testing. However, the questions on these versions for teenagers are identical to those on the child version, except the teen versions include an additional 2 questions identified as important by community-based participatory research with youth in San Francisco2. The additional teen items are intimate partner violence and bullying experienced by the teen, which have been found to impact health. These items have been tested clinically as part of the CYW ACE-Q tools for parents and caregivers reporting on their teens’ experiences and teens reporting for themselves.

2 Purewal Boparai, Sukhdip; Marie, Tiffani; Aguayo, Eduardo; Brooks, Jordan; Juarez, Estefany; Soriano, Sheana; Waters, Alasia; Donaldson, Jaquez; Reagans, Joseph; Anguiano, Gracee; and Ipsen, Allison (2017) “Adversity and academic performance among adolescent youth: a community-based participatory research study,” Journal of Adolescent and Family Health: Vol. 8 : Iss. 1 , Article 2. https://scholar.utc.edu/jafh/vol8/iss1/2

What is the Pediatric ACEs Screening and Resilience Study?

The BARC partnership between Center for Youth Wellness, UCSF Benioff Children’s Hospital Oakland, the UCSF School of Medicine and Pharmacy (Adversity Bio-Core (ABC) Bank), is founded on an ongoing three-year randomized, clinical, controlled trial, called the Pediatric ACEs Screening and Resilience Study. The study’s 3 main goals are: to extensively validate universal use of the PEARLS tool in pediatric primary care; to implement and evaluate interventions to mitigate the impacts of toxic stress in children; and to identify biomarkers that can help provider diagnose and/or predict. This study was funded by generous grants from the Tara Health Foundation and Genentech.

Note: the PEARLS tool developers gave it the same name as the study to reflect their admiration and appreciation for the dedicated professionals, funders, and, most importantly, families, throughout San Francisco and Oakland, who contribute to this groundbreaking work every day. Even though the acronym is slightly different, the study’s “pearls” of wisdom feel eternal!

What setting is the PEARLS designed for?

The tool was developed for use in pediatric primary care, including other child-serving primary care settings like family practice. The PEARLS enables rapid screening to help inform clinical management of children and adolescents, including novel guidance and referrals virtually all primary care providers can offer and in-depth changes to management of different diseases, which are currently being tested and studied.

While the tool is designed for physician use as part of routine clinical care, the full provider team–including support staff, care coordinators/navigators and behavioral health professionals–often interact with the tool. Thus it’s highly recommended that medical practices using the PEARLS ensure that all staff are trained in the science of ACEs and toxic stress as well as family-centered practice workflow for sensitive screening. Additionally, practices should ensure, to the best of their abilities and resources, that adequate support and follow-up care are available for families with a positive score.

How is the PEARLS administered and scored?

The tool is designed to identify children and teens as early as possible who have experienced ACEs or other potentially traumatic events that may increase their risk for toxic stress and negative health outcomes. It is not intended to directly diagnose disease. It is one tool among several others to help inform a provider’s clinical assessment and judgment of each and every child’s current development, health, and well-being and future risk. The PEARLS should be used in concert with other child development and maternal depression screeners, in alignment with American Academy of Pediatrics Guidelines, and should never replace a full assessment of each patient, family and their unique biology and circumstances.

Administration

Routine and universal screening in pediatric primary care offers the opportunity to identify individuals at high risk of toxic stress and offer anticipatory guidance before the child becomes symptomatic. It is recommended that the PEARLS be presented to the parent/caregiver and/or teen at primary-care well child visits.

Periodicity schedule

In alignment with the Bright Futures recommended periodicity schedule for social determinants of health screening, the PEARLS tool should be administered at regular intervals starting in infancy. It is an ongoing assessment of experiences that research shows can occur at any point throughout childhood.

Implementation & Follow up

A clinic specific protocol guiding how the screening should be administered and how scoring leads to follow up care should be developed, including consideration of anticipatory guidance and education on ACEs, toxic stress and resilience, care coordination, follow up medical care, and connection to a comprehensive range of interventions (e.g., sleep, nutrition, mental and behavioral health, parenting support, physical exercise, and mindfulness) .

Does the PEARLS assess for symptoms?

The tool only asks about exposure to potentially traumatic experiences, it does not ask about symptoms of trauma or toxic stress explicitly. However, the screening tool should be considered one part of a comprehensive assessment that also considers symptomatology indicative of toxic stress.

In the absence of a clear way to diagnose toxic stress, and in consideration of the complex interplay between exposure to ACEs, individual vulnerabilities, as well as protective factors, one approach to evaluation of patients at risk for a toxic stress response is to assess for both exposure to ACEs and clinical symptomatology in the child. In the presence of exposure to ACEs, biomedical, psychological, and social presentations may all be indicative of a dysregulation of the stress response and neuro-endocrine-immune disruption.

What permissions are needed to use the PEARLS?

The tool is currently available and free of charge. We encourage all medical providers and practices interested in using the tool to contact and connect with the National Pediatric Practice Community on ACEs at the Center for Youth Wellness (CYW) for guidance and resources. We also highly recommend you connect to our large network of practitioners, researchers and innovators addressing ACEs and toxic stress as part of healthcare.

Can I use the tool as part of my own research study?

Absolutely! Anyone interested should reach out to the NPPC. We’re always looking for new ideas and partners in practice-based stress research and innovation. Although the science is clear that ACEs and toxic stress affect the health of children and adults, there is still much we need to learn about the full scope of their impact on children and parents, and how we can best address those effects in primary care. Join our growing network of healthcare providers advancing the science and best-practices of ACEs and toxic stress!

If you use the PEARLS in your research, please use the following citation:
Koita K, Long D, Hessler D, Benson M, Daley K, Bucci M, et al. (2018) Development and implementation of a pediatric adverse childhood experiences (ACEs) and other determinants of health questionnaire in the pediatric medical home: A pilot study. PLoS ONE 13(12): e0208088. https://doi.org/10.1371/journal.pone.0208088

Where can I get more information or training on how to use the PEARLS?

This tool was made publically available for use as of its first peer-reviewed journal article published December 12, 2018.  For more detailed information about how to use the tool or for training assistance, please contact the CYW NPPC:

National Pediatric Practice Community on ACEs (NPPC)
Center for Youth Wellness
329 Evans Avenue
San Francisco, CA 94124-1705
(415) 684-9520
nppc@centerforyouthwellness.org
www.nppcaces.org