The tools below can help provide additional support for the pediatric medical home to identify and more effectively care for children and adolescents who have been exposed to violence. This list does not include all tools but rather ones that relate most. Additional resources can be found on the Practice and Providers Resources page.
ACEs Family Health History and Health Appraisal Questionnaire
The Family Health History and Health Appraisal questionnaires developed by Dr. Vince Felitti and Kaiser Permanente were used to collect information on childhood maltreatment, household dysfunction, and other socio-behavioral factors examined in the ACE Study. The questionnaires are not copyrighted and there are no fees for their use.
ACEs screening tool for children and adolescents
The ACEs screening tool for children and adolescents was developed by Dr. Nadine Burke Harris for use in her clinic. The ACE Questionnaire is free and is intended to be used solely for informational or educational purposes. You must register to use it.
Parental ACEs screening tool
Dr. R.J. Gilespie developed this tool to screen for parental ACEs in his practice, providing an opportunity to discuss how a parent’s ACE score can affect their parenting. This tool also include the resilience questionnaire listed below. For more information on use, watch Dr. Gilespie’s Webinar available on the Webinars page.
This tool developed and used with permission by Dr and Mrs Burtt and Gladys Richardson) from Resilience Trumps Aces assesses for parental resilience and support systems.
Parental Screening Questionnaire: A Safe Environment for Every Kid
The PSQ was developed by Dr. Howard Dubowitz as a tool for pediatric practices to screen parents briefly for major psychosocial problems and risk factors for child maltreatment (eg, maternal depression, substance abuse in the family, intimate partner violence). The PSQ was designed to be easy for pediatricians to assess by readily noting the yes responses. For more information see: Dubowitz H, Feigelman S, Lane W, et al. Screening for depression in an urban pediatric primary care clinic. Pediatrics. 2007;119:435–443.
Pediatric Intake Form
Bright FuturesTM Pediatric Intake Form, also known as the Family Psychosocial Screen, as a whole can help the primary care health professional develop a general understanding of the history, functioning, questions, and concerns of each family. In addition, specific areas of the Pediatric can be scored to provide further insight into specific areas of a family’s functioning.
Child Stress Disorders Checklist (CSDC)
National Child Traumatic Stress Network
This checklist, developed by Dr. Glenn N. Saxe, Department of Child and Adolescent Psychiatry at Boston University School of Medicine, is used to identify stress disorders as a result of traumatic stress. The National Child Traumatic Stress Network (NCTSN) lists additional instruments for assessing traumatic stress in young children on their website.