PEdiatric ACEs Screening and Resiliency Study (PEARLS)

The Pediatric Early Adversity and Related Life Effect Screen (PEARLS) was developed and validated by investigators from UCSF Benioff Children’s Hospital Oakland (PI: Long) and the UCSF School of Medicine (PI: Thakur), as a collaborative effort with the Center for Youth Wellness. PEARLS is the first prospective, pediatric ACEs screen iteratively developed for clinical practice. The 17-item screen includes the 10 traditional ACEs questions, plus items assessing exposure to bullying, community violence, discrimination, family separation, low family cohesion, caregiver death or physical illness, food insecurity, and housing instability over the life course. The PEARLS tool was iteratively developed with patient families and providers to ensure high face validity, acceptability and usability by caregivers and providers. Please see this link for more information:

To accompany the PEARLS tool, we developed with clinical providers an anticipatory guidance script on ACEs that focuses on family and resilience. The script focuses on the biological effects of toxic stress and provides practical recommendations on how parents can build resilience in their children. This anticipatory guidance script takes approximately 2-3 minutes to deliver and we have trained all participating pediatricians at BCHO on how to incorporate into practice.

The PEARLS tool is one of several products of the Pediatric ACEs and Resiliency Study, which started in 2014 and encompasses four clinical studies that address ACEs screening, intervention, and response. Through this effort, participants (0-12 years) were randomized to ACEs screening and referral vs. usual care. Those who reported one or more ACE, were then randomized to one of two interventions: Resilience Clinic and Care Coordination. These are both novel, low-cost interventions that have strong potential for replication in pediatric primary care settings.

The Resilience Clinic is designed to increase the capacity of caregivers and their children (jointly referred to as “dyads”) to understand and manage both the emotional and physical health effects of unmitigated stress. Our Resilience Clinic facilitators introduced Dyads to trauma-informed practices and hands-on tools that they can replicate at home. Each family has access to both a psychotherapist and nurse practitioner and participate in six monthly group classes or sessions facilitated by a mental health provider. The aim of Resilience Clinic is to support family members in the acquisition of greater self- and co-regulation skills using a team-based approach.

The second, less-intensive intervention offered to families who screen positive on PEARLS involves care coordination visits for unmet social needs that take place in BCHO’s Primary Care Clinic. Study coordinators support each participating family, who receive close follow-up via email, mail, phone call, or in-person visits until all needs are met

The goal of this study is to advance the field’s ability to identify and measure toxic stress and remediate it in the primary care setting. Over the past three years, we have successfully recruited 555 patients ages 0-12, We have collected a rich set of measurements including demographic, medical, mental/behavioral health, and biomarker data from our study participants and their families. As shared with our Scientific Advisory Committee in 2019, preliminary results already point to significant differences in health and well-being among children with high versus low ACEs, including higher rates of asthma, obesity, and school absenteeism, and an overall lower quality of life. Their parents and caregivers have significantly higher perceived stress as well.

 At the conclusion of PEARLS in 2020, we anticipate we will:

  • Have created the first validated ACES screening tool for children, specifically ages 0-12 (PEARLS Tool,
  • Have data on the impact of interventions for children with high ACEs and their impact on these children’s evolving health and well-being.
  • Have set the stage for furthering scientific insights into the early biology of toxic stress and ways pediatric practices can intervene.