Adverse childhood experiences—known in the research literature as ACEs—are potentially traumatic events such as abuse, neglect, household dysfunction, or community violence that occur during childhood and cast long shadows across the life course. Decades of epidemiological work, beginning with the landmark Felitti studies of the late 1990s, have linked cumulative ACE exposure to elevated risks of cardiovascular disease, mental illness, substance use, and socioeconomic hardship in adulthood. Because these experiences are preventable and their effects potentially modifiable, major medical societies and the Centers for Disease Control and Prevention have called for health systems to identify and respond to childhood adversity early. One response has been routine ACE screening in pediatric settings, a practice that remains scientifically contested—no definitive evidence yet shows that screening itself improves health outcomes—but that has been associated with increased referrals to behavioral health and social work services.
Most of what is known about how families view ACE screening comes from primary care. Far less is known about school-based health centers, or SBHCs, the clinics embedded on or near school campuses that serve millions of students, often those with Medicaid coverage and limited access to conventional care. A new exploratory qualitative study published in Pediatric Research by Rebecca K. Tsevat of the University of California, Los Angeles, and colleagues is, to the authors’ knowledge, the first to ask adolescents and parents directly how they feel about addressing ACEs—encompassing everything from initial screening through post-screening response and intervention—inside these school-adjacent clinics. The answer, in a word, is relationships.
The research team partnered with school health leaders from a large public school district in Southern California that operates fourteen embedded SBHCs serving patients from age one through eighteen, and special education students through age twenty-two; the vast majority of patients are Hispanic/Latine and insured through Medicaid. To capture a broader range of views, the investigators deliberately recruited participants from beyond the partnering district, drawing on patient and family advisory groups, primary care clinic waiting rooms, and snowball sampling. Eligible adolescents were between sixteen and twenty-two, an age range chosen to include those currently in or recently finished with high school, while adult participants had to be parents or primary caregivers of youth aged three to seventeen. There were no exclusion criteria beyond language, with interviews offered in English or Spanish.
The methodological architecture of the study reflects contemporary qualitative standards. The semi-structured interview guide was built around constructs from the Consolidated Framework for Implementation Research, focusing on the individuals receiving the intervention, the inner setting, and the implementation process. Before data collection began, a focus group of six adolescent and young adult members of a Youth Research Advisory Council affiliated with the San Francisco YMCA and the University of California, San Francisco, reviewed the questions and prompted concrete revisions—abstract phrasings were clarified, and the framing shifted from asking about a clinic’s role to asking what schools should do to support youth with ACEs. Between December 2024 and October 2025, the team conducted twenty interviews, ten with adolescents and ten with parents or caregivers, mostly over Zoom and lasting twenty to thirty minutes. Interviews and analysis proceeded concurrently, with coding continuing until thematic saturation was reached—the point at which no new codes emerged and existing themes were merely reinforced.
The analytic pipeline was deliberately layered. Audio recordings were transcribed and verified, then analyzed in Dedoose software through an iterative thematic approach led by the two interviewers and overseen by two senior qualitative researchers, a medical anthropologist and a pediatric health services researcher. The two leads independently developed codes line by line, harmonized them into a shared codebook, independently coded the first four interviews, resolved discrepancies through discussion, and then coded the remaining transcripts sequentially. Themes were generated across all participants simultaneously rather than by subgroup, with a sensitivity analysis confirming that themes did not differ substantially between adolescents under and over eighteen. Candidate themes were tested against the full transcripts for internal consistency and coherence, then reviewed by practicing SBHC clinicians and ACEs content experts, and presented to providers at the partnering district. Throughout, the team recorded reflexive memos about how their clinical training might shape interpretation.
Four themes emerged, and three of them describe what the authors call a relational ecosystem resembling a social ecological model—nested circles of influence surrounding every screening conversation. The innermost circle is the patient-provider relationship. Participants consistently expected trust before they would disclose sensitive information. Some preferred a pre-existing relationship with a clinician who sees the patient regularly; others prioritized provider characteristics or thoughtful clinical practices. Timing mattered: one parent suggested that personal questions should come at the end of a visit so patients feel comfortable enough to open up. Adolescents emphasized clear explanations of why screening was happening, and parents stressed language children could understand. Personalization also surfaced repeatedly—one parent described how her son with a disability needed questions read aloud rather than presented on paper—and participants wanted responses tailored to individual circumstances and preferences, not generic referrals.
The second circle is the school’s social environment, and here the adolescent and parent perspectives diverged most sharply. The absence of parents from the school setting was simultaneously a barrier and a facilitator. Adolescents often saw it as liberating: one noted that schools are a special place to address ACEs precisely because kids are separated from their parents, which matters if the home situation is not good. Others worried about confidentiality and mandated reporting, fearing retaliation if disclosures reached parents without consent. Parents, conversely, worried about losing awareness and control—one parent of an older teen observed that she often cannot advocate for herself the way her family can—while parents of younger children feared young children might misconstrue questions or answer inaccurately alone. Peers cut both ways as well. Some adolescents found comfort in being on their own territory among peers; others worried about stigma, with one noting that friends might mock someone simply for visiting the clinic office to get help. School personnel were viewed positively by many parents as an extra layer of support, but some adolescents distrusted the permeability of the school setting, wondering whether providers might talk to teachers and worrying that anybody could be hearing.
The outermost circle extends beyond school walls. Pre-existing relationships with community providers shaped where families preferred to address ACEs: some who had negative or limited experiences with community clinics viewed SBHCs favorably, while one parent explained that her son’s nine-year relationship with his outside provider outweighed his familiarity with the school clinic staff. Prior healthcare experiences also colored willingness to disclose—one adolescent reflected that withholding information wastes both the patient’s and the doctor’s time. Parents additionally pointed to community-level forces: the scarcity of SBHCs in some states breeds unfamiliarity and hesitancy, social networks can normalize conversations about ACEs when even one friend understands the terminology, and communal mistrust of educational and healthcare systems, including experiences of racialization and classism within schools, can erect barriers that no screening protocol alone can dismantle.
The fourth theme was the one on which adolescents and parents agreed almost uniformly: addressing ACEs in SBHCs can promote the health of the entire school community. Even participants wary of undergoing the process themselves believed the clinics have a role. Some emphasized education—helping students recognize that they are in a bad situation, understand treatment options, and realize they are not alone—with one adolescent connecting ACE education to bullying prevention. Others highlighted holistic care that addresses home adversity alongside school workload, early intervention before adversity derails learning and development, and the clinic’s capacity to serve as a bridge connecting students to therapists, counselors, social workers, and outside medical resources.
The study’s implications are practical as well as conceptual. The authors recommend that SBHCs develop clear, contextually sensitive screening and referral protocols, ideally co-designed with youth and parents, that address privacy concerns and clarify how support follows disclosure; that clinics leverage the school community, involving trusted personnel when patients desire it while guaranteeing confidentiality absent safety concerns; and that they practice culturally sensitive care attuned to systemic mistrust. Limitations deserve note: participants were recruited from multiple sources and were not representative of the partnering district’s demographics—most parents were highly educated mothers residing in California, where ACE screening is already incentivized—and the interview guide did not systematically probe all implementation domains. Whether ACE screening in SBHCs actually improves health or academic outcomes remains untested. Still, the core finding stands: the promise and peril of addressing childhood adversity in school clinics hinge not on the questionnaire but on the relational ecosystem surrounding it, and interventions designed with youth and family perspectives at the center are far more likely to be accepted by the people they aim to help.
Subject of Research: Adolescent and parent perspectives on screening for and responding to adverse childhood experiences in school-based health centers
Article Title: Adolescents’ and parents’ perspectives on addressing adverse childhood experiences in school-based health centers
Article References: Tsevat, R. K., Franco, R., Villanueva, R., Diaz Roldan, K., Ryan, G. W., Thyne, S. M., Gordon, B., Tanimura, R., Russ, S. A., & Dudovitz, R. N. (2026). Adolescents’ and parents’ perspectives on addressing adverse childhood experiences in school-based health centers. Pediatric Research. https://doi.org/10.1038/s41390-026-05535-x
Image Credits: AI Generated
DOI: 10.1038/s41390-026-05535-x
Keywords: adverse childhood experiences, school-based health centers, ACE screening, adolescent health, qualitative research, trauma-informed care, patient-provider trust, pediatric research, school health, confidentiality, stigma, social ecological model
News Source: Denise Maddox. (October 8, 2026). Trust, Stigma and the School Clinic: Why Relationships Decide Whether Teens Talk About Childhood Trauma. Scienmag.
