Background Adverse Childhood Experiences (ACEs) screenings are increasingly being used in primary care clinics to identify toxic stress and potential trauma in children. ACEs are negative life events (e.g., violence exposure) occurring before age 18, that can increase health risks when unaddressed. However, we lack evidence on the impact of ACEs screenings and how they can be feasibly implemented in community-based clinics. We partnered with federally qualified health clinics to test the impact of a multifaceted implementation strategy on ACEs screening reach and mental health referrals for children ages 0–5. Methods We conducted a Hybrid Type 2 pilot trial using a stepped-wedge design (2021–2024). Reach data was measured as the proportion of eligible children screened for ACEs, with data collected from Electronic Health Records. We also assessed the percentage of mental health service referrals among all eligible children. Study clinics (n = 3) switched from no ACEs screenings (control) to implementing ACEs screenings supported by the multi-faceted ACE implementation strategy (intervention). The tested strategy comprised personnel training (e.g., trauma-informed care), integrated technology, team-based screening workflows, and ongoing care team implementation support. Additional clinics (n = 2) implemented ACEs screenings as usual without the strategy and served as additional comparison sites for exploratory analyses. Log-binomial and robust Poisson regression models examined differences in screening reach and referrals and were adjusted for site and patient race. Results Screening reach rates increased in the intervention period, from 0.0% of patients screened during control to 11.2% screened during intervention. Mental health service referrals increased from 0.4% at control to 7.2% during the intervention, resulting in a risk difference (95% confidence interval) of 6.9% (6.0%, 7.7%). For both the reach and referral outcomes, risk differences were significantly greater for 18-to-60-month-old patients than for patients under 18-months-old. Discussion Healthcare policy efforts promoting ACEs screenings in primary care are commendable. We found that a multi-faceted implementation strategy informed by partners and designed to support ACEs screenings in community-based clinics was feasible. However, its impact was attenuated by policy requirements, clinics’ capacity to add ACEs screenings to strained workflows, and multiple impactful outer-context events related and unrelated to the COVID-19 pandemic. Trial registration Trial # NCT04916587 registered at clinicaltrials.gov on June 4, 2021, https://clinicaltrials.gov/study/NCT04916587

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