Contribution of an under-recognized adversity to child health risk: large-scale, population-based ACEs screening

Whereas adverse early life experiences (ACEs) correlate with cognitive, emotional and physical health at the population level, existing ACEs screens are only weakly predictive of outcomes for an individual child. This raises the possibility that important elements of the early-life experiences that drive vulnerability and resilience are not being captured. We previously demonstrated that unpredictable parental and household signals constitute an ACE with cross-cultural relevance. We created the 5-item Questionnaire of Unpredictability in Childhood (QUIC-5) that can be readily administered in pediatric clinics. Here, we tested if combined screening with the QUIC-5 and an ACEs measure in this real-world setting significantly improved prediction of child health outcomes.

Leveraging existing screening with the Pediatric ACEs and Related Life Events Screener (PEARLS) at annual well-child visits, we implemented QUIC-5 screening in 19 pediatric clinics spanning the diverse sociodemographic constituency of Orange County, CA. Children (12yr+) and caregivers (for children 0-17years) completed both screens. Health diagnoses were abstracted from electronic health records (N=29,305 children).

For both screeners, increasing exposures were associated with a higher probability of a mental (ADHD, anxiety, depression, externalizing problems, sleep disorder) or physical (obesity abdominal pain, asthma, headache) health diagnosis. Across most diagnoses, PEARLS and QUIC provided unique predictive contributions. Importantly, for three outcomes (depression, obesity, sleep disorders) QUIC-5 identified vulnerable individuals that were missed by PEARLS alone.

Screening for unpredictability as an additional ACE in primary care is feasible, acceptable and provides unique, actionable information about child psychopathology and physical health.