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A five-question screen about unpredictable childhood experiences identified mental health risks among some children who were not flagged by a standard adversity questionnaire, according to a study published in Nature Mental Health. Both questionnaires were linked to mental health diagnoses in nearly 30,000 children.
Adverse childhood experiences (ACEs) include events such as abuse, neglect and witnessing violence. These experiences are linked to a greater chance of mental and physical health problems, and in 2020 California became the first state to launch a publicly supported program to screen children for them. But existing ACEs questionnaires are better at describing risk across groups than at predicting which particular child may need support.
One experience that standard ACEs questionnaires do not capture is unpredictability, such as inconsistent behavior from parents and a lack of structure or routine in the home. Animal research first suggested that unpredictable signals from caregivers are stressful for the developing brain, and studies in humans have since linked unpredictable childhood experiences to poorer cognitive development and a higher risk of depression and anxiety, even after accounting for other adversities.
Laura M. Glynn of Chapman University and colleagues set out to compare a standard ACEs questionnaire with a short measure of unpredictability. Their aim was to see whether adding questions about unpredictable family and household experiences could help identify children at risk of mental health problems beyond what the existing screen detects.
The study analyzed screening data from 29,861 children (14,418 girls) aged 0 to 17 who attended well-child visits between 2021 and 2024 at 19 pediatric clinics affiliated with Children’s Hospital of Orange County in California.
Caregivers completed the Pediatric ACEs and Related Life-events Screener (PEARLS), a clinical tool used to assess ACEs, as well as the five-item Questionnaire on Unpredictability in Childhood, known as QUIC-5. Children aged 12 and older also completed the screens themselves. The researchers then compared scores with mental and physical health diagnoses recorded in the children’s electronic health records.
Exposure to both ACEs and unpredictability was common even among the youngest children and increased with age. Among children aged 4 and younger, 13% had experienced at least one ACE and 23% at least one form of unpredictability, according to caregivers. Scores on the two screens were moderately correlated, meaning children who experienced more ACEs also tended to experience more unpredictability.
Higher scores on either screen were associated with a greater likelihood of depression, anxiety, externalizing problems, sleep disorders, headaches and abdominal pain. Externalizing problems are difficulties that tend to be directed outward, such as disruptive or aggressive behavior. The associations generally grew stronger as the number of reported experiences increased, and they held after the researchers accounted for whether families had public or private insurance, a rough indicator of socioeconomic status.
The unpredictability measure added information beyond the standard screen. When both scores were considered together, each was independently linked to most of the diagnoses, and unpredictability was the stronger predictor of sleep disorders.
For depression, the researchers compared children with different combinations of scores on the two screens, based on the children’s own reports. Children who reported four or more ACEs but no unpredictability had about 8 times the odds of a depression diagnosis as children who scored zero on both screens. A small group of 50 children who reported no ACEs but high unpredictability had about 12 times the odds, meaning they were at elevated risk even though the standard screen would not have flagged them.
Glynn and colleagues summarized their findings: “for depression and sleep disorders, the QUIC-5 identified vulnerable individuals missed by ACEs screen, improving risk detection and facilitating future interventions.” The authors note that unpredictability may be relatively amenable to change, for example through family routines or policies that give parents more predictable work schedules.
Some limitations should be noted. The study was cross-sectional, so it cannot show whether unpredictable experiences or ACEs preceded the diagnoses or caused them. Diagnoses were drawn from medical records and may not include symptoms that had not been reported to a clinician, and odds ratios show relative associations within the study rather than an individual child’s absolute risk.
The standard ACEs screen recorded only the total number of experiences, not which ones children had, and some of the score combinations, including the group with no ACEs but high unpredictability, involved small numbers of children. The study also took place in a single county’s clinic network.
The study, “Unpredictability is a childhood adversity that contributes to mental health problems,” was authored by Laura M. Glynn, Sabrina R. Liu, Charles Golden, Michael Weiss, Candice Taylor Lucas, Dan M. Cooper, Louis Ehwerhemuepha, Hal S. Stern and Tallie Z. Baram.
