Over the last quarter-century, a number of pivotal studies focusing on adverse childhood experiences (ACEs) have powerfully documented the cumulative effects of exposure to potentially traumatic experiences on a wide range of health conditions affecting the brain and body. Abuse, neglect, and exposure to violence in and beyond the household setting are now understood to take a heavy toll on young people, with impacts often extending far beyond childhood.

In 2020, California became the first state to implement a publicly supported screening program, with the goal of significantly reducing the burden of ACEs in the population. The value of this public health initiative has been questioned on several grounds, the main one being that existing ACE screens identify risk at the level of large populations, “yet perform little better than chance at the level of the individual, limiting their ability to direct prevention or intervention resources to the most vulnerable children.”

This observation is made by a team led by BBRF Scientific Council member Tallie Z. Baram, M.D., Ph.D., of the University of California Irvine, in a newly published paper in Nature Mental Health reporting on their efforts to test a new screening instrument designed to capture sources of stress and trauma occurring in childhood that may be missed in existing screens. The team’s overall aim is to help make routine screening—say, at a regular “well-child” visit to a primary care doctor—a procedure that will generate results that directly reflect each child’s risk, effectively opening the way to preventive measures or interventions to limit the impact of ACEs. The paper’s first author was Laura M. Glynn, Ph.D.

Dr. Baram is a developmental neuroscientist and child neurologist focusing on the influence of early-life experiences on brain maturation. She has studied stress-related and activity-dependent neural plasticity in the context of how early-life experiences including adversity and stress promote enduring vulnerability to cognitive and emotional disorders.

Among her interests is the contribution of unpredictability to childhood adversity, something she argues is not sufficiently recognized. The unpredictability of parental and environmental signals received by the child activates the brain’s stress responses, a concept first explored in studies with animals. Since those experiments, “unpredictable parental care and lack of structure in the family and home environment have been shown to strongly predict poorer cognitive and emotional development across a broad range of cultures and sociodemographic groups,” Dr. Baram and co-authors note in their new paper.

Specifically, unpredictability in childhood has been linked to decreased executive control, slower cognitive development, poorer memory, and increased risk of depression, anhedonia, anxiety, and PTSD later in life. Importantly, “these associations persist” after factoring in other well-established conditions associated with ACEs, including poverty, abuse, and neglect, “suggesting that unpredictable experiences in themselves are a robust risk factor for poor mental health outcomes, and their absence from existing assessments of ACEs may account for some of the limitations of these assessments” in predicting risk at the individual level.

In their newly reported research, Dr. Baram and colleagues tested the value of adding the well-validated five-item Questionnaire on Unpredictability in Childhood (QUIC-5) to a screen called the Pediatric ACEs and Related Life-events Screen (PEARLS), widely used in routine pediatric primary care to assess mental health risks. Over 29,000 children were screened at 19 pediatric clinics of the dominant healthcare provider in Orange County, California, home of 3 million people and fully reflective of the county and state’s population in socioeconomic and ethnic terms.

Perhaps unsurprisingly, the two co-administered screens showed that older children experienced, on average, more exposure to both traditionally measured ACEs and unpredictability. It was notable, though, that even in the youngest children (ages 0-4), there was exposure to at least one ACE (13%) or at least one form of unpredictability (23%). It was also noteworthy that youths generally reported more exposures (to both traditional ACEs and unpredictability) than did their caregivers. In general, “exposure to adversity as measured with both screens is prevalent even among the youngest children and increases with age,” the team reported.

Increasing exposure to ACEs, assessed with PEARLS, and to unpredictability, measured with QUIC-5, was associated with a higher probability of mental health problems (depression, anxiety externalizing problems, sleep disorder) as well as bodily symptoms (abdominal pains, headache).

Most important, perhaps, was the team’s observation that measuring unpredictability uncovered children at risk for mental health problems that were not detected by the PEARLS screen alone. “QUIC-5 predicts mental and physical health problems at least as well, and in some cases better, than current ACEs screens,” the team noted. For mental health issues, QUIC-5 was superior in detecting risk for depression and sleep disorders.

While prevention of ACEs “is a daunting task,” the team says, their research suggests unpredictability of a child’s parental and environmental input is “an actionable ACE: introducing predictability into a child’s world may exert protective influences on child development and buffer children from adversity.” In the cases, for example, of poverty, parental substance-use disorders, or divorce, “family routines predict child resilience.” Similarly, during the pandemic,” children living in families that maintained predictable routines were largely spared the increased oppositional behavior and externalizing symptoms” experienced by many preschoolers.

There are multiple opportunities for prevention and intervention, the team points out. At the level of the individual these include altering caregiver attitudes regarding the importance of predictability. At the family level they include making plans to implement family routines. “Addressing the full range of ACEs should be a top priority to improve the well-being of children and families,” they write.

The team’s findings “suggest that adding a screen for unpredictability will identify children at risk who will otherwise be missed and may provide an opportunity for monitoring and counseling intervention in the pediatric primary care setting with the potential to make meaningful positive impacts on children’s mental health.”

Future studies might explore how structural and social determinants of health influence exposures to unpredictability and their associations with mental health. In the team’s view, “this is of particular importance because structural determinants of ACEs and unpredictability are not evenly distributed,” with those who are marginalized and underserved by the healthcare system at disproportionate risk.