Standard questionnaires about adverse childhood experiences (ACEs) ask about abuse, neglect and other severe events. But they do not account for unpredictability - when parents' behavior is inconsistent and there is no routine or order at home. A study in the journal Nature Mental Health showed that a short questionnaire about this helps identify children at increased risk of mental health problems whom the usual questionnaire misses.
Researchers analyzed data from children aged 0 to 17 who underwent preventive checkups in 2021-2024 at pediatric clinics affiliated with Children's Hospital of Orange County in California. Parents filled out the standard PEARLS questionnaire about adverse childhood experiences and a short five-item QUIC-5 questionnaire about unpredictability in the family. Children over 12 answered themselves. The responses were then matched against diagnoses from electronic medical records.
Both types of adversity were common even among young children and became more frequent with age. Among children under 4, according to parents, 13% had at least one adverse experience on the ACEs measure, and 23% had at least one sign of unpredictability. Scores on the two questionnaires correlated moderately: children with more ACEs also more often faced unpredictability. A correlation is a statistical association that by itself does not prove causation.
Higher scores on either questionnaire were associated with a greater likelihood of depression, anxiety, externalizing behavior problems (such as aggression or disobedience), sleep disturbances, headaches and abdominal pain. The associations strengthened with the number of reported events and persisted after adjustment for insurance type - a rough indicator of socioeconomic status.
The unpredictability questionnaire provided additional information. When both scores were considered together, each independently predicted most diagnoses, and unpredictability was more strongly associated with sleep disturbances. The example with depression is especially telling. Children who reported four or more ACEs but no unpredictability had roughly 8 times the odds of a depression diagnosis compared with children with zero scores on both questionnaires. A small group of 50 children who had no ACEs but high unpredictability had roughly 12 times the odds. The standard questionnaire would not have classified them as at risk, even though their risk was elevated.
The authors, led by Laura M. Glynn of Chapman University, write: "For depression and sleep disturbances, the QUIC-5 identified vulnerable children missed by ACEs screening, improving risk detection and opening the way for future interventions." In their view, unpredictability is relatively easier to change - for example, through family rituals or policies that give parents more predictable work schedules.
The study has limitations. It is cross-sectional, so it cannot be said that unpredictability or ACEs preceded the diagnoses or caused them. Diagnoses were taken from medical records and may not include symptoms that were not reported to the doctor. Odds ratios show relative associations within the sample, not absolute risk for an individual child. The standard questionnaire recorded only the total number of events, not which events they were. Some score combinations, including the group with no ACEs but high unpredictability, relied on a small number of children. Finally, the study was conducted in clinics in a single county.