Population vs Individual Prediction of Poor Health From Results of Adverse Childhood Experiences Screening

Abstract

Importance: Adverse childhood experiences (ACEs) are well-established risk factors for health problems in a population. However, it is not known whether screening for ACEs can accurately identify individuals who develop later health problems.

Objective: To test the predictive accuracy of ACE screening for later health problems.

Design, setting, and participants: This study comprised 2 birth cohorts: the Environmental Risk (E-Risk) Longitudinal Twin Study observed 2232 participants born during the period from 1994 to 1995 until they were aged 18 years (2012-2014); the Dunedin Multidisciplinary Health and Development Study observed 1037 participants born during the period from 1972 to 1973 until they were aged 45 years (2017-2019). Statistical analysis was performed from May 28, 2018, to July 29, 2020.

Exposures: ACEs were measured prospectively in childhood through repeated interviews and observations in both cohorts. ACEs were also measured retrospectively in the Dunedin cohort through interviews at 38 years.

Main outcomes and measures: Health outcomes were assessed at 18 years in E-Risk and at 45 years in the Dunedin cohort. Mental health problems were assessed through clinical interviews using the Diagnostic Interview Schedule. Physical health problems were assessed through interviews, anthropometric measurements, and blood collection.

Results: Of 2232 E-Risk participants, 2009 (1051 girls [52%]) were included in the analysis. Of 1037 Dunedin cohort participants, 918 (460 boys [50%]) were included in the analysis. In E-Risk, children with higher ACE scores had greater risk of later health problems (any mental health problem: relative risk, 1.14 [95% CI, 1.10-1.18] per each additional ACE; any physical health problem: relative risk, 1.09 [95% CI, 1.07-1.12] per each additional ACE). ACE scores were associated with health problems independent of other information typically available to clinicians (ie, sex, socioeconomic disadvantage, and history of health problems). However, ACE scores had poor accuracy in predicting an individual's risk of later health problems (any mental health problem: area under the receiver operating characteristic curve, 0.58 [95% CI, 0.56-0.61]; any physical health problem: area under the receiver operating characteristic curve, 0.60 [95% CI, 0.58-0.63]; chance prediction: area under the receiver operating characteristic curve, 0.50). Findings were consistent in the Dunedin cohort using both prospective and retrospective ACE measures.

Conclusions and relevance: This study suggests that, although ACE scores can forecast mean group differences in health, they have poor accuracy in predicting an individual's risk of later health problems. Therefore, targeting interventions based on ACE screening is likely to be ineffective in preventing poor health outcomes.

Figure 1.. Timeline for Assessments of Adverse Childhood Experiences (ACEs) and Health in the Environmental Risk (E-Risk) Longitudinal Twin Study and the Dunedin Multidisciplinary Health and Development Study

A, In the E-Risk study (N = 2232; 93% participation at 18 years), we examined whether prospectively assessed ACEs predicted mental and physical health problems at 18 years. Analyses testing incremental prediction controlled for clinically available childhood risk factors. B, In the Dunedin study (N = 1037; 94% participation at 45 years), we examined whether prospectively assessed ACEs predicted mental and physical health problems at 45 years. Analyses testing incremental prediction controlled for clinically available childhood risk factors. We also examined whether retrospectively assessed ACEs (measured at 38 years) predicted mental and physical health problems at 45 years. Analyses testing incremental prediction controlled for clinically available adult risk factors. CTQ indicates Childhood Trauma Questionnaire; DIS, Diagnostic Interview Schedule; and FHS, Family History Screen. ^aAssessments of depression, anxiety, self-harm, suicide attempt, attention-deficit/hyperactivity disorder, alcohol dependence, and drug dependence in both cohorts were made through the DIS. ^bIn both cohorts, obesity was defined as a body mass index of 30 or higher (calculated as weight in kilograms divided by height in meters squared), inflammation was assessed via dried blood spots (in E-Risk study) or serum (in Dunedin study) and was defined as a C-reactive protein level higher than 0.3 mg/dL (to convert to milligrams per liter, multiply by 10), asthma was assessed through self-report, sexually transmitted diseases were assessed through self-report, sleep problems were defined as scores higher than 5 on the Pittsburgh Sleep Quality Index, and daily cigarette smoking was assessed through self-report.

Figure 2.. Prevalence of Health Problems in the Environmental Risk Longitudinal Twin (E-Risk) Study and Dunedin Multidisciplinary Health and Development Study Cohorts According to Adverse Childhood Experience (ACE) Score

A, The prevalence of health problems at 18 years in the E-Risk cohort, as assessed with a prospective ACE measure. B, The prevalence of health problems at 45 years in the Dunedin cohort, as assessed with a prospective ACE measure. C, The prevalence of health problems at 45 years in the Dunedin cohort, as assessed with a retrospective ACE measure. The sample size as reported in the legend varies according to the health outcome (as reported fully in eTable 1 in the Supplement). Error bars indicate 95% CIs.

Figure 3.. Predictive Accuracy for Health Problems Based on Adverse Childhood Experience (ACE) Scores in the Environmental Risk (E-Risk) Longitudinal Twin Study and Dunedin Multidisciplinary Health and Development Study Cohorts

A, Any mental health problem. B, Any physical health problem. The numbers on the lines indicate the number of ACEs. The lines display receiver operating characteristic curves with cutoffs for each ACE score. The dotted diagonal line indicates discrimination at chance level. Corresponding positive and negative likelihood ratios for the prediction of individual health outcomes by ACE scores are presented in eTable 7 in the Supplement. AUC indicates area under the curve.