Can the adverse childhood experiences (ACEs) checklist be utilized to predict emergency department visits among children and adolescents?

BACKGROUND: Extensive literature has shown an association of Adverse Childhood Experiences (ACEs) with adverse health outcomes; however, its ability to predict events or stratify risks is less known. Individuals with mental illness and ACE exposure have been shown to visit emergency departments (ED) more often than those in the general population. This study thus examined the ability of the ACEs checklist to predict ED visits within the subsequent year among children and adolescents presenting to mental health clinics with pre-existing mental health issues. METHODS: The study analyzed linked data (n = 6100) from two databases provided by Alberta Health Services (AHS). The Regional Access and Intake System (RAIS 2016-2018) database provided data on the predictors (ACE items, age, sex, residence, mental health program type, and primary diagnosis) regarding children and adolescents (aged 0-17 years) accessing addiction and mental health services within Calgary Zone, and the National Ambulatory Care Reporting System (NACRS 2016-2019) database provided data on ED visits. A 25% random sample of the data was reserved for validation purposes. Two Least Absolute Shrinkage and Selection Operator (LASSO) logistic regression models, each employing a different method to tune the shrinkage parameter lambda (namely cross-validated and adaptive) and performing 10-fold cross-validation for a set of 100 lambdas in each model were examined. RESULTS: The adaptive LASSO model had a slightly better fit in the validation dataset than the cross-validated model; however, it still demonstrated poor discrimination (AUC 0.60, sensitivity 37.8%, PPV 49.6%) and poor calibration (over-triaged in low-risk and under-triaged in high-risk subgroups). The model's poor performance was evident from an out-of-sample deviance ratio of - 0.044. CONCLUSION: The ACEs checklist did not perform well in predicting ED visits among children and adolescents with existing mental health concerns. The diverse causes of ED visits may have hindered accurate predictions, requiring more advanced statistical procedures. Future studies exploring other machine learning approaches and including a more extensive set of childhood adversities and other important predictors may produce better predictions. Furthermore, despite highly significant associations being observed, ACEs may not be deterministic in predicting health-related events at the individual level, such as general ED use.

Relationship Between Adverse Childhood Experience Survey Items and Psychiatric Disorders.

CONTEXT: Developmental psychopathology theory suggests a relationship between early childhood adversity and mental disorder. OBJECTIVE: To examine the relationship between the specific items on the Adverse Childhood Experiences (ACE) survey and the International Classification of Diseases, Tenth Revision (ICD-10) categories of psychiatric diagnoses in a pediatric sample. DESIGN: The sample included patients enrolled in the Child and Adolescent Addiction Mental Health and Psychiatry Program with both a completed ACE survey and at least 1 diagnosis of record (per admission). These criteria yielded 2 samples for each sex (ACE survey item frequencies and values in collapsed and multiple-admission groups). Data were analyzed employing tetrachoric correlation, hierarchical regression, and polychoric factor analysis. RESULTS: Hierarchical regression analysis identified that ICD-10 diagnostic categories, except for substance disorders, were not consistently related to ACE total score and tended to reduce the magnitude of the ACE total score in the multiple-admission group. Tetrachoric correlation revealed very low (< 0.4) positive and negative correlations between ICD-10 categories and ACE items in both multiple-admission and collapsed sample groups. Polychoric factor analysis indicated that the ACE survey items and the ICD-10 categories for both sexes were independent, with only the diagnostic ICD-10 category substance disorders being marginally associated with the ACE items factor for females. CONCLUSION: The nominal relationship between ACE items and ICD-10 diagnostic categories indicates the need to include ACE assessment in advance of differential diagnosis and implementation of conventional mental health interventions for children and adolescents.