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

BMC Med Res Methodol. 2021 Sep 25;21(1):195. doi: 10.1186/s12874-021-01392-w.


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.

Keywords: ACEs; Adverse childhood experiences; Emergency department visit; Least absolute shrinkage and selection operator; Mental illness; Prediction.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adverse Childhood Experiences*
  • Checklist
  • Child
  • Child, Preschool
  • Emergency Service, Hospital
  • Humans
  • Infant
  • Infant, Newborn
  • Logistic Models
  • Mental Health