Tallie Z. Baram, MD, discusses unpredictable childhood environments and mental health risks

Pediatricians screening for adverse childhood experiences (ACEs) typically ask about exposures such as abuse, neglect, and household violence. New research suggests another aspect of children's environments—how predictable their daily experiences are—may provide additional information about their mental health risk.^1,2

In a study published in Nature Mental Health, researchers evaluated 29,861 children aged 0 to 17 years seen at 19 pediatric primary care clinics in Orange County, California. Children were assessed using both the Pediatrics ACEs and Related Life-events Screen (PEARLS) and the 5-item Questionnaire on Unpredictability in Childhood (QUIC-5).

The results suggest the measures capture overlapping but distinct dimensions of childhood adversity. Both were associated with mental health outcomes, while QUIC-5 identified risk among some children who would not have been flagged by ACEs screening alone.

What does unpredictability look like for a child?

Tallie Z. Baram, MD, PhD, a study author and child neurologist at the University of California, Irvine, said traditional approaches tend to define adversity from an adult perspective.

"We came at that in terms of really trying to understand not what we, as adult outsiders, think is adverse, but what it is like to be a child and what really is important?" Baram said.

For children, unpredictability can involve inconsistency in ordinary experiences—when meals occur, who provides care, whether school attendance is consistent, or what happens next in the day.

Baram contrasted environments with similarly limited resources but different levels of routine. In one, she recalled, "You got up at 7:00 in the morning, you got breakfast with mom or dad, you went to school or kindergarten, somebody picked you up, you know who it's going to be. There was routine and structure."

That distinction helped lead researchers to examine whether unpredictability itself could represent an important childhood exposure.

How was unpredictability associated with mental health?

Higher scores on both PEARLS and QUIC-5 were associated with greater probability of depression, anxiety, externalizing problems, sleep disorders, headache, and abdominal pain. Associations generally increased as the number of exposures increased.

Unpredictability was already present among young children. Among children aged 0 to 4 years, 23% had at least 1 form of unpredictability identified by QUIC-5, compared with 13% who had at least 1 ACE.

One analysis highlighted the potential additional value of screening for unpredictability. Among 50 children with no ACEs identified by PEARLS but a QUIC-5 score of 4 or greater, the odds of a depression diagnosis were 11.7 times higher than among children who scored 0 on both measures.

The researchers emphasized that the cross-sectional study cannot establish whether unpredictability caused these diagnoses. Mental health diagnoses also came from electronic health records, and odds ratios represented relative rather than absolute risk.

Why might routines matter during brain development?

Baram said basic science research offers a potential explanation for why patterns and predictability could be important during childhood.

Early in development, neural circuits remain highly plastic, with connections strengthening or disappearing in response to experiences. Baram pointed to evidence from sensory systems suggesting that patterned input plays a role in optimal circuit development.

"Repeated predictable sequence of sensory input from the parent, from the family, from the environment seemed to be really important," Baram said. "At a different time scale, these routines in a family seem to be critical."

The study does not demonstrate that prescribing routines will prevent mental health disorders. However, the authors described predictability as a potentially modifiable component of adversity and noted that family routines have previously been associated with resilience in children experiencing circumstances including poverty, parental substance use disorders, and divorce.

For pediatricians, incorporating questions about consistency and routine alongside established adversity screening may provide additional context about a child's environment. The researchers concluded that adding unpredictability screening could identify children who otherwise might be missed and potentially create opportunities for earlier monitoring and counseling.

References

1. Glynn LM, Liu SR, Golden C, et al. Unpredictability is a childhood adversity that contributes to mental health problems. Nat Ment Health. 2026;4:1219-1226. doi:10.1038/s44220-026-00681-x.

2. University of California - Irvine. UC Irvine-led study links unpredictability in early years to elevated mental health risk. Eurekalert. July 21, 2026. Accessed September 18, 2026. https://www.eurekalert.org/news-releases/1136772