Quantifying and visualising heterogeneity in cumulative adverse childhood experiences scores: A national survey of US children.

Abstract

Adverse childhood experiences (ACEs) scores mask substantial heterogeneity within the 2-, 3-, and ≥ 4-ACE exposure categories. This exposure heterogeneity has not been systematically investigated. Using the US-based 2023 National Survey of Children's Health (N = 55,162), caregivers reported lifetime exposure to 10 ACEs covering family dysfunction and community- and discrimination-related adversities. We quantified heterogeneity of ACE co-occurrence within ACE exposure categories using combinatorial coverage (CC; proportion of possible patterns observed) and visualised common patterns with an UpSet. Analyses used complete ACE data (N = 51,468; 93.3% of the total sample); co-occurrence analyses were restricted to children with ≥2 ACEs (n = 7897). Across the 2-, 3-, and ≥ 4-ACE categories, 582 of 1013 combinations were observed: all 45/45 patterns for 2 ACEs (CC₂ = 1.00), 110/120 for 3 ACEs (CC₃ = 0.92), and 427/848 for ≥4 ACEs (CC ≥ 4 = 0.50). Fifty combinations met the display threshold (unweighted n ≥ 30) and accounted for 5204 (66%) of children with ≥2 ACEs. Parental divorce/separation appeared in 34 of the 50 displayed patterns, household substance use in 23, and household mental illness in 20. ACE scores masked heterogeneity in exposure patterns. Simple diagnostics such as combinatorial coverage and UpSet plots can make this heterogeneity explicit and may support pattern-specific analyses of outcomes.