Childhood Adversity Questionnaire Proves Reliable for Postpartum Mothers, Study Finds

A widely used screening tool for childhood adversity holds up surprisingly well among new mothers, according to a new study published in Frontiers in Psychiatry. Researchers at Children’s Hospital Los Angeles found that the Adverse Childhood Experiences Questionnaire, or ACEQ, showed good test-retest reliability when administered to postpartum women at six and twelve months after delivery, even as many of the participants were navigating the emotional turbulence of the first year of motherhood. The finding matters because the postpartum period is precisely when clinicians most want trustworthy information about a mother’s history of early adversity, a factor strongly linked to postpartum depression and long-term health outcomes.

The Adverse Childhood Experiences Questionnaire traces its origins to a landmark 1998 investigation conducted by investigators at Kaiser Permanente San Diego, which first drew systematic connections between childhood abuse and household dysfunction and the leading causes of adult death. The ten-item retrospective instrument asks respondents to recall categories of trauma experienced during their first eighteen years of life, including abuse, neglect, and household dysfunction, with each endorsed category adding one point to a total score ranging from zero to ten. At the population level, higher scores have been associated with cardiovascular disease, diabetes, cancer, and a range of psychiatric conditions. But the questionnaire’s retrospective design has long raised a methodological worry: whether a respondent’s current emotional state colors how they remember and report the past.

That worry is especially acute during the postpartum period. Perinatal depression, which begins during pregnancy or within the first year after delivery, affects roughly one in seven individuals and is characterized by persistent sadness, sleep disruption, anxiety, and difficulty bonding with the baby. Previous research has suggested that people experiencing depression or psychological distress are more likely to report adverse childhood experiences that they had not disclosed on earlier administrations, raising the possibility that emotional state systematically inflates reported adversity. If true, this would undermine the questionnaire’s value as a stable screening measure in exactly the population where early adversity screening could be most clinically useful, since birthing parents with high adversity exposure face elevated risk of postpartum depression.

To test whether the instrument remains stable under these conditions, the research team drew on 317 mother-infant dyads enrolled in the larger Family First Research Study, a longitudinal investigation of how early life adversity shapes infant and toddler neurodevelopment. Participants were recruited primarily through a partnership with Kaiser Permanente in the greater Los Angeles area, and the sample was predominantly Hispanic, with 66.2 percent of mothers identifying as Hispanic and 67.3 percent as White. Mothers completed the de-identified ACEQ, the Patient Health Questionnaire-9 for depressive symptoms, and the Perceived Stress Scale at approximately six and twelve months postpartum. The de-identified format, in which participants report a total score rather than endorsing individual items, was chosen to reduce reluctance to answer sensitive questions honestly, though it also meant the researchers could not track which specific adversity categories drove any changes in reporting.

The statistical centerpiece of the study was the intraclass correlation coefficient, calculated using two-way mixed-effects models. The absolute agreement ICC came in at 0.79, with a 95 percent confidence interval of 0.75 to 0.83, indicating that 79 percent of the variance in scores reflected true differences between people rather than measurement error. A sensitivity analysis using a consistency ICC produced a nearly identical estimate of 0.79, suggesting no systematic bias between the two timepoints. A linear mixed-effects model confirmed that reported scores did not drift upward or downward over the six-month interval, and Bland-Altman analysis showed a mean difference of just 0.04 points with no proportional bias across score magnitudes. Cohen’s kappa for agreement on categorical risk levels, which group mothers into low, intermediate, and high adversity bands, was 0.62, indicating substantial agreement.

Yet the study also quantified an important limitation. The standard error of measurement was 1.12 points, which yields a minimum detectable change at 95 percent confidence of 3.10 points, roughly a third of the entire scale range. In practical terms, only shifts of three or more endorsed categories can be distinguished from measurement noise. Nearly half of the mothers, 47.3 percent, reported a different total score at twelve months than at six months, but the vast majority of those changes were small. In fact, 95.6 percent of participants were stable within the measurement-error threshold, and only 14 mothers, or 4.4 percent, showed changes large enough to represent genuine shifts in reported adversity, split evenly between increases and decreases.

The relationship between emotional state and reported adversity proved more nuanced than the recall-bias hypothesis predicted. Mothers with higher baseline stress and depressive symptoms did report more adverse childhood experiences at both timepoints: each one-point increase on the PHQ-9 was associated with 0.21 additional ACEs reported, and mothers with mild-to-severe depressive symptoms reported an average of 1.45 more ACEs than those without symptoms. But crucially, emotional distress was not associated with whether scores changed between visits, and its association with reported scores did not vary across timepoints. In other words, distress shaped how many adversities mothers reported, but not how consistently they reported them, meaning it does not compromise the instrument’s reliability even though it may influence absolute score levels.

The apparent link between baseline adversity scores and reporting changes also dissolved under scrutiny. Mothers at intermediate and high adversity risk had 5.17 and 7.33 times higher odds, respectively, of reporting a changed score compared with low-risk mothers, but the researchers show this pattern is largely structural. Mothers reporting zero adversities at baseline sit at the floor of the scale and can only remain stable or increase, while those with higher baseline scores have more room to move in either direction, and regression to the mean pushes high scorers downward. When the analysis was restricted to mothers with at least one baseline adversity, among whom decreases were actually possible, the association between baseline score and direction of change attenuated to non-significance. About 91 percent of observed discrepancies fell within the measurement-error threshold, reinforcing that most changes reflected statistical variability rather than genuine shifts in remembered adversity.

The study’s demographic breadth adds weight to the findings. The original ACEs research was conducted in a population that was 80 percent White, whereas this cohort included a majority of Hispanic participants along with Black, Asian, American Indian, and multiracial mothers, suggesting the questionnaire performs reliably in a more ethnically diverse population than the one in which it was first validated. The sample also reported adversity prevalence substantially above recent national figures from the Centers for Disease Control and Prevention, with 24.3 percent of mothers in the high-risk category of four or more ACEs, compared with a median ACEQ score of just 1 in this cohort overall.

The authors caution that several questions remain before the ACEQ can be deployed clinically in perinatal care. Reliability was assessed only over a single six-month interval in late postpartum, and the instrument’s stability earlier in the postpartum period or during pregnancy, when depression is more prevalent and screening would be most valuable, has yet to be established. The de-identified format prevents item-level tracking, the questionnaire cannot capture the severity or chronicity of adversity, and the predominantly middle-to-high-income, well-educated sample limits generalizability across socioeconomic strata. Still, the core message is clear: during the first year after delivery, a mother’s report of childhood adversity is a stable quantity, one that clinicians can reasonably use to identify those who may need closer mental health monitoring, even as small individual changes in the score should be interpreted with statistical humility.

Subject of Research: Test-retest reliability of the Adverse Childhood Experiences Questionnaire in postpartum women

Article Title: The reliability of the adverse childhood experiences questionnaire for late postpartum use in relation to maternal emotional health

Article References: Ozuna, A., Rezvan, P. H., Legido, J., Dubbaka, S., Levitt, P., & Gateau, K. (2026). The reliability of the adverse childhood experiences questionnaire for late postpartum use in relation to maternal emotional health. Frontiers in Psychiatry, 17, Article 1914194. https://doi.org/10.3389/fpsyt.2026.1914194

Image Credits: AI Generated

DOI: 10.3389/fpsyt.2026.1914194

Keywords: adverse childhood experiences, ACE questionnaire, postpartum depression, test-retest reliability, maternal mental health, perinatal screening, intraclass correlation coefficient, perceived stress, PHQ-9, recall bias, psychometrics, longitudinal study