Cumulative and dimensional associations of adverse childhood experiences with behavioural and developmental outcomes in Chinese preschool children: evidence from the Shanghai Maternal-Child Pairs Cohort

Extensive evidence has linked adverse childhood experiences (ACEs) to a wide range of adverse health outcomes in adulthood, but evidence from the preschool period remains limited, particularly in a Chinese setting. This study examined cumulative ACE burden and threat and deprivation dimensions in relation to behavioural and developmental outcomes among Chinese preschool children. This cross-sectional analysis included 3,102 children aged 3–5 years from the Shanghai Maternal–Child Pairs Cohort (SMPC). Caregivers retrospectively reported ACEs from birth to preschool follow-up. Behavioural and developmental outcomes were assessed concurrently using the Strengths and Difficulties Questionnaire (SDQ) and Ages & Stages Questionnaires, Third Edition (ASQ-3). Linear and logistic regression examined cumulative exposure and mutually adjusted threat- and deprivation-related dimensional associations. Missing covariates were multiply imputed, and P values were corrected using the Benjamini–Hochberg false discovery rate. Overall, 19.7% experienced ≥ 1 ACE and 4.2% experienced ≥ 2. Relative to no ACEs, 1 and ≥ 2 ACEs were associated with higher SDQ total difficulties scores (aβ = 1.75, 95% CI: 1.33–2.18; and aβ = 4.39, 95% CI: 3.62–5.17) and odds of abnormal-range total difficulties (aOR = 2.07, 95% CI: 1.55–2.75; and aOR = 5.35, 95% CI: 3.55–8.06), respectively. Exposure to ≥ 2 ACEs was also associated with lower ASQ-3 total scores (aβ = -16.54, 95% CI: -21.53 to -11.56) and suspected global developmental delay (aOR = 2.39, 95% CI: 1.36–4.20). In mutually adjusted models, each additional threat-related ACE was associated with higher SDQ total difficulties scores (aβ = 2.07, 95% CI: 1.71–2.43) and odds of abnormal-range total difficulties (aOR = 2.30, 95% CI 1.85–2.86), whereas each additional deprivation-related ACE was associated with lower ASQ-3 total scores (aβ = -6.35, 95% CI: -9.26 to -3.43) and odds of suspected global developmental delay (aOR = 1.59, 95% CI: 1.12–2.26). Among Chinese preschool children, caregiver-reported ACEs showed graded cumulative associations and distinct threat- and deprivation-related patterns across behavioural and developmental outcomes. Further longitudinal and multi-informant studies are needed to confirm these associations and evaluate the potential value of cumulative and dimensional ACE assessments.