Measuring Childhood Adversity: Psychometric Challenges and a Novel Scoring Proposal based on a Nationally Representative Study in Serbia

Adverse Childhood Experiences (ACEs) are robust predictors of later mental and physical health problems, yet methodological inconsistencies in their measurement complicate prevalence estimates and cross-cultural comparisons. The present study provides the first nationally representative data on ACEs in Serbia while critically examining current scoring practices and proposing a novel normalized scoring system. Data were collected from a stratified national sample of adults in Serbia using the ACE-International Questionnaire (ACE-IQ; WHO, 2018). Thirteen ACE domains were assessed with binary and scaled items. Prevalence was calculated using two recommended WHO scoring methods (binary and frequency), and a new normalized scoring approach in which each domain was rescaled to a 0–1 range. Criterion validity was tested against trauma-related symptoms and physical health outcomes. Prevalence estimates varied dramatically depending on the scoring method: physical abuse was reported by 50.2% (binary) versus 7.8% (frequency), and emotional abuse by 78.8% versus 23.9%. Binary scoring suggested that over half of respondents experienced four or more ACEs, while frequency scoring indicated that 37% reported none. The normalized scoring approach produced more nuanced distributions and showed consistent associations with both trauma symptoms and health outcomes, particularly respiratory and neurological problems. Findings underscore the need for standardized ACE scoring methods. The proposed normalized approach enhances psychometric clarity, facilitates cross-cultural comparability, and improves the utility of ACE assessment for epidemiological research, clinical practice, and public health interventions.