The impact of adverse childhood experiences on healthcare utilization in children

Outcomes of adverse childhood experience during late adolescence: Evidence from college and community samples

Scant studies have investigated adverse childhood experience (ACE) outcomes and mastery during adolescence in different cultural contexts. This cross-sectional study examines the impact of ACEs on subjective well-being, health complaints, and healthcare utilization during late adolescence, including the mediating role of the sense of mastery in the Saudi context. Adolescents (N = 396) aged 17-21 years were recruited via convenience sampling from colleges and local communities from two regions in Saudi Arabia. Data were collected using a paper-pencil anonymous survey and analyzed using path analysis. Of the sample, 85.5% experienced at least one ACE. ACEs had a direct effect on subjective well-being (p = 0.034), health complaints (p < 0.001), healthcare utilization (p < 0.001), and sense of mastery (p < 0.001). Sense of mastery had an effect on subjective well-being (p < 0.001) and health complaints (p < 0.001), but not on healthcare utilization (p = 0.436). Sense of mastery partially mediated the relationship between ACEs and subjective well-being (p = 0.034) and health complaints (p < 0.001), but not healthcare utilization (p = 0.438). ACEs have detrimental effects on adolescent health. Attention should be paid to primary prevention and early detection to avoid further harm, and interventions that address the role of the sense of mastery should be developed for adolescents.

Health Insurance Coverage Gaps Among Children With a History of Adversity

Health insurance stability among children with adverse childhood experiences (ACEs) is essential for accessing health care services. This cross-sectional study used an extensive, multi-year, nationally representative database of children aged 0 to 17 to examine the association between ACE scores and continuous or intermittent lack of health insurance over a 12-month period. Secondary outcomes were reported reasons for coverage gaps. Compared with children having 0 ACEs, those with 4+ ACEs had a higher likelihood of being part-year uninsured rather than year-round private insured (relative risk ratio [RRR]: 4.20; 95% CI: 3.25, 5.43), year-round public insured (RRR: 1.37; 95% CI: 1.06, 1.76), or year-round uninsured (RRR: 2.28; 95% confidence interval [CI]: 1.63, 3.21). Among children who experienced part-year or year-round uninsurance, a higher ACE score was associated with a greater likelihood of coverage gap due to difficulties with the application or renewal process. Policy changes to reduce administrative burdens may improve health insurance stability and access to health care among children who endure ACEs.

A window of opportunity: Adverse childhood experiences and time alone with a provider in the United States

BACKGROUND

To date, there is limited literature on the relationship between Adverse Childhood Experiences (ACEs) and the quality of health care provider encounters. This is key, as people with a history of ACEs have a greater burden of illness.

METHODS

This study uses data from the 2020-2021 National Survey of Children's Health to examine relationships between ACEs and (1) spending less than ten minutes with a health care provider, and (2) spending time alone with a health care provider.

RESULTS

In general, our results suggested most ACEs were associated with higher odds of a provider spending <10 min with a child during their last preventative care visit, while ACEs were inconsistently related to spending time alone with a provider. Each additional ACE was found to be associated with higher odds of both outcomes.

CONCLUSIONS

This work emphasizes the importance of ACEs screening in a health care setting and may set the groundwork for future research investigating mechanisms within these associations. Given the established link between health care quality and patient-provider trust, and health outcomes, intervention work is needed to develop healthcare practices that may encourage the length and quality of health care provider visits.

Family and Neighborhood Resilience Are Associated with Children's Healthcare Utilization

OBJECTIVE

To evaluate the association of external factors of resilience, neighborhood, and family resilience with healthcare use.

STUDY DESIGN

A cross-sectional, observational study was conducted using data from the 2016-2017 National Survey of Children's Health. Children aged 4-17 years were included. Multiple logistic regression was used to determine aOR and 95% CIs for association between levels of family resilience, neighborhood resilience and outcome measures: presence of medical home, and ≥2 emergency department (ED) visits per year while adjusting for adverse childhood experiences (ACEs), chronic conditions, and sociodemographic factors.

RESULTS

We included 58 336 children aged 4-17 years, representing a population of 57 688 434. Overall, 8.0%, 13.1%, and 78.9% lived in families with low, moderate, and high resilience, respectively; 56.1% identified their neighborhood as resilient. Of these children, 47.5% had a medical home and 4.2% reported ≥2 ED visits in the past year. A child with high family resilience had 60% increased odds of having a medical home (OR, 1.60; 95% CI, 1.37-1.87), and a child with moderate family resilience or resilient neighborhood had a 30% increase (OR, 1.32 [95% CI, 1.10-1.59] and OR, 1.31 [95% CI, 1.20-1.43], respectively). There was no association between resilience factors and ED use, although children with increased ACEs had increased ED use.

CONCLUSIONS

Children from resilient families and neighborhoods have an increased odds of receiving care in a medical home after adjusting for the effects of ACEs, chronic conditions, and sociodemographic factors, but no association was seen with ED use.

Disparate Impact: How Does Social Deprivation Affect Patient-reported Outcomes After ACL Reconstruction in Children and Adolescents?

BACKGROUND

Research has indicated that lower socioeconomic status is associated with delays in the treatment of anterior cruciate ligament (ACL) injuries; however, there is a paucity of literature evaluating its association with patient-reported outcomes (PROs). Using the Area Deprivation Index (ADI), a validated proxy for socioeconomic status, the study aimed to determine how relative socioeconomic disadvantage is related to PROs after primary ACL reconstruction (ACLR) in pediatric patients.

METHODS

This retrospective cohort study included all patients 18 years old or above who underwent primary ACLR at an academic institution between 2018 and 2021. Exclusion criteria included multiligament injury, congenital ACL absence, and absent outcomes data. The minimum follow-up was 6 months. A Patient-reported Outcomes Measurement Information System (PROMIS) 50 Pediatric self-report questionnaire was completed at postoperative visits, and domain scores for pain, physical function/mobility, fatigue, anxiety, depression, and peer relationships were generated. The National ADI percentile was calculated using the patients' addresses. Patients were divided into quartiles (low, moderate, moderate-severe, and severe ADI), and comparative analyses were performed to determine the relationship between ADI and PROMIS.

RESULTS

A total of 413 patients were identified, including 49% (n=207), 33% (n=139), 11% (n=48), and 7% (n=30) from the low, moderate, moderate-severe, and severe deprivation areas, respectively. As compared with those in the low-deprivation quartile, patients in the severe deprivation quartile had delayed time to the first clinic visit (11 vs. 16.5 d, P=0.044) and surgery (51 vs. 80 d, P=0.004). There were no differences in the number of additional procedures required at index surgery. All quartiles had progressive improvements in physical function/mobility and pain scores throughout recovery, but at 9 months, there was significantly more pain in the severe deprivation cohort, despite no difference in self-reported physical function and mobility. Those with severe socioeconomic disadvantage had worse psychosocial outcomes, including significantly increased depression, fatigue, and anxiety and decreased peer relationship scores.

CONCLUSIONS

Although there were no differences in preoperative PROMIS scores, pediatric patients living in areas with higher levels of socioeconomic deprivation/disadvantage had worse psychosocial PROs after ACLR.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Adverse Childhood Experiences and Family-Centered Care

Adverse Childhood Experiences (ACEs) include experiences of child maltreatment and household dysfunction. Prior work has shown that children with ACEs may have suboptimal utilization of preventive health care, including annual well-visits, however little is known about the relationship between ACEs and quality of patient care. Using data from the 2020 National Survey of Children's Health (N = 22,760) a series of logistic regression models estimated associations between ACEs, both individually and cumulatively, and five components of family-centered care. Most ACEs were consistently associated with lower odds of family-centered care (e.g. financial hardship was associated with doctors always spend enough time with children, AOR = 0.53; 95% CI = 0.47, 0.61), except for having a parent or guardian die, which was associated with higher odds. Cumulative ACE score was also associated with lower odds of family-centered care (e.g. doctors always listened carefully to the parent, AOR = 0.86; 95% CI = 0.81, 0.90). These findings emphasize the importance of the consideration of ACEs in the context of family-centered care, and support the need for ACEs screening in the clinical setting. Future work should focus on mechanisms explaining the observed associations.

Population-based affective-disorder-related biomedical/biophysical multi-hyper-morbidity across the lifespan: A 16-year population study

BACKGROUND

There are few if any life-span population-based studies of psychiatric disorder-associated biomedical and biophysical disorders and diseases (morbidity).

AIM

To scope the present state of research regarding the biomedical and biophysical morbidity associated with affective and mental disorder in epidemiological samples, and to examine the life-span relationship between affective disorders and biomedical/biophysical disorders to illustrate a novel approach employing the odds ratio to represent the intensity of biomedical and biophysical morbidity associated in time in a population.

METHODS

A repeatable systematic literature search of PubMed was represented in summary. Additionally, a regional population-based dataset was constructed and analyzed to represent the age- and sex-specific diagnoses (International Classification of Diseases Version 9, ICD-9) for those with and without affective disorder. The analysis presents a novel index of the relative age-specific frequency of life-span biomedical and biophysical diagnoses associated with affective disorder.

RESULTS

The volume of biomedical and biophysical morbidity associated with mental disorder literature has increased, yet few studies measure comprehensive temporal hyper-morbidity (over-representation of diseases over time, either before or after the index diagnostic event) in populations. Further, there have been only a few population-based studies examining the morbidity associated with affective disorder and only one that examines the full diagnostic range of lifespan morbidity. Substantial differences arose between males and females with more females than males having greater frequencies of diagnoses. The age-specific distributions of the maximum proportional diagnosis frequency ratios for each sex illustrate the greatest diagnosis-specific differences when comparing the biomedical and biophysical diagnoses of those with and without affective disorder when the same diagnosis was represented in each grouping at the same age.

CONCLUSION

Clinical research needs to focus on more than one or two comorbid biomedical or biophysical disorders at a time. Comprehensive population-based examination of the lifespan biomedical and biophysical multi-morbidity associated with affective disorder has the potential to directly inform clinical practice. Representing the proportional ratios of age-specific frequency of diagnoses for the full range of ICD-9 diagnoses is a novel analytical model. Diagnostic frequency appears a viable representation of a given disease state, such as affective disorder. Fortunately, the WPA has developed a global education section to better understand the biomedical and biophysical morbidity associated with all psychiatric disorders. This has been identified by the WPA as the psychiatric practice challenge of the 21^st century.

Adverse Childhood Experiences, health insurance status, and health care utilization in middle adulthood

RATIONALE

Adverse childhood experiences (ACEs) negatively impact health over the life-course. Yet, compared to the robust literature on the consequences for ACEs for health, substantially fewer studies assess the implications of exposure to ACEs for health insurance status and health care utilization in adulthood.

OBJECTIVE

To assess the association between accumulating ACEs and (1) an individual's health insurance status, and (2) usual source of care, as well as examine the mediating role of adult socioeconomic status.

METHODS

Data are from the National Longitudinal Study of Adolescent to Adult Health (N = 8,757). Multinomial logistic regression is used to assess the relationship between ACEs and health insurance status and the usual source of care.

RESULTS

Net of control and mediating variables, accumulating exposure to ACEs -particularly four or more ACEs- is associated with a higher likelihood of being uninsured and utilizing the emergency room as the usual source of care. Adult socioeconomic status including educational attainment, household income, employment status, and being uninsured-in the case of usual source of care-substantially mediates these associations.

CONCLUSION

ACEs carry negative repercussions for health insurance and patterns of healthcare utilization that spans into adulthood, and this is largely driven by poor adult socioeconomic status.

Utility of screening for adverse childhood experiences (ACE) in children and young people attending clinical and healthcare settings: a systematic review

OBJECTIVE

To examine and synthesise the literature on adverse childhood experience (ACE) screening in clinical and healthcare settings servicing children (0-11) and young people (12-25).

DESIGN

A systematic review of literature was undertaken.

DATA SOURCE

PsycInfo, Web of Science, Embase, PubMed and CINAHL were searched through June 2021. Additional searches were also undertaken.

ELIGIBILITY CRITERIA

English language studies were included if they reported results of an ACE tool being used in a clinical or healthcare setting, participants were aged between 0 and 25 years and the ACE tool was completed by children/young people or by parents/caregivers/clinicians on behalf of the child/young person. Studies assessing clinicians' views on ACE screening in children/young people attending health settings were also included.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data and assessed for risk of bias using the Mixed Methods Appraisal Tool. Results were synthesised qualitatively.

RESULTS

Initial searches identified 5231 articles, of which 36 were included in the final review. Findings showed that the most commonly used tool for assessing ACE was the ACE questionnaire; administering ACE tools was found to be feasible and acceptable; there were limited studies looking at the utility, feasibility and acceptability of assessing for ACE in First Nations people; and while four studies provided information on actions taken following ACE screening, no follow-up data were collected to determine whether participants accessed services and/or the impact of accessing services.

CONCLUSION

As the evidence stands, widespread ACE screening is not recommended for routine clinical use. More research is needed on how and what specific ACE to screen for and the impact of screening on well-being.

PROSPERO REGISTRATION NUMBER

University of York Centre for Reviews and Dissemination (CRD42021260420).

Developmental trauma: Conceptual framework, associated risks and comorbidities, and evaluation and treatment

Children exposed to adverse childhood experiences (ACEs) and pervasive interpersonal traumas may go on to develop PTSD and, in most cases, will further undergo a significant shift in their developmental trajectory. This paper examines contemporary research on Developmental Trauma (DT), which is inextricably linked to disruptions in social cognition, physiological and behavioral regulation, and parent-child attachments. Developmental trauma associated with early experiences of abuse or neglect leads to multi-faceted and longstanding consequences and underscores critical periods of development, complex stress-mediated adaptations, and multilevel, trans-theoretical influences in the diagnostic formulation and treatment of traumatized children, adolescents, and adults. Psychological and medical correlates of Developmental Trauma Disorder are considered, and directions for future research are discussed.

Association Between Adverse Childhood Experiences at Age 5 Years and Healthcare Utilization at Age 9 Years

OBJECTIVE

To determine associations between adverse childhood experiences (ACEs) at age 5 years and healthcare utilization patterns at age 9 years.

STUDY DESIGN

We conducted a secondary analysis using longitudinal data from the Fragile Families and Child Wellbeing Study. Caregivers (n = 2521) provided data on their child's ACEs at age 5 years and on 4 types of healthcare utilization at age 9 years: past-year well visits, dental visits, primary care sick visits for injury or illness, and emergency room (ER) visits. Logistic regression analysis was used to examine the association between ACEs at age 5 and each type of healthcare utilization, adjusting for relevant sociodemographic covariates.

RESULTS

Among the 2521 children (51% male, 48% Non-Hispanic Black), 77% had ≥1 ACE at age 5. Children with ≥4 ACEs had lower odds of a dental visit (aOR, 0.51; 95% CI, 0.29-0.91) and higher odds of a primary care sick visit (aOR, 1.77; 95% CI, 1.20-2.64) and an ER visit (aOR, 1.70; 95% CI, 1.11-2.59) compared with children with no reported ACEs.

CONCLUSION

Our findings demonstrate suboptimal healthcare utilization patterns among families with ACEs and indicate a need for targeted interventions that support appropriate healthcare utilization for children who endure adversity.

Adverse Childhood Experiences and Subjective Cognitive Decline in the US

OBJECTIVE

The aim of this study was to determine the association between adverse childhood experiences (ACEs) and subjective cognitive decline (SCD) among a representative sample of the adult US population.

METHODS

Data were obtained from the 2019 Behavioral Risk Factor Surveillance System (N = 82,688, ≥45 years). Adverse childhood experiences included sexual, physical/psychological and environmental ACEs, and a score. Multivariable logistic regression was used to determine the association between ACEs and SCD, and SCD-related outcomes.

RESULTS

Sexual (adjusted OR (aOR: 2.83; 95% CI: 2.42-3.31)), physical/psychological (aOR: 2.05; 95% CI: 1.83-2.29), and environmental (aOR: 1.94; 95% CI: 1.74-2.16) ACEs were associated with SCD in the past year. There was also a dose-response relationship between ACE score and SCD.

CONCLUSION

ACEs were associated with SCD. Interventions to maximize cognitive health in aging and prevent future cognitive impairment should consider the potential role of ACEs among affected populations.

Adverse childhood experiences, sex, and cardiovascular habituation to repeated stress

Adverse childhood experiences (ACEs) are robustly associated with later cardiovascular disease. Alterations in cardiovascular responses to stress may be an underlying mechanism. The present study examined whether ACEs predicted habituation of cardiovascular responses across two acute laboratory stress tasks, and whether this differed between men and women. During a single laboratory visit, 453 healthy young adults completed two identical stress-inducing protocols, each involving a 10-minute baseline and 4-minute acute psychological stress task. Heart rate (HR) and systolic/diastolic blood pressure (S/DBP) were recorded throughout. Participants also completed the Adverse Childhood Experiences scale. Cardiovascular responses habituated from the first to second stress task on average across the entire sample. However, women-but not men-with higher self-reported ACEs displayed less habituation of HR and DBP, but not SBP, across the stress tasks. Results suggest that ACEs may alter the body's ability to adaptively respond to stress exposures in adulthood, specifically in women.

Older adolescents and young adults willingness to receive the COVID-19 vaccine: Implications for informing public health strategies

Importance

The success in ending the COVID-19 pandemic rests partly on the mass uptake of the COVID-19 vaccine. Little work has been done to understand vaccine willingness among older adolescents and young adults. This is important since this age group may be less likely to adhere to public health guidelines.

Objective

To understand willingness of getting a vaccine and reasons for vaccine hesitancy among a sample of older adolescents and young adults.

Design

Data were from the Well-Being and Experiences study (The WE Study), a longitudinal community-based sample of older adolescents and young adults collected from Winnipeg, Manitoba, Canada from 2017 to 2020 (n = 664).

Setting

The study setting was a community-based observational longitudinal study.

Participants

Participants for the study were aged 14 to 17 years old at baseline in 2016–17 (n = 1000). Data were also collected on one parent/caregiver. Waves 2 (n = 747) and 3 (n = 664) were collected in 2019 and 2020, respectively.

Exposures

The main exposures were sociodemographic factors, health conditions, COVID-19 knowledge, and adversity history.

Main Outcomes

The main outcomes were COVID-19 vaccine willingness, hesitancy, and reasons for hesitancy.

Results

Willingness to get a COVID-19 vaccine was 65.4%. Willingness did not differ by age, sex, or mental health conditions, but did differ for other sociodemographic characteristics, physical health conditions, COVID-19 knowledge, practicing social/physical distancing, and adversity history. The most common reasons for not wanting a vaccine were related to safety, knowledge, and effectiveness. Sex differences were noted.

Conclusions and Relevance

Increasing uptake of the COVID-19 vaccine among older adolescents and young adults may rely on targeting individuals from households with lower income, financial burden, and adversity history, and generating public health messaging specifically aimed at vaccine safety, how it works to protect against illness, and why it is important to protect oneself against a COVID-19 infection.