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Stressful Life Events and Healthcare Utilization Among U.S. Children Aged 2-17 Years
Abstract
Objective-Associations between stressful life events (SLEs) during childhood and suboptimal healthcare access and use has been documented. Recent changes to the National Health Interview Survey's questionnaire enabled the inclusion of SLEs in the child sample, resulting in an additional national data source where SLEs can be tracked. In this report, the latest SLE estimates are examined for children aged 2-17 years in the United States and their associations with healthcare utilization. Methods-Data from the 2021 National Health Interview Survey were used to examine the percentage of children who experienced one or more SLEs-emotional abuse, unmet basic needs, experiences of racism, household mental illness, household substance abuse, parental incarceration, and exposure to neighborhood violence-and describe the association between SLEs and selected healthcare utilization indicators over the past 12 months (as in no well-child visit, emergency room visits, urgent care visits, unmet medical care needs due to cost, use of prescription medications for mental health, and use of any mental health therapy). Multivariate logistic regression models were fit to produce prevalence ratios for selected healthcare utilization indicators by SLEs, after adjusting for child and family sociodemographic characteristics. Results-In 2021, one in five children aged 2-17 years had ever experienced an SLE. In general, all SLEs were related to higher healthcare utilization (as in emergency department visits or mental health therapy) and unmet medical care needs. In general, no significant associations were found between experiencing SLEs and not receiving preventive health care. After adjusting for demographic characteristics, higher rates of healthcare utilization, unmet medical care needs, and mental healthcare utilization generally persisted for children with SLEs. Conclusion-This report expands knowledge on the relationship between childhood SLEs and the use of preventive care, healthcare utilization, and mental health care. National Health Interview Survey data can be used to monitor trends in these associations over time.
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Background: Youth from marginalized groups may be less likely to receive quality health care services. Adverse Childhood Experiences (ACEs) are known to impact long-term health, but it is unclear if there is a relationship between ACEs and receipt of Family Centered Care (FCC)—one indicator of high-quality health care. To assess this relationship, this study used a nationally representative sample of youth from the National Survey of Children’s Health 2016–2017 combined data set. Caregivers of children who had at least one health care visit in the last 12 months (sub-sample n = 63,662) were asked about five indicators of FCC including if they felt the provider: (1) spent enough time, (2) listened carefully, (3) helped family feel like a partner, (4) provided information requested, and (5) showed sensitivity to culture. Methods: Logistic regression analyses examined the association between ACE score and each FCC quality indicator, as well between ACEs score and the overall FCC dichotomous score. Results: ACE exposure did not significantly predict access to a health care visit in the past 12 months. However, children with higher rates of ACEs were significantly less likely to receive FCC. Other factors that significantly predicted lower FCC included child race and ethnicity, insurance type, language in the home, and access to a regular health provider. Conclusions: Providers and health systems must identify, implement, and advocate for effective trauma-informed and care coordination interventions that ensure quality health care services for vulnerable children and families.
The ongoing longitudinal Adverse Childhood Experiences Study of adults has found significant associations between chronic conditions; quality of life and life expectancy in adulthood; and the trauma and stress associated with adverse childhood experiences, including physical or emotional abuse or neglect, deprivation, or exposure to violence. Less is known about the population-based epidemiology of adverse childhood experiences among US children. Using the 2011-12 National Survey of Children's Health, we assessed the prevalence of adverse childhood experiences and associations between them and factors affecting children's development and lifelong health. After we adjusted for confounding factors, we found lower rates of school engagement and higher rates of chronic disease among children with adverse childhood experiences. Our findings suggest that building resilience-defined in the survey as "staying calm and in control when faced with a challenge," for children ages 6-17-can ameliorate the negative impact of adverse childhood experiences. We found higher rates of school engagement among children with adverse childhood experiences who demonstrated resilience, as well as higher rates of resilience among children with such experiences who received care in a family-centered medical home. We recommend a coordinated effort to fill knowledge gaps and translate existing knowledge about adverse childhood experiences and resilience into national, state, and local policies, with a focus on addressing childhood trauma in health systems as they evolve during ongoing reform.
Project HOPE—The People-to-People Health Foundation, Inc.
This report details the National Center for Health Statistics' (NCHS) development of the 2006 NCHS Urban-Rural Classification Scheme for Counties and provides some examples of how the scheme can be used to describe differences in health measures by urbanization level.
The 2006 NCHS urban-rural classification scheme classifies all U.S. counties and county-equivalents into six levels--four for metropolitan counties and two for nonmetropolitan counties. The Office of Management and Budget's delineation of metropolitan and nonmetropolitan counties forms the foundation of the scheme. The NCHS scheme also uses the cut points of the U.S. Department of Agriculture Rural-Urban Continuum Codes to subdivide the metropolitan counties based on the population of their metropolitan statistical area (MSA): large, for MSA population of 1 million or more; medium, for MSA population of 250,000-999,999; and small, for MSA population below 250,000. Large metro counties were further separated into large central and large fringe metro categories using classification rules developed by NCHS. Nonmetropolitan counties were assigned to two levels based on the Office of Management and Budget's designated micropolitan or noncore status. The 2006 scheme was applied to data from the National Vital Statistics System (NVSS) and the National Health Interview Survey (NHIS) to illustrate its ability to capture health differences by urbanization level.
Application of the 2006 NCHS scheme to NVSS and NHIS data shows that it identifies important health disparities among communities, most notably those for inner city and suburban communities. The design of the NCHS Urban-Rural Classification Scheme for Counties makes it particularly well-suited for assessing and monitoring health differences across the full urbanization continuum.
To examine the effect of child abuse and other household dysfunction on child health outcomes.
Data from the Longitudinal Studies of Child Abuse and Neglect collected through interviews and questionnaires administered when target children were 4 years old and 6 years old.
Children in the South, East, Midwest, Northwest, and Southwest United States.
One thousand forty-one children at high risk for child abuse and neglect (3 cohorts derived primarily from among children recruited through social service mechanisms, 1 cohort recruited at birth from among high-risk infants, and 1 cohort recruited from a medical setting).
(1) Association of 7 adverse exposures (3 categories of child abuse [physical abuse, sexual abuse, and psychological maltreatment] and 4 categories of household dysfunction [caregiver problem drinking, caregiver depression, caregiver treated violently, and criminal behavior in the household]) derived from data collected when the child was 4 years old. (2) Indexes of child physical health at age 6 years (caregiver overall assessment of child health and reports of illness requiring medical attention).
Two thirds of the sample had experienced at least 1 adverse exposure. One adverse exposure almost doubled the risk of overall poor health (odds ratio, 1.89; 95% confidence interval, 1.02-3.48), and 4 adverse exposures or more almost tripled the risk of illness requiring medical attention (odds ratio, 2.83; 95% confidence interval, 1.10-7.31).
Adverse environmental exposures, including child abuse and other household dysfunction, are associated with poor child health even at an early age, although our data do not support a dose-response relationship.
Objective:
Examine relationships between adverse childhood experiences (ACEs) and related life events and allostatic load (AL) - "wear and tear" from chronic stress - in a pediatric population.
Methods:
Children were screened with the PEARLS tool, a 17-item questionnaire capturing experiences of abuse, neglect, household challenges, and related life events. Biologic data was available for 207 participants and AL was operationalized using clinical or empirical cutoff points across 4 physiologic systems (i.e., cardiac, metabolic, inflammatory, neurologic). Covariate-adjusted multivariable regression models were used to examine associations between AL with adversity and health.
Results:
Children (Mean age = 6.5 years, range = 1-11 years) had an average AL score of 1.9 (SD 1.7), and a U-shaped relationship was observed with child's age. Continuous PEARLS and original ACE scores were not associated with AL. However, children with a reported PEARLS score of 1-2 or original ACEs score of 1-3 had 1.5 (IRR 1.50; 95% CI 1.09, 2.08) and 1.4 (IRR 1.41; 95% CI 1.08, 1.84) times greater AL, respectively, compared to participants with none reported. In secondary analyses, caregiver mental illness was associated with higher child AL (adjusted IRR 1.27; 95% CI 1.01, 1.58). AL was also associated with poorer perceived child general health (aß = -0.87, 95% CI: -1.58, -0.15) and greater odds of child obesity (aOR 1.51; 95% CI: 1.23, 1.89).
Conclusions:
Measuring AL in a pediatric population requires careful consideration of age. Higher AL was associated with a greater number of reported adversities and worse child health.
Objective
Adverse childhood experiences (ACEs) can affect health and development across the life course. Despite a general understanding that adversity is associated with lower income, we know less about how ACEs manifest at different income levels and how these income-related patterns affect children's health and development.
Methods
Data from the 2011 to 2012 National Survey of Children's Health were used to examine the prevalence of 9 ACEs in US children, across 4 levels of household income, and in relationship to 5 parent-reported measures of child health. Bivariate analyses and multivariable logistic regression models were used to examine the associations between number of ACEs and children's health outcomes on the basis of the 4 income groups.
Results
When partitioned according to income strata, the proportion of children who experienced ACEs showed a steep income gradient, particularly for children who experienced ≥4 ACEs. The linear gradient across income groups was less pronounced for each specific ACE, with several ACEs (experience of divorce, drug and alcohol exposure, parental mental illness) showing high reported prevalence in all but the highest income group. Multivariate analysis showed a consistent income-related gradient for each of the health outcomes. However, higher income was not necessarily found to be a protective factor against ACEs.
Conclusions
ACEs are distributed across the income ladder and not just concentrated below the poverty level. This suggests that a more comprehensive policy strategy that includes targeted as well as universal interventions is warranted.
Objectives:
Adverse childhood experiences (ACEs) have been consistently linked in a strong and graded fashion to a host of health problems in later adulthood but few studies have examined the more proximate effect of ACEs on health and emotional well-being in adolescence.
Study design:
Nationally representative cross-sectional study.
Methods:
Using logistic regression on the 2011/12 National Survey of Children's Health, we examined the cumulative effect of total ACE score on the health and emotional well-being of US adolescents aged 12 to 17 years. We investigated the moderating effect of family functioning on the impact of ACE on adolescent health and emotional well-being.
Results:
Adolescents with higher ACE scores had worse reported physical and emotional well-being than adolescents with fewer ACEs net of key demographic and socio-economic characteristics. Family functioning moderated the negative impact of cumulative ACE on adolescent health and emotional well-being.
Conclusions:
Adolescent well-being has enduring consequences; identifying children with ACE exposure who also have lower-functioning family could also help identify those families at particular risk.
To examine the relationship between adverse childhood experiences (ACE), access to a medical home and a global measure of well-being among children ages 6-17 using the 2011-2012 National Survey of Children's Health.
Multivariate linear regressions assessed the associations between each adverse experience and an index of child well-being with and without the impact of other events. The number of ACE was summed for each respondent and the analyses were repeated with the cumulative score as a continuous variable. The cumulative model was repeated with the addition of an interaction term between ACE score and medical home access. All analyses were conducted separately for children ages 6-11 and adolescents 12-17.
Over half (53 %) of US children ages 6-17 have experienced some adverse experience during childhood. Over a quarter (28 %) has experienced at least two adverse experiences, while 15 % have experienced three or more hardships. Results suggest that the accumulation of ACE reduces well-being in children. The associations remained significant after controlling for gender, race/ethnicity, age, parental education, special health condition, and medical home access. Medical home access was consistently associated with higher levels of child well-being and was a significant moderator of the relationship between the total ACE and child well-being among children ages 6-11. Children with ACE exposure and access to a medical home have higher levels of well-being than comparable children without access to a medical home.
Children exposed to adverse experiences have measurably lower levels of well-being, although younger children with access to a medical home are protected at increasing exposure.
Trauma in childhood is a psychosocial, medical, and public policy problem with serious consequences for its victims and for society. Chronic interpersonal violence in children is common worldwide. Developmental traumatology, the systemic investigation of the psychiatric and psychobiological effects of chronic overwhelming stress on the developing child, provides a framework and principles when empirically examining the neurobiological effects of pediatric trauma. This article focuses on peer-reviewed literature on the neurobiological sequelae of childhood trauma in children and in adults with histories of childhood trauma.
National Center for Health Statistics data presentation standards for proportions. National Center for Health Statistics
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Childhood adversity associated with poorer health: Evidence from the U.S. National National Health Statistics Reports Number 190
- B H Walker
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National Health Statistics Reports Number 190 August 8, 2023