The Relationship between Adverse Childhood Experiences (ACEs) and Behavioral Health Outcomes in Child-Welfare Involved Youth

Background and Purpose: Exposure to adverse childhood experiences (ACEs), which includes violent victimization, is pervasive in childhood. Although much is known about the impacts of ACE exposure on behavioral health outcomes in adulthood, few studies have examined the relationship between ACEs and child behavioral health. A large body of research indicates that the accumulation of ACEs, as opposed to exposure to single types of trauma or victimization, is a stronger predictor of behavioral health outcomes. Children involved with the child welfare system due to child abuse and neglect have high rates of exposure to other types of violence in addition to violence perpetrated by caregivers. However, most research with child welfare samples have focused on singular incidents of maltreatment and fails to recognize the complex interactions between multiple victimization and adversities. This study attempts to fill gaps in the literature by exploring the relationship between childhood victimization and adversity and behavioral health outcomes for child-welfare involved youth.

Methods: Data was drawn from the National Survey of Child and Adolescent Well-Being (NSCAW II), a longitudinal, nationally representative survey of children who have been the subject of a child welfare investigation. Information was collected from three sources (the child, the caregiver, and the child welfare caseworker). A sub-sample was drawn of participants aged 8-17 years at the time of Wave 1 data collection for a total of 1,887 youth. An ACE index was created using NSCAW II available measures and included six domains: Caregiver Maltreatment, Non-Caregiver Physical Assault, All Sexual Victimization, Peer Victimization, Witnessing Violence in the Home and Community, and Caregiver Behavioral Health Problems. The main outcome of interest (behavioral health) was measured using the Child Depression Inventory, Trauma Symptom Checklist, and the internalizing and externalizing sub-scales of the Child Behavior Checklist. Logistic regression was used to explore the association between the number of complex victimization and adversity reported and the risk of clinical-range behavioral health symptoms. Analyses were adjusted for the cluster-based sampling design of NSCAW. Sampling weights were applied to provide nationally representative estimates.

Results: On average youth experienced three domains of ACEs with more than 60% of the sample experiencing three or more domains. The number of complex victimization and adversity domains experienced was associated with all four behavioral health outcomes (p < .001). Children exposed to five or more domains were more likely to report high depressive symptoms (odds ratio [OR] = 5.0), high trauma symptoms (OR=7.0), and to have internalizing or externalizing symptoms reported by caregivers (OR = 18.0), as compared to children reporting one or less domains.

Conclusions: Youth involved with the child welfare system are exposed to staggeringly high rates of victimization and adversity. Based on this nationally representative sample, these youth experienced double the rates of victimization and adversity compared to similar national samples of youth. For children who are already at great risk for behavioral health challenges and life-long difficulties, research to understand risk for complex victimization and adversity is needed to inform policy and practice initiatives to prevent and mitigate harm.