Developmental Differences in ACEs As Predictors of Complex Health Profiles Among Children Involved in Child Welfare

Background/Purpose: Children involved in the child welfare system have special health care needs, with higher-than-average rates of physical, behavioral, and developmental disorders that are often related to increased vulnerability associated with maltreatment. Over one-half of child welfare-involved children have four or more Adverse Childhood Experiences (ACES), a threshold associated with increased chronic disease incidence in adulthood. As ACES are increasingly recognized as a public health problem, patient-centered medical homes (PCMH) are needed that will meet the complex service needs of this service population. This study describes the relationship between ACES and complex health among four age-groups of children referred to child welfare, testing the ACES rubric with children to inform PCMH strategies. Our study questions are: (1) to what extent are clusters of physical, behavioral, and developmental conditions similar or different across four developmental periods? (2) what is the relationship between ACES and complex health profiles? and (3) what number of ACES relate to complex health concerns for children in different age groups?

Methods: Data from 5,873 children and youth (age 2 months to 18 years) participating in the National Survey of Child and Adolescent Well-Being (NSCAW) were used. Latent class analyses using 11 indicators derived from standardized measures of physical, developmental, and behavioral health were used to form complex health profiles, or classes, for children in each age-group (infants, young children, school-age, and adolescents). Controlling for demographic variables, health class was then regressed on the total number of ACES, a dichotomous ACES variable (4 or more ACES as previously tested in literature), and individual ACE indicators. Regression analyses used sampling weights to generalize to the national population of child welfare-involved children.

Results: For all ages, a two-class solution was the best fitting LCA model, identifying a lower-concern class and higher-concern class. Children in the higher-concern class demonstrated higher rates of developmental, behavioral, and physical health concerns. The number of children with high complex health concerns increased with age, to nearly one-half of adolescents. ACES significantly predicted complex health among the three older child age-groups; for every additional ACE, children ages 2-18 were 1 to 1.5 times more likely to be in the high-concern class. Children who experienced 4 or more ACEs were more than twice as likely to have high complex health concerns (ages 2-18). Although infants had a relatively high number of ACES, ACES did not predict complex health concerns in this group, suggesting that the study measures may not adequately capture the health impact of ACES at this young age.

Conclusions and Implications: As health care increasingly aims to provide comprehensive, “whole-health” care that addresses the upstream determinants of health such as ACES, social workers and behavioral health practitioners are needed to provide expertise in the prevention and treatment of the complex biopsychosocial needs of child welfare-involved children. Multidisciplinary teams would be beneficial at each age-level, with increasing need for integrated behavioral health in primary care at school-age and adolescence. In younger age-groups, preventing the accumulation of ACES is a high priority in patient centered medical homes.