Adverse Childhood Experiences and Behavioral Health Service Utilization: A Systematic Review

Background and Purpose: Understanding behavioral healthcare service utilization (BHSU) patterns among at-risk populations can inform cost-effective policies that support well-being. Adverse childhood experiences (ACE; childhood maltreatment, childhood adversity) are associated with negative long-term health outcomes and increased healthcare utilization. Behavioral health disorders are associated with high healthcare utilization but decreased access to care which often results in inappropriate use of acute care services. Such utilization/access may vary by race/ethnicity. This systematic review had three aims: (1) to describe characteristics of studies exploring ACE and BHSU; (2) to examine the evidence linking ACE and BHSU with attention to racial/ethnic variations; (3) and to evaluate the methodological quality of these studies

Methods: The PRISMA checklist guided this systematic review. Medline, Web of Science, PsycINFO, and Social Services Abstracts databases were systematically searched to identify peer-reviewed, English language studies conducted in the United States (US) that met the following criteria: (1) examined ACEs as independent variables and BHSU as an outcome; (2) reported original, empirical research; and (3) had a sample of at least 23% racial/ethnic minorities (consistent with US Census estimates of national racial composition).The Effective Public Health Practice Project (EPHPP) Quality Assessment Tool was used to evaluate each study’s methodological rigor. A PRISMA diagram, tables, and data extraction form were used to capture study characteristics (methodological features, ACE definition, BHSU conceptualization, key findings). Data were analyzed using thematic analysis and a two-step narrative synthesis methodology that included data extraction and preliminary synthesis (including within/between relationship exploration); and robustness assessment. After data extraction, thematic analysis was used to group data and identify themes, disparities, and relationships within and between studies. Robustness of synthesis results were assessed using quality assessment and by comparing findings to existing review findings. Discrepancies were resolved by consensus, and when necessary by consulting a third reviewer.

Results: Across databases, 524 non-duplicate studies were identified; 76 underwent full-text review and of these studies, 36 were eligible for inclusion. Forty-seven percent of studies were longitudinal (17/36), 28% were case control (10/36), and 25% were cross-sectional (9/36); 36% (12/36) utilized nationally representative datasets. Child welfare database records (12/36) and the ACE questionnaire (9/36) were used most frequently to measure ACE; the Child and Adolescent Services Assessment (7/36) was the most used BHSU measure. Forty-seven percent of studies had a weak global methodological rating (17/36); 47% were rated moderate (17/36); 6% were rated strong (2/36). Thematic analysis and narrative synthesis revealed three key findings: (1) the relationship between ACE and BHSU varies by ACE type; (2) among foster children, BHSU varies by placement type and behavioral health need; (3) minorities exposed to ACE are less likely to receive behavioral healthcare than Whites. Wide variation in measurement and operationalization of ACE and BHSU existed across studies.

Conclusions/Implications: Future research should continue to explore best practices for behavioral health service provision for persons exposed to ACE. Research examining the role of minority identity in behavioral healthcare receipt is absent, which highlights the need for research on non-dominant populations.