Do Families Exposed to Adverse Childhood Experiences Receive Quality Healthcare Services?

Background & Aims: Adverse childhood experiences (ACEs) are a continued public health issue given the strong evidence on how early life trauma can significantly affect physical and behavioral health throughout the life course. Screening for ACEs in pediatric settings is growing, yet little is known about the quality of care provided to children and families who experience high ACE exposure. Integrated health care and care coordination are evidence-informed models to enhance quality of care and ensure care utilization. Research suggests children with high ACEs access care similarly to children without ACE exposure, yet little is known about the quality of care. Therefore, using a nationally representative sample of children, this study attempted to identify if children exposed to ACEs receive similar quality of health services.

Methods: Data was drawn from the 2011/2012 National Survey of Children’s Health (NSCH), a nationally representative data set of youth ages 0-17 in the U.S. collected by the National Center for Health Statistics at the CDC and Maternal and Child Health Bureau. A total of 95,677 children are included and caregivers were the primary respondent of the survey. NSCH includes nine items to measure ACE exposure. Four indicators of health provider quality were dichotomized (enough time spent with family, listened carefully to family, partners with family, and respects family values). Bivariate analyses examined the relationship between the number of ACEs reported and quality indicators. Four logistic regressions examined the relationship between ACE score and each quality indicator, controlling for race of the child. Analyses were weighted to provide nationally representative estimates.

Results: About half (49%) of the sample experienced more than 1 ACE and close to 24% experienced two or more ACEs. There was no significant difference in health care utilization between children who experienced 0 ACEs and 1 or more ACEs in the previous year. However, caregivers who reported 0 ACEs were more likely to report experiencing all four quality indicators, as compared to caregivers whose children experienced 1 or more ACEs (p<.001). For example, 91% of caregivers with a child of 0 ACEs reported their health provider partnered with them in their child’s care whereas 81% of caregivers with a child of 4+ ACEs felt this partnership. Similarly, 93% of caregivers with a child of 0 ACEs reported their health provider listened to their concerns compared with 82% of caregivers with 4+ ACEs. Logistic regression analyses identified there was a dose-response relationship between the number of ACEs reported and the quality of health care received for each indicator. Specifically, for every 1 more ACE reported, the odds the caregiver felt the health provider spent enough time decreased by 20% (p<.001).

Conclusions: This study identified that although children with high ACE exposure access services at the same rate as children with no ACE exposure, the quality of care significantly varied. A critical next step is to identify integrated care and care coordination interventions that not only increase access to care, but also ensures quality of health care services for vulnerable children and families.