The Effects of ACEs on Physical and Mental Health Outcomes across Gender, Race/Ethnicity, Economic Status, and Their Intersectionality

Background

Adverse childhood experiences (ACEs) are harmful events and conditions, though their burden is borne disproportionately by disadvantaged and marginalized populations. It is unclear, however, whether the health-related consequences of ACEs differ among population subgroups. Efforts to explore variation across social categories such as race/ethnicity, economic status, and gender have been largely limited to fixed effects models that test the moderating effects of one category at a time. This study aims to advance the literature by conducting a quantitative intersectional analysis to examine the extent to which the association between ACEs and health-related outcomes vary across strata composed of intersecting racial/ethnic, economic, and gender categories.

Methods

Data for this secondary data analysis were drawn from the National Longitudinal Study of Adolescent Health (Add Health). The final analytic sample included 13,439 participants who were subdivided into three racial/ethnic groups (Non-Hispanic White, Black, Hispanic) and two gender groups (male; female); non-binary gender data were unavailable. Income and public assistance data were used to classify participant economic status based on whether or not their childhood household income was below the federal poverty level. Self-reported and parent-reported data from the first four waves were used to measure 10 ACEs, and cumulative ACE scores were used to categorize participants as having four or more ACEs or less than four ACEs. Health outcomes included general physical health and depressive symptoms measured by the CESD-4 scale.

Descriptive statistics were computed to estimate the prevalence of ACEs among the subgroups of interest. Multivariate linear regression models were used to test the moderating effects of gender, race/ethnicity, and economic status. Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) was applied to determine whether the associations between ACEs and health outcomes varied across intersectional strata.

Results

Supporting prior research, higher ACE scores were observed among Black and Hispanic participants than White participants (M = 1.67, 1.63, and 1.41, respectively), low-income than more economically advantaged participants (M = 2.07 and 1.36), and females than males (M = 1.53 and 1.48). Moderation analyses revealed that the ACE-physical health relationship was moderated by Black race and economic status, suggesting that ACEs had greater negative effects on White adults than Black adults and higher-income adults than lower-income adults. The ACE-depression relationship was moderated by gender and economic status, suggesting that ACEs had greater negative effects on females and higher-income adults.

MAIHDA results indicated that 8.3% of the total variance in general health was accounted for by intersectional between-stratum effects above and beyond the additive effects of ACEs, race/ethnicity, economic status, and gender. Descriptively, all strata with four-plus ACEs had poorer outcomes than all strata with less than four ACEs, while economic status had a stronger stratifying influence than race/ethnicity and gender.

Conclusion

The findings underscore that the harmful effects of ACEs appear to vary across social groups. Pending replication, the results may be used to target ACE prevention and intervention efforts. Future research along these lines should employ quantitative intersectional approaches such as MAIHDA, which represent the gold standard for exploring health disparities.