Associations between Adverse Childhood Experiences and Modifiable Health Behaviors in a National Sample of Children

Background and Purpose:
Adverse childhood experiences (ACEs)—including abuse, neglect, and household dysfunction—are prevalent and strongly associated with negative health trajectories across the life course (Felitti et al., 1998; Shonkoff et al., 2012). These events generate toxic stress that can disrupt neurodevelopment, alter physiological systems, and increase the risk of chronic diseases such as depression, obesity, cardiovascular disease, and cancer (Chapman et al., 2004; Wiss & Brewerton, 2020; Holman et al., 2016). Although ACEs are linked to a wide array of poor outcomes, modifiable behaviors like physical activity, screen time, and sleep may serve as protective factors that can be targeted in prevention and intervention strategies (Fakhouri et al., 2013; Paruthi et al., 2016). This study examined the associations between ACE exposure and three modifiable health behaviors—daily physical activity, limited screen time, and adequate sleep—among U.S. children aged 6 to 17 years. It also explored variations in these associations by child sex.

Methods:
Data came from the 2019 National Survey of Children’s Health (NSCH), a nationally representative, cross-sectional survey. The sample included 18,705 children. ACEs were measured using nine parent-reported indicators and grouped into four categories (0, 1, 2, and 3+ ACEs). Outcomes were defined using CDC and AAP guidelines: 60 minutes of physical activity daily (Piercy et al., 2018), ≤2 hours of recreational screen time per day (Guram & Heinz, 2018), and age-appropriate sleep duration (Paruthi et al., 2016). Multivariate logistic regression models, adjusted for child, household, and neighborhood characteristics, were used to estimate associations. The study also examined whether the associations between ACEs and these three health behaviors varied by child sex.

Results:
ACEs were common, with 45.4% of children exposed to at least one and 12.8% exposed to three or more. Only 21.2% of children met physical activity guidelines, 54% had limited screen time, and 65.9% achieved adequate sleep. Compared to children with no ACEs, those with 1, 2, or 3+ ACEs had 26%, 30%, and 31% lower odds, respectively, of meeting screen time guidelines. Children with 2 ACEs had 30% lower odds of adequate sleep, and those with 3+ ACEs had 33% lower odds. No significant association was found between ACEs and physical activity in the full sample. Among boys, ACEs were associated with significantly lower odds of limited screen time. Among girls, 3+ ACEs were associated with significantly lower odds of adequate sleep.

Conclusions:
Children with ACE exposure are less likely to engage in healthy behavioral practices, particularly adequate sleep and limited screen time. These findings suggest that toxic stress may disrupt daily functioning and regulation.

Implications:
Health promotion strategies that address screen time hygiene and sleep routines could serve as accessible and cost-effective buffers against the long-term harms of ACEs. Pediatric settings, schools, and family-centered policies should prioritize interventions that support the development of healthy behavioral routines in at-risk children.