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Timing Matters: The Effect of Adverse Childhood Experiences on Healthcare Utilization

October 30, 2024

In an article and accompanying video abstract being early released this week in Pediatrics, Charles Golden, DO, Raymen R. Assaf, MD, and colleagues from Children’s Hospital of Orange County and the University of California-Irvine retrospectively analyzed adverse childhood experiences (ACE) screening data for over 37,000 patients (ages 0–18 years) within a southern California health system during the early phase of the COVID-19 pandemic (January 2020–September 2021) (10.1542/peds.2023-064838).

They tested the hypothesis that ACEs were associated with increased emergency department (ED) visits and hospitalizations within the 6 months after the screening was completed.

This study was conducted in the context of prior knowledge that infants and young children accounted for the highest proportion of ED visits and hospitalizations. Previous studies demonstrated no difference in hospitalization and ED usage among all children with elevated ACE scores but did not segregate the data by age.

The central, and perhaps most counterintuitive, finding of this study is that children 0–4 years old with ACEs have lower healthcare utilization than their age-matched peers with no ACEs, but older children/adolescents with ACEs had higher healthcare utilization than their similarly aged-matched peers with no ACEs.

One of many plausible explanations offered by the authors for the observed findings may be that children 4 and older spend a considerable amount of their waking hours around other professionals (teachers, childcare providers, etc.) who are themselves mandated reporters and may refer children who appear to have been abused or neglected to the ED.

The authors admit that they did not track the reasons for the ED visits or hospitalizations. Additionally, they did not capture whether the patients accessed healthcare outside of the health care system network from which they received their primary care. And they were forthright in acknowledging the myriad reasons (e.g., pregnancy, mental health concern, substance misuse, etc.) that older children/adolescents with ACEs may be seen in an ED and/or need to be admitted.

Regardless, the difference in utilization by age may speak to the more salient manifestations that ACEs have in older children, which, if true, may suggest that we as pediatricians need to refine our ability to identify other markers to follow in the younger children who developmentally may not be able to articulate or demonstrate the toll that ACE-related stressors have.

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