Abstract
Purpose: Adverse childhood experience (ACE) exposure and poor mental health are closely intertwined. In 2020, the prevalence of both began precipitously increasing among adolescents. We explored associations of individual and cumulative ACE exposure with cost and COVID-19 pandemic-related unmet health needs to assess ACEs as risk markers for broader structural adversity. Methods: We conducted a nationally representative analysis of 5,536 adolescents (weighted N = 20,294,070) aged 13–17 years using the 2019 and 2021 National Health Interview Survey. Outcomes included mental health symptoms, preventive care access, cost and COVID-19-related unmet needs, and health care use. We estimated associations with lifetime exposure to 4 ACEs using marginal effects from multivariable logistic regressions. Results: Millions of adolescents were exposed to parental incarceration (7.8%, N = 1,407,670), neighborhood violence (6.9%, N = 1,567,483), a guardian with serious mental illness (10.3%, N = 2,088,957), and/or a guardian with alcohol or drug problems (11.4%, N = 2,304,953). Overall, 77.7% (N = 15,758,023), 13.2% (N = 2,671,342), and 9.2% (N = 1,864,704) were exposed to 0, 1, and 2+ of these ACEs. In adjusted models, compared with exposure to 0 ACEs, exposure to 1 or 2+ ACEs was positively associated with anxiety and depression symptom frequency, urgent care and emergency department use, trouble paying medical bills, delayed and forgone mental health care due to cost, and delayed and forgone care due to the COVID-19 pandemic. Discussion: Adolescents exposed to ACEs experienced mutually reinforcing disadvantages: a worse mental health symptom burden, yet greater barriers to accessing needed medical and mental health care. ACEs must be reconceptualized as markers of structural—rather than individual—adversity and addressed through structural and policy interventions.
| Original language | English (US) |
|---|---|
| Journal | Journal of Adolescent Health |
| DOIs | |
| State | Accepted/In press - 2025 |
Funding
Dr. Heard-Garris's efforts were supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number K01HL147995. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Conflicts of interest: Dr. Khazanchi reported serving as a strategic advisory board member for the Rise to Health Coalition; serving as a commissioner on The Lancet's Commission on Antiracism and Solidarity; and receiving grant funding from the Joel and Barbara Alpert Endowment for Children of the City, Boston Children's Hospital, and Brigham & Women's Hospital, all outside the submitted work. Dr. Brewster reported receiving grant funding from Boston Children's Hospital and the Joel and Barbara Alpert Endowment for the Children of the City outside the submitted work. Dr. Tolliver reported receiving grant funding from the Joel and Barbara Alpert Endowment for Children of the City outside the submitted work. Dr. Vasan reported receiving grant funding from the Agency for Healthcare Research and Quality outside the submitted work. Dr. Hadland reported receiving grant funding from the National Institute on Drug Abuse (K23DA045084, R01DA057566, K18DA059913) and honoraria for educational initiatives from the American Academy of Pediatrics outside the submitted work. No other relevant conflicts were reported. Dr. Heard-Garris\u2019s efforts were supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number K01HL147995. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Dr. Khazanchi reported serving as a strategic advisory board member for the Rise to Health Coalition; serving as a commissioner on The Lancet\u2019s Commission on Antiracism and Solidarity; and receiving grant funding from the Joel and Barbara Alpert Endowment for Children of the City, Boston Children\u2019s Hospital, and Brigham & Women\u2019s Hospital, all outside the submitted work. Dr. Brewster reported receiving grant funding from Boston Children\u2019s Hospital and the Joel and Barbara Alpert Endowment for the Children of the City outside the submitted work. Dr. Tolliver reported receiving grant funding from the Joel and Barbara Alpert Endowment for Children of the City outside the submitted work. Dr. Vasan reported receiving grant funding from the Agency for Healthcare Research and Quality outside the submitted work. Dr. Hadland reported receiving grant funding from the National Institute on Drug Abuse (K23DA045084, R01DA057566, K18DA059913) and honoraria for educational initiatives from the American Academy of Pediatrics outside the submitted work. No other relevant conflicts were reported.
Keywords
- Access to care
- Adverse childhood experiences (ACEs)
- Coronavirus disease 2019 (COVID-19)
- Health care utilization
- Mental health
- Neighborhood violence
- Parental incarceration
ASJC Scopus subject areas
- Pediatrics, Perinatology, and Child Health
- Public Health, Environmental and Occupational Health
- Psychiatry and Mental health
