Adverse Childhood Experiences and Unmet Health Care Needs due to Cost and the COVID-19 Pandemic: A Nationally Representative Analysis of U.S. Adolescents

J Adolesc Health. 2025 Apr 3:S1054-139X(25)00064-3. doi: 10.1016/j.jadohealth.2025.02.001. Online ahead of print.

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.

PMID:40183723 | DOI:10.1016/j.jadohealth.2025.02.001