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Published in final edited form as: Matern Child Health J. 2023 Dec 23;28(1):5–10. doi: 10.1007/s10995-023-03864-5

Adverse Childhood Experiences and Developmental Delay in Young US Children

Carleigh Nivens c, Eleanor Bimla Schwarz b, Rosa Rodriguez c, Adrienne Hoyt-Austin a,b
PMCID: PMC10922342  NIHMSID: NIHMS1954051  PMID: 38142261

Abstract

Introduction

Adverse childhood experiences (ACEs) are common and have been associated with poor developmental outcomes. We aimed to investigate the relationship between early ACE exposure, subsequent diagnosis of developmental delay, and receipt of developmental delay services by young children. In addition, we aimed to assess the impact of health-promoting behaviors such as breastfeeding and daily reading on these relationships.

Methods

In this cross-sectional analysis of nationally-representative data from the 2017–2018 National Survey of Children’s Health, we examined the relationship between ACEs, prior breastfeeding, daily reading, and developmental delay diagnosis among 7,837 children aged 3-5 years, using multivariate logistic regression to adjust for family, personal, and sociodemographic characteristics.

Results

We found a dose-dependent relationship between ACEs and developmental delay diagnosis; compared to those without ACEs, developmental delay was more common among those with either one ACE (aOR= 2.03, 95% CI 1.17-3.52) or two or more ACEs (aOR= 2.34, 95% CI 1.25-4.37). Neither breastfeeding (exclusively breastfed for 6 months vs never breastfed aOR=0.70, 95% CI 0.33-1.46) nor daily reading (no reading versus daily reading aOR=1.15, CI 0.57-2.33) were associated with incidence of developmental delay among study participants. There was no significant difference in receipt of services intended to meet developmental needs between children with and without ACEs.

Discussion

Children with very early ACE exposure are at increased risk for diagnosis of developmental delay. Early screening for ACEs and developmental delay may mitigate the early developmental manifestations of ACE exposure in vulnerable children.

Keywords: Adverse Childhood Experiences (ACEs), developmental delay, breastfeeding, reading, young children

Introduction

Adverse childhood experiences (ACEs) are maladaptive ongoing experiences that can result in toxic stress, affect an estimated 42% of United States (US) children, and are associated with a range of negative health conditions (Bright et al., 2016; Oh et al., 2018). ACEs exposure before five years of age is less well-described, although ACEs have been associated with developmental delay in this age group (Cprek et al., 2020). Recently, the American Academy of Pediatrics (AAP) has advocated for an integrated approach to mitigate the effects of toxic stress in childhood (Garner & Yogman, 2021). The guideline advises that having engaged and responsive caregivers, high quality education, developmentally appropriate play with peers, and shared book reading can improve outcomes when children experience ACEs. It also recommends breastfeeding as a specific biological protector against the negative impact of toxic stress because exclusive breastfeeding is associated with decreased DNA methylation of the glucocorticoid receptor in infants (Lester et al., 2018).

As pediatric primary care providers give anticipatory guidance on breastfeeding (Meek & Noble, 2022) and shared reading (High et al., 2014), we were interested in examining how these behaviors may ameliorate an association between ACEs and developmental delay. Reading to children (Weisleder et al., 2018) and breastfeeding (Belfort et al., 2013) is beneficial for early cognitive development; yet, little is known about how these protective behaviors interact with ACEs and diagnosis of developmental delay. Few studies characterize receipt of developmental services in children with ACEs (Berg et al., 2018; Finkelhor et al., 2021), and those that have suggest limited and delayed access to services for this group. In this study, we examined the relationship between ACEs in young children (ages 3-5 years), diagnosis of developmental delay, and receipt of developmental services. Additionally, we investigated how breastfeeding and daily reading impact the association between ACEs and developmental delay. We hypothesized that young children who experienced ACEs would have greater incidence of diagnosis of developmental delay and reduced access to services. We also hypothesized that those exposed to the protective behaviors of breastfeeding and shared reading would have reduced risk of diagnosis of developmental delay.

Methods

We conducted a secondary analysis of nationally representative data from the 2017-2018 National Survey of Children’s Health (NSCH) (Child and Adolescent Health Measurement Initiative, 2019). The NSCH is administered by the US Census Bureau online and by mail; randomly selected non-institutionalized households across the US are mailed invitations to fill out the survey. Respondents initially answer a screener with the age and sex of all children in the household. One child is then randomly selected to be the subject of the full questionnaire. Of the 52,129 children ages 0 to 17 surveyed in the NSCH from 2017-2018, we limited the analysis to respondents with all data for ACEs exposure. Further analysis was limited by age group: (1) diagnosis of developmental delay (survey limited to children ages three and above); and (2) breastfeeding history and shared reading behaviors (survey limited to children ages five and under). This reduced the sample to 7,718 children ages 3 to 5 years old. Imputation methods were not utilized as < 10% of data was missing from other variables of interest (Langkamp et al., 2010). As survey data is publicly available, this analysis was exempt from IRB review.

We estimated developmental delay from responses to the following: “Has a doctor, other health care provider, or educator ever told you that this child has developmental delay?” We estimated receipt of services using responses to the following: “Has this child ever received special services to meet his or her developmental needs, such as speech, occupational, or behavioral therapy?” Respondents were asked about eight ACEs (Figure) that have validity when reported on by caregivers / parents (Health Resources & Services Administration, 2020) as they do not ask about child abuse or neglect. Responses were dichotomous and limited to “yes” and “no” and were grouped into 0, 1, and 2 or more ACEs (Health Resources & Services Administration, 2020).

Figure:

Figure:

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Adverse Childhood Experiences Surveyed in the National Survey of Children’s Health, 2017-2018

We estimated exposure to reading at home through responses to the following: “During the past week, how many days did you or other family members read to this child?” Responses were “0 days,” “1-3 days,” “4-6 days,” and “every day.” Breastfeeding history, including exclusive breastfeeding for the first 6 months of life as recommended (Meek & Noble, 2022), was estimated using the following: “Was this child ever breastfed or fed breastmilk?” Responses were dichotomous “yes” and “no.” The NSCH prompted those answering “yes” to this question to write in their answers to: “How old was this child when he or she was first fed formula?” and “How old was this child when he or she was first fed anything other than breastmilk or formula?” We used the responses to group breastfeeding into three exposure groups: “ever breastfed,” “never breastfed,” and “breastfed exclusively for 6 months.”

Multivariable logistic regression was used to estimate the relationship between ACEs, developmental delay, and receipt of developmental support services. We controlled for variables known to interact with ACEs exposure (Giano et al., 2020), breastfeeding (Meek & Noble, 2022), and developmental delay (Chen et al., 2022; Gallegos et al., 2021; Oh et al., 2018); such as race, ethnicity, family income, and caregiver education level, household reading, breastfeeding, preterm birth, and birthweight. We conducted all analyses using SAS software, Version 9.4 (SAS Software, 2017).

Results

Among US children aged 3-5 years, 18% experienced at least one ACE, 10.8% had two or more ACEs, and 5.6% had a diagnosis of developmental delay (see Table). Children exposed to ACEs were more likely to have diagnosis of developmental delay when compared with the non-ACEs group. Exposure to one ACE increased the risk of developmental delay diagnosis two-fold (cOR=1.58, 95% CI 1.06-2.35; aOR= 2.03, 95% CI 1.17-3.52). Two or more ACEs increased the risk of developmental delay diagnosis even further (cOR= 3.26, 95% CI 2.07-5.14; aOR= 2.34, 95% CI 1.25-4.37).

Table:

Diagnosis of developmental delay and receipt of services, by adverse childhood experience (ACEs) and demographic characteristics of children 3-5 years old, National Survey of Children’s Health 2017-2018 (N = 7,718)

All Participants Diagnosis of Developmental Delay Receipt of Services
Exposure/Characteristic N (%) % Crude OR1 (95% CI) Adjusted2 OR (95% CI) % Crude OR (95% CI) Adjusted OR (95% CI)
Race & ethnicity
 Hispanic 877 (11.4) 7.8 0.97 (0.62-1.51) 0.92 (0.50-1.71) 10.8 0.88 (0.58-1.33) 1.34 (0.70-2.56)
 Non-Hispanic white 5290 (68.5) 5.0 1.00 [ref] 1.00 [ref] 8.2 1.00 [ref] 1.00 [ref]
 Non-Hispanic Black 460 (6.0) 8.9 2.12 (1.27-3.55) 1.27 (0.64-2.51) 10.7 0.56 (0.35-0.90) 1.16 (0.61-2.19)
 Non-Hispanic Asian 383 (5.0) 4.2 0.45 (0.22-0.92) 0.90 (0.37-2.16) 5.5 1.96 (1.04-3.68) 0.64 (0.31-1.33)
 Multi-racial 708 (9.2) 5.8 0.84 (0.53-1.34) 0.72 (0.38-1.38) 9.5 1.04 (0.72-1.52) 0.99 (0.62-1.58)
Birthweight
 Normal birthweight 6865 (88.9) 4.9 1.00 [ref] 1.00 [ref] 8.1 1.00 [ref] 1.00 [ref]
 Low birthweight 519 (6.7) 9.4 1.93 (1.15-3.25) 1.48 (0.67-3.28) 11.8 0.82 (0.52-1.31) 0.82 (0.44-1.55)
 Very low birthweight 83 (1.1) 27.7 6.63 (2.89-15.22) 2.52 (1.24-5.10) 25.3 0.26 (0.12-0.62) 1.70 (0.86-3.36)
Prematurity
 Full-term birth 6891 (89.3) 4.8 1.00 [ref] 1.00 [ref] 8.2 1.00 [ref] 1.00 [ref]
 Premature birth 767 (9.9) 12.1 2.76 (1.79-4.25) 2.72 (1.52-4.88) 13.0 0.63 (0.41-0.95) 0.73 (0.44-1.22)
Breastfeeding history
 Never breastfed 1372 (17.8) 7.6 1.00 [ref] 1.00 [ref] 11.1 1.00 [ref] 1.00 [ref]
 Ever breastfed 5586 (72.4) 5.0 0.65 (0.43-0.97) 0.76 (0.46-1.24) 8.0 0.72 (0.50-1.04) 0.82 (0.51-1.34)
 Exclusively breastfed 6 months 682 (8.8) 5.9 0.79 (0.40-1.54) 0.70 (0.33-1.46) 8.7 0.99 (0.57-1.74) 1.10 (0.56-2.16)
Household income
 0-99% FPL 942 (12.2) 8.2 1.48 (0.89-2.47) 0.42 (0.20-0.88) 11.1 0.69 (0.44-1.08) 1.78 (0.75-4.24)
 100-199% FPL 1263 (16.4) 7.4 1.26 (0.77-2.08) 0.65 (0.33-1.29) 10.2 0.85 (0.57-1.26) 1.12 (0.62-2.0)
 200-399% FPL 2442 (31.6) 5.3 1.07 (0.70-1.63) 0.68 (0.37-1.27) 8.9 0.89 (0.65-1.23) 1.13 (0.71-1.82)
 400% FPL or above 3071 (39.8) 4.4 1.00 [ref] 1.00 [ref] 6.9 1.00 [ref] 1.00 [ref]
ACE exposure
 0 ACEs 5493 (71.2) 4.2 1.00 [ref] 1.00 [ref] 7.2 1.00 [ref] 1.00 [ref]
 1 ACE 1393 (18.0) 7.4 1.58 (1.06-2.35) 2.03 (1.17-3.52) 10.0 1.18 (0.78-1.77) 0.79 (0.44-1.4)
 2 or more ACEs 832 (10.8) 12.2 3.26 (2.07-5.14) 2.34 (1.25-4.37) 15.7 2.56 (1.73-3.80) 1.54 (0.91-2.62)
Reading at home
 Read to daily 3415 (44.2) 5.2 1.00 [ref] 1.00 [ref] 8.1 1.00 [ref] 1.00 [ref]
 Read to 4-6 days/week 1803 (23.4) 4.8 0.80 (0.52-1.25) 0.57 (0.32-1.0) 8.3 0.91 (0.64-1.29) 1.52 (0.97-2.37)
 Read to 1-3 days/week 2255 (29.2) 6.7 0.98 (0.66-1.45) 0.91 (0.54-1.55) 9.7 0.92 (0.65-1.30) 1.25 (0.76-2.07)
 Read to 0 days/week 223 (2.9) 7.6 1.47 (0.62-3.51) 1.15 (0.57-2.33) 8.5 0.75 (0.34-1.66) 0.83 (0.45-1.51)
Parental education level
 College or graduate degree 4932 (63.9) 4.7 1.00 [ref] 1.00 [ref] 7.8 1.00 [ref] 1.00 [ref]
 Some college or technical school 1760 (22.8) 6.6 1.16 (0.80-1.69) 1.58 (0.89-2.83) 9.2 1.06 (0.77-1.45) 0.59 (0.30-1.15)
 High school or GED 909 (11.8) 8.0 1.49 (0.93-2.41) 1.82 (0.89-3.70) 11.2 0.88 (0.57-1.35) 0.48 (0.21-1.08)
 Less than high school 117 (1.5) 8.5 1.11 (0.48-2.56) 1.07 (0.34-3.35) 12.8 1.06 (0.51-2.21) 0.47 (0.12-1.8)
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1

OR: odds ratio

2

Adjusted for: prematurity of birth, birthweight, race/ethnicity, income, parental education, breastfeeding history, reading at home

Any breastfeeding was associated with a 35% risk reduction in diagnosis of developmental delay (cOR 0.65, 95% CI 0.43-0.97), but after adjusting for other variables this association was not significant (aOR=0.76, 95% CI 0.46-1.24). We did not find an association among exclusive breastfeeding for 6 months (cOR=0.79, 95% CI 0.40-1.54; aOR=0.70, 95% CI 0.33-1.46) nor being read to daily (cOR=1.47, 95% CI 0.62-3.51; aOR=1.15, CI 0.57-2.33) as protective against developmental delay in young children with ACEs. There was no significant difference in receipt of developmental support services between children with and without ACEs (see Table).

Discussion

In this nationally representative sample of US children, we found that young children who had experienced ACEs were at increased risk for diagnosis of developmental delay, regardless of exposure to protective behaviors like breastfeeding and daily reading. Our results also demonstrate that young children with ACEs were no less likely to receive developmental services than those without ACEs. This might mean that the detrimental experience of toxic stress has significant impact on developmental outcomes before children begin school, pointing to a need for comprehensive developmental screening and referral for young children who experience ACEs. This work contributes to a limited body of evidence that poor developmental outcomes are associated with ACE exposure in young children (Cprek et al., 2020; Enlow et al., 2012; Yamaoka & Bard, 2019).

Our study results conflict with prior research in important ways. First, we did not find any protective effect of exclusive breastfeeding on diagnosis of developmental delay among young children with exposure to ACEs. It is possible that the low rates of exclusive breastfeeding in this study population, only 8.8% at 6 months compared to US national rates of 24.9% the same year of the study (Breastfeeding Report Card United States, 2020), could have underestimated the impact that exclusive breastfeeding has in young children exposed to ACEs. This differs from prior work by Belfort and colleagues where they found that exclusive breastfeeding through 6 months was associated with higher vocabulary and intelligence scores at 3 and 7 years of age (Belfort et al., 2013). Second, in this study, where almost half of young children were read to daily, we did not find a protective association among daily reading and diagnosis of developmental delay in young children exposed to ACEs. In previous randomized trials investigating the impact of shared reading on developmental outcomes, participants were given books along with training sessions about the importance of reading aloud (Mendelsohn et al., 2018; Weisleder et al., 2018). It is possible that the parental training component is of greater importance in young children exposed to ACEs. Third, we found that young children with ACEs are no less likely to receive services for developmental delay than those without ACEs. This is in contrast to previous work describing an association among ACEs, delay of diagnosis, and connection to developmental services (Berg et al., 2018; Finkelhor et al., 2021). Further research is needed to characterize access to developmental services among young children at high risk for developmental delay, with special consideration to changes in healthcare availability and utilization related to the COVID-19 pandemic.

Limitations

This study’s cross-sectional design precludes causal inference. Additional limitations are that ACEs exposure is self-reported by family members, who may not be aware of all exposures and who may be impacted by social desirability bias. In addition, the NSCH does not ask about all possible ACEs nor all possible protective factors against ACEs exposure at the individual, family, and community level, which could have impacted the results of this analysis. Lastly, other medical conditions impacting cognitive development were not considered in this analysis.

Conclusions

Experiencing ACEs in young childhood is associated with poor developmental outcomes and developmental surveillance and screening tools do not universally include ACEs as risk factors for developmental delay. Screening for ACEs provides information and connection to resources that can help providers and patients understand how their lived experiences impact medical outcomes. This work contributes to the emerging body of literature that ACEs can negatively impact developmental outcomes before children begin school. However, best practices in surveilling young children with ACEs for developmental delay is not known. Regardless, it will remain important for primary care providers to screen young children for both developmental delay and ACEs and connect these vulnerable children to appropriate developmental services.

Significance:

As poor developmental outcomes are related to ACEs, children aged 3-5 years should be routinely screened for ACE exposure. Although breastfeeding and daily reading have multiple benefits to children, they do not adequately mitigate the developmental delays associated with ACE exposure.

Funding:

Dr. Nivens was supported by a research grant from UC Davis School of Medicine. Dr. Hoyt-Austin was supported by the National institute of Health, Building Interdisciplinary Research Careers in Women’s Health at UC Davis through Grant Number: 5K12HD051958. This work was also supported by the National Center for Advancing Translational Sciences within National Institutes of Health [UL1 TR001860] and the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number T32HP19025 for Research in Primary Care for $1,982,060 over 5 years, 0% financed with nongovernmental sources. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, the National Institutes of Health, or the U.S. Government.

Footnotes

Conflicts of interest: The authors have no conflicts of interests to disclose.

Ethics approval: Not applicable.

Consent to participate: Not applicable.

Consent for publication: Not applicable.

Code availability: SAS software, Version 9.4

Availability of data and material:

National Survey of Children’s Health publicly available data set

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

National Survey of Children’s Health publicly available data set

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