Association Between Adverse Childhood Experiences at Age 5 Years and Healthcare Utilization at Age 9 Years.

OBJECTIVE: To determine associations between adverse childhood experiences (ACEs) at age 5 years and healthcare utilization patterns at age 9 years. STUDY DESIGN: We conducted a secondary analysis using longitudinal data from the Fragile Families and Child Wellbeing Study. Caregivers (n = 2521) provided data on their child's ACEs at age 5 years and on 4 types of healthcare utilization at age 9 years: past-year well visits, dental visits, primary care sick visits for injury or illness, and emergency room (ER) visits. Logistic regression analysis was used to examine the association between ACEs at age 5 and each type of healthcare utilization, adjusting for relevant sociodemographic covariates. RESULTS: Among the 2521 children (51% male, 48% Non-Hispanic Black), 77% had ≥1 ACE at age 5. Children with ≥4 ACEs had lower odds of a dental visit (aOR, 0.51; 95% CI, 0.29-0.91) and higher odds of a primary care sick visit (aOR, 1.77; 95% CI, 1.20-2.64) and an ER visit (aOR, 1.70; 95% CI, 1.11-2.59) compared with children with no reported ACEs. CONCLUSION: Our findings demonstrate suboptimal healthcare utilization patterns among families with ACEs and indicate a need for targeted interventions that support appropriate healthcare utilization for children who endure adversity.

Parents' Self-efficacy for Tobacco Exposure Protection and Smoking Abstinence Mediate Treatment Effects on Child Cotinine at 12-Month Follow-up: Mediation Results from the Kids Safe and Smokefree Trial.

INTRODUCTION: Compared with the general smoking population, low-income smokers face elevated challenges to success in evidence-based smoking cessation treatment. Moreover, their children bear increased disease burden. Understanding behavioral mechanisms related to successful reduction of child tobacco smoke exposure (TSE) could inform future smoking interventions in vulnerable, underserved populations. METHODS: Smoking parents were recruited from pediatric clinics in low-income communities and randomized into a multilevel intervention including a pediatric clinic intervention framed in best clinical practice guidelines ("Ask, Advise, Refer" [AAR]) plus individualized telephone counseling (AAR + counseling), or AAR + control. Mediation analysis included treatment condition (independent variable), 12-month child cotinine (TSE biomarker, criterion), and four mediators: 3-month end-of-treatment self-efficacy to protect children from TSE and smoking urge coping skills, and 12-month perceived program (intra-treatment) support and bioverified smoking abstinence. Analyses controlled for baseline nicotine dependence, depressive symptoms, child age, and presence of other residential smokers. RESULTS: Participants (n = 327) included 83% women and 83% African Americans. Multilevel AAR + counseling was associated with significantly higher levels of all four mediators (ps < .05). Baseline nicotine dependence (p < .05), 3-month self-efficacy (p < .05) and 12-month bioverified smoking abstinence (p < .001) related significantly to 12-month child cotinine outcome. The indirect effects of AAR + counseling intervention on cotinine via self-efficacy for child TSE protection and smoking abstinence (ps < .05) suggested mediation through these pathways. CONCLUSIONS: Compared with AAR + control, multilevel AAR + counseling improved all putative mediators. Findings suggest that fostering TSE protection self-efficacy during intervention and encouraging parental smoking abstinence may be key to promoting long-term child TSE-reduction in populations of smokers with elevated challenges to quitting smoking. IMPLICATIONS: Pediatric harm reduction interventions to protect children of smokers from tobacco smoke have emerged to address tobacco-related health disparities in underserved populations. Low-income smokers experience greater tobacco-related disease burden and more difficulty with smoking behavior change in standard evidence-based interventions than the general population of smokers. Therefore, improving knowledge about putative behavioral mechanisms of smoking behavior change that results in lower child exposure risk could inform future intervention improvements.