Early childhood adversity associated with high-intensity public service use

Experiences of early childhood adversity are common, with 1 in 6 children having high levels of adversity in their childhood.¹ These exposures have detrimental effects on children’s health and developmental trajectories and are associated with poor physical and mental health outcomes across the life course.² Individuals exposed to high levels of childhood adversity might require increased support and services. Research exploring health service use among individuals exposed to childhood adversity has been fragmented. Understanding how exposure to childhood adversity can affect future service use across different domains and sectors is crucial.

In The Lancet Public Health, a study by Bertina Kreshpaj and colleagues³ takes a comprehensive, life-course approach, examining the effects of early childhood adversity on the high use of services across the health, social welfare, and justice sectors. Using the DANLIFE cohort from Denmark, with longitudinal data on more than 500 000 individuals from birth to age 40 years, the authors found that individuals who experienced high childhood adversity were far more likely to require a higher number of hospital visits, weeks of social welfare, or to be convicted of a crime. The authors provide a clear and persuasive picture of the challenging and costly trajectory associated with high levels of childhood adversity. At a time when many high-income countries are facing mental health, addiction, and homelessness crises, these findings point to the need to address poverty, family separation, mental illness, and substance misuse, which undermines healthy child development.

Previous research has shown that exposure to early adversity is associated with increased resource demands,⁴ and ultimately costs,⁵ if left unaddressed. Costs related to adverse childhood experiences exceed US$500 billion annually in Europe and North America.⁵ A reduction of 10% in the prevalence of early adversity would result in savings of $105 billion.⁵ The findings from Kreshpaj and colleagues’ study³ are clear: reducing early childhood adversity is crucial for mitigating hardship and suffering, and is good for economic policy. Governments around the world need to prioritise policies that strengthen economic support for families, promote social norms that protect against violence, provide early intervention services for children and families in need, and enhance integrated services in the community and in schools that address multiple domains of adversity, such as poverty, substance misuse, and mental health challenges.^6,7

Within their analyses, Kreshpaj and colleagues identified 3·6% of individuals (20 396 children) who experienced high levels of material deprivation, family loss, and other familial challenges (ie, parental mental illness, substance abuse, and being placed in foster care). These children were significantly more likely to become high-intensity users of the justice system (adjusted odds ratio 3·62 [95% CI 3·50–3·75]), health-care system (2·81 [2·71–2·93]), and social welfare system (8·88 [8·50–9·27]) than their low adversity counterparts. Findings from this study indicate that childhood adversities cluster together and that there are thus striking disparities between the experiences of children who have adverse exposures in childhood and those who do not. In line with theories of “cumulative risk and cumulative outcome”,⁸ the children exposed to the most adversity ultimately fared the worst regarding high public service use. This is the reality for children in foster care, where longstanding adverse experiences combined with living in the foster system create further accumulation of adversity and eventual severe outcomes.⁹ It is important to note that Denmark is a country with a robust social safety net and universal health care; thus, these findings might be exacerbated in other sociopolitical contexts.

When considering the sociodemographic characteristics of individuals who might be most at risk for being high-intensity service users, findings from this study show that low education and younger maternal age were risk factors. Given that this study only captures Danish-born individuals, only 1–2% of the sample were characterised as “non-Western”. Therefore, this study is limited in the insights it can provide regarding other dimensions of marginalisation and discrimination, such as race, Indigeneity, migrant status, sexual diversity, or gender diversity.

A crucial future direction is establishing targeted policies and approaches that reduce childhood adversity, particularly among children who are exposed to cumulative adversity. Early integrated intervention programmes that can provide wrap-around support to families facing poverty and other family challenges might be the most effective in mitigating risk and promoting more optimal life-course trajectories for children. The current study provides a clarion call to governments and policy makers worldwide to prevent and address exposure to adversity in childhood.