Income Inequality and the Differential Effect of Adverse Childhood Experiences in US Children

Neal Halfon, Kandyce Larson, John Son, Michael Lu, Christina Bethell

Research output: Contribution to journalComment/debatepeer-review

47 Scopus citations


Objective Adverse childhood experiences (ACEs) can affect health and development across the life course. Despite a general understanding that adversity is associated with lower income, we know less about how ACEs manifest at different income levels and how these income-related patterns affect children's health and development. Methods Data from the 2011 to 2012 National Survey of Children's Health were used to examine the prevalence of 9 ACEs in US children, across 4 levels of household income, and in relationship to 5 parent-reported measures of child health. Bivariate analyses and multivariable logistic regression models were used to examine the associations between number of ACEs and children's health outcomes on the basis of the 4 income groups. Results When partitioned according to income strata, the proportion of children who experienced ACEs showed a steep income gradient, particularly for children who experienced ≥4 ACEs. The linear gradient across income groups was less pronounced for each specific ACE, with several ACEs (experience of divorce, drug and alcohol exposure, parental mental illness) showing high reported prevalence in all but the highest income group. Multivariate analysis showed a consistent income-related gradient for each of the health outcomes. However, higher income was not necessarily found to be a protective factor against ACEs. Conclusions ACEs are distributed across the income ladder and not just concentrated below the poverty level. This suggests that a more comprehensive policy strategy that includes targeted as well as universal interventions is warranted.

Original languageEnglish (US)
Pages (from-to)S70-S78
JournalAcademic pediatrics
Issue number7
StatePublished - Sep 2017


  • adverse childhood experiences
  • child health
  • childhood trauma
  • income inequality

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health


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