Adverse Childhood Experiences (ACEs) are potentially traumatic events that occur in childhood (0–17 years) that include different forms of abuse, neglect, and other household challenges, such as witnessing violence or living with someone with mental illness.¹ These experiences are associated with increased rates of various mental health conditions, including depression, anxiety and substance use disorders, in both childhood and adulthood.^2,3 Previous work suggests that access to mental health care, including therapy, is effective in reducing mental health symptoms among teenagers.⁴ Despite this, about half of teenagers with a mental health disorder have an unmet mental health need in the U.S.⁵

The current evidence base shows that an individual’s history of ACEs is associated with both increased use of mental health services and increased barriers to use of mental health services.^6–9 Children and teenagers with ACEs have an increased odds of mental health service use and use of psychotropic medications,^7,8 and ACEs have been linked with difficulties accessing mental health treatment.⁹ That is, while individuals with ACEs may have greater use of mental health care, they may also experience more obstacles with getting treatment. Additionally, having a high number of cumulative ACEs, or having high distress symptoms have been associated with a lack of receipt of behavioral health services.⁶

Apart from associations between ACEs and mental health care use, there is limited nationally representative data that examines the underlying reasons for unmet mental health care need among teenagers. Qualitative research among teenage populations both inside and outside the U.S. suggest that teenagers may forgo mental health care because they do not want their parents to know, or are unsure how to access services.^10–12 Apart from these reasons, prior works also suggests that systemic barriers, including a lack of available providers and waiting times for appointments may also impact the likelihood of teenagers accessing mental health services.¹³ There is a gap in the literature as to whether these reasons may be related to the associations between ACEs and unmet mental health care. Yet, most of the extant literature examining ACEs and use of mental health care relies on parent report or guardian report on the child’s experience of ACEs, which typically excludes items on abuse or neglect where the parent or guardian is more likely to be the perpetrator (e.g. emotional abuse),^7,8 potentially leading to under-reporting of ACEs. Lower parent-teen concordance on ACEs reporting may also be related to teenagers having experiences outside the home that their parents are unaware of and therefore are unable to report on (e.g. discrimination due to race/ethnicity). Additionally, teenagers may be reluctant to disclose their need or receipt of mental health care services to their parents, leading to possible underreporting on the part of the parents.

To address current gaps in knowledge, this analysis uses a nationally representative sample of teenagers (12– 17 years old) to examine associations between a wide range of ACEs and mental health care use, as well as selected reasons for delaying or not getting mental health care. Thus, this design may help corroborate prior work that relied on parent or guardian reporting of ACEs and expands our understanding about barriers to mental health care.

Table 1 presents weighted descriptive statistics. Teenagers were split approximately evenly by age group (12–14 years: 49.1%; 15–17 years: 50.9%), and sex (male: 51.1%, female: 48.9%). Most teenagers were Non-Hispanic White (50.9%), lived in two-parent families (70.7%), and had private insurance (59.1%) and family incomes that were greater than 200% FPL (65.6%). Less than one-tenth of teenagers reported fair or poor health (8.7%), about a quarter reported depression or anxiety symptoms (25.6%), and just over 1/10 had been diagnosed with ADHD (12.1%).

Among the selected ACEs measured in the current analysis, the percentage of parental divorce or separation was the highest (27.9%), followed by household mental illness (20.3%), racism (17.6%), household substance abuse (15.9%), emotional abuse (15.5%), being a victim of or witnessing violence in the neighborhood (13.2%), parental incarceration (9.7%), death of a parent or guardian (6.8%), and unmet basic needs (6.0%) (Figure 1). Just over 1 in 10 teenagers had four or more selected ACEs (11.5%), while 1 in 5 had 2–3 ACEs (20.2%), 23.7% had 1 ACE, and 44.7% did not have any ACEs (Supplemental Table 1).

In respect to mental health care use, the percentage was highest for receiving therapy for mental health in the past 12 months (18.7%), followed by taking prescription medication (15.2%), and delaying or not getting mental health care due to (1) not knowing where to go (12.2%), (2) stigma (11.4%), or (3) cost (5.3%) (Figure 2).

Table 2 presents associations between each ACE and receipt of therapy or prescription medication for mental health. In unadjusted models, each ACE was related to a higher prevalence of taking prescription medication for mental health in the past 12 months. Following adjustment for covariates, four or more ACEs (APR: 1.43, 95% CI: 1.02–2.01), being a victim of or witnessing violence in the neighborhood (APR: 1.41, 95% CI: 1.06–1.88), experiencing emotional abuse (APR: 1.50, 95% CI: 1.12–2.02), and experiencing racism (APR: 1.46, 95% CI: 1.10–1.94) were related to a higher prevalence of taking prescription medication for mental health in the past 12 months. Each ACE was also related to a higher prevalence of receiving therapy for mental health in the past 12 months in unadjusted models. In adjusted models, four or more ACEs (APR: 2.24, 95% CI: 1.64–3.05), being a victim of or witnessing violence in the neighborhood (APR: 1.62, 95% CI: 1.20–2.19), parental incarceration (APR: 2.08, 95% CI: 1.52–2.85), household mental illness (APR: 1.97, 95% CI: 1.50–2.58), household substance use (APR: 1.53, 95% CI: 1.15–2.03), death of a parent or guardian (APR: 1.79, 95 % CI: 1.21–2.66), parental divorce or separation (APR: 1.44, 95% CI: 1.04–1.99), and experiencing emotional abuse (APR: 1.93, 95 % CI: 1.48–2.52) were related to a higher prevalence of receiving therapy for mental health in the past 12 months.

Multivariable logistic regression models examining associations between ACEs and reasons for unmet mental health care are presented in Table 3. In unadjusted models, each ACE, except for experiencing the death of a parent or guardian, was related to a higher prevalence of unmet mental health care due to cost. Following adjustment for covariates, four or more ACEs (APR: 2.46, 95 % CI: 1.59–3.83), household mental illness (APR: 2.56, 95% CI: 1.60–4.09), household substance use (APR: 1.74, 95% CI: 1.12–2.69), experiencing emotional abuse (APR: 2.50, 95% CI: 1.66–3.78), experiencing unmet basic needs (APR: 1.98, 95% CI: 1.14–3.45), and experiencing racism (APR: 2.58, 95% CI: 1.64–4.05) were related to higher prevalence of unmet mental health care due to cost.

Unadjusted for covariates, four or more ACEs (PR: 2.41, 95% CI: 1.61–3.59), being a victim of or witnessing violence in the neighborhood (PR: 2.07, 95% CI: 1.42–3.00), household mental illness (PR: 3.04, 95% CI: 2.17–4.27), household substance use (PR: 2.36, 95% CI: 1.64–3.38), experiencing emotional abuse (PR: 3.91, 95% CI: 2.82–5.41), and experiencing racism (PR: 1.95, 95% CI: 1.32–2.87) were related to higher prevalence of unmet mental health care need due to stigma. After adjustment for covariates, only household mental illness (APR: 1.57, 95% CI: 1.06–2.32), household substance use (APR: 1.60, 95% CI: 1.05–2.45), and experiencing emotional abuse (APR: 2.14, 95% CI: 1.47–3.10) were still related.

In unadjusted models, four or more ACEs (PR: 3.39, 95% CI: 2.42–4.74), being a victim of or witnessing violence in the neighborhood (PR: 2.39, 95% CI: 1.67–3.44), household mental illness (PR: 4.20, 95% CI: 3.11–5.67), household substance use (PR: 2.91, 95% CI: 2.10–4.05), parental divorce or separation (PR: 1.86, 95% CI: 1.34–2.58), experiencing emotional abuse (PR: 3.83, 95% CI: 2.80–5.23), experiencing unmet basic needs (PR: 2.35, 95% CI: 1.46–3.77), and experiencing racism (PR: 2.69, 95% CI: 1.91–3.79) were related to higher prevalence of unmet mental health care need due to not knowing where to go. Following adjustment for covariates, four or more ACEs (APR: 1.72, 95% CI: 1.11–2.67), household mental illness (APR: 2.08, 95% CI: 1.47–2.95), household substance (APR: 1.75, 95% CI: 1.20–2.53), parental divorce or separation (APR: 1.60, 95% CI: 1.08–2.37), experiencing emotional abuse (APR: 1.77, 95% CI: 1.25–2.53), and experiencing racism (APR: 1.62, 95% CI: 1.16–2.27) were still related to higher prevalence of unmet mental health care need due to not knowing where to go.

This study provides insights into how selected ACEs impact mental health care utilization by teenagers. Results of this study were broadly consistent with prior work that shows that selected ACEs are associated with higher rates of using mental health services and prescription medications to treat mental health conditions among children and teenagers.^8,28 Prior work suggests that people with mental health conditions are more likely to both need and use mental health services, including those with selected ACEs.^22–23 The present study built upon this literature by presenting associations between ACEs and mental health care use beyond adjustment of multiple measures of potential need for health services, such as the presence of specific mental health symptoms (i.e. anxiety and depression), lifetime ADHD diagnosis, and health status. Therefore, the elevated use of therapy among those with selected ACEs may be explained by other factors like severity or complexity of mental health conditions or number of mental health conditions. Future work may help to understand how ACEs shape mental health symptoms and subsequent outcomes after receiving health care services.

The specific findings of the present study align with prior work that examined prescription medication use among children. For example, prior work using the National Survey of Children’s Health (NSCH) examined the association between ACEs and psychotropic medication use among children and found that most ACEs were not associated with use of medication after accounting for demographic characteristics and need.⁸ These results were similar to the present study, which found that the majority of selected ACEs were not related to taking prescription medication in the past 12 months, following adjustment for covariates.

Prior work had also established that ACEs are associated with forgoing mental health care among children.²⁹ The present study expanded on this by looking at reasons for delaying or forgoing care, revealing that, after adjustment, teenagers with the majority of selected ACEs are more likely to report not receiving services they needed but did not get (i.e. have unmet mental health care needs) due to cost and not knowing where to go for care. These findings align with previous work among adults and children that individuals with ACEs are more likely to be of lower socioeconomic status and lack health literacy, which have been shown to increase barriers to mental health care.^30–33

Findings of multivariate models also highlighted that not all ACEs are associated with mental health care use in the same way. For example, while many measures of household challenges were not associated with taking prescription medication, these same measures were associated with increased use of therapy. Living with someone who suffered from mental illness was significantly associated with most study outcomes after adjustment, and emotional abuse was related with all study outcomes, suggesting that there may be something unique about these experiences in contrast to other ACEs. In general, associations between ACEs and mental health care use may highlight the importance of routine ACEs screenings during clinical visits, which have been found to help providers identify patients in need of mental health care.³⁴

This study benefits from self-reported data collected from a nationally representative sample of teenagers, linked to parent-reported measures of sociodemographic characteristics. Bridging existing gaps in the literature, these analyses present associations between ACEs, mental health care, and selected reasons for forgoing mental health care. However, in respect to limitations, all data are self-reported and may be affected by recall bias or social desirability bias, especially if teenagers perceive that their parents may learn of their responses, despite assurances that study protocol does not allow for it. The NHIS may also underestimate unmet need, as it fails to capture individuals that need care but have not attempted to access it, and only measures unmet need in the past 12 months.

Further, the NHIS measure is not comprehensive of all potential reasons for unmet need, as it does not include systemic barriers to care like transportation or health care access. This additional information may be important for informing interventions focused on improving mental health care use among children with ACEs. Given that the study period (July 2021-December 2023) began during the aftermath of the height of the COVID-19 pandemic, reporting on mental health care use and ACEs may have been affected. Additionally, important ACEs, including physical and sexual abuse, were not fielded as part of NHIS-Teen, and were therefore not included in this analysis. The exclusion of these items may underestimate the composite ACEs score examined. However, it should also be noted that, due to sensitivity concerns, these items have also not been fielded on other national surveys that support existing literature in this area.

The sample size of NHIS-Teen limited our ability to examine sociodemographic differences, which may be important for identifying the most groups that are disproportionately affected. The binary ACEs items also lack information on the severity and timing of events, which may also influence their impact.