Adverse childhood experiences or adverse childhood socioeconomic conditions?

If a child lives with an adult who has a mental health disorder or an alcohol-related illness, how does that affect the risk of emergency hospital admission for that child? In The Lancet Public Health, Shantini Paranjothy and colleagues1 use the excellent record linkage system established in Wales to address this question, showing that these exposures independently increase the risk of childhood admission due to all causes, external causes and injury, and victimisation. A great strength of this study is the use of population data linkage across all children in Wales, with a research platform that is helping to address fundamental questions in child health. The study’s findings, however, illustrate wider issues in the debate about policy implications of so-called adverse childhood experiences, which are worthy of closer examination. The authors frame their analysis in the context of the adverse childhood experiences agenda, suggesting that children living in families with mental disorders and alcohol misuse should be identified and appropriately supported, but is this interpretation of the data the most appropriate for policy?

Although it is clear from the study of Paranjothy and colleagues that family alcohol misuse and mental health problems are associated with worse outcomes for children in those families, the question remains as to the most appropriate public health response.2 There is interest in identifying populations of children at risk of poor health outcomes to inform resource allocation and service planning,3 and there are moves to screen children for adverse childhood experiences so that they can be referred to services in the hope that outcomes can be improved.2 But if the purpose of the exercise is to identify children at risk of poor outcomes who might benefit from intervention, the study’s findings suggest that childhood socioeconomic conditions and factors such as maternal smoking in pregnancy might be more useful as predictors.

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