PC2047: Additional Adverse Childhood Experiences (ACEs) in a Cohort of Children Experiencing Homelessness Are Associated with Greater Odds of Psychiatric and Medical Illnesses

Background: Children and adolescents experiencing homelessness have high rates of adverse childhood events (ACEs) and poor health. This study characterizes a large cohort of children experiencing homelessness and investigates patient demographics, psychiatric diagnoses, and utilization of emergency department (ED) resources depending on the presence of additional ACEs.

Methods: Patients under the age of 18 who presented to the ED of the Cleveland Clinic from January 2014 to July 2019 were included. Homelessness was determined by address field or ICD-10 code for homelessness (Z59.0). Demographics and ED visits were extracted from the electronic health record. Past medical history, ACEs, chief complaint (CC), length of stay (LOS), imaging, and labs were extracted by chart review. ACEs collected included runaway or previous foster, neglect, physical abuse, sexual abuse, emotional abuse, unspecified child maltreatment, absence of relatives, and interparental violence. T-tests, chi square tests, and Fisher’s exact tests were completed for each sub-analysis.

Results: This retrospective cohort study identified 1001 children experiencing homelessness and 3478 unique ED visits. 360 (36%) patients had experienced at least one ACE in addition to homelessness. The cohort was almost equally male to female (n=513, 51.2% male). The mean age was 5.9 vs 8.0 years for patients with no additional ACEs versus patients with at least one additional ACE, respectively (p < 0.001).

Children experiencing homelessness with at least one additional ACE had higher odds of the following medical and psychiatric disorders: depression (OR=5.2, 95% CI=3.4-7.9), anxiety (OR=3.4, 2.1-5.5), behavioral disorder (OR=7.2, 5.1-10.4), psychoses (OR=6.0, 1.9-18.4), bipolar disorder (OR=19.8, 4.6-84.9), suicidal ideation (OR=8.0, 4.8-13.4), post-traumatic stress disorder (OR=10.1, 5.4-18.6), attention deficit hyperactive disorder (OR=4.1, 3.0-5.7), alcohol use disorder (OR=3.6, 0.3-39.6), asthma (OR=1.4, 1.0-2.0), diabetes (OR=2.2, 0.7-7.1), and a sexually transmitted infection (OR=5.1, 1.8-14.4). Patients with additional ACEs were also more likely to have a prior psychiatric admission (p < 0.001).

The mean LOS in the ED was 137.2 vs 198.9 minutes for patients with no additional ACEs versus patient with an additional ACE, respectively (p < 0.001). 22.5% of visits by patients with additional ACEs resulted in hospital admission compared to 2.8% of visits by patients without additional ACEs (p < 0.001). A higher proportion of children experiencing homelessness with at least one additional ACE presented with a psychiatric CC (p < 0.001). Bloodwork and urine screening were done at a higher rate for patients with additional ACEs (p < 0.001) although this difference was not observed for imaging (p=0.720).

Conclusion: Children experiencing homelessness with exposure to additional ACEs are more likely to have serious medical and psychiatric diagnoses compared to other homeless children. Patients with more ACEs also have longer LOS in the ED, have higher rates of blood and urine testing, and are more likely to be admitted to the hospital.