Maternal and Child Health Journal (2024) 28:5–10

https://doi.org/10.1007/s10995-023-03864-5

BRIEF REPORT

Adverse Childhood Experiences and Developmental Delay in Young US

Children
Carleigh Nivens1 · Eleanor Bimla Schwarz2 · Rosa Rodriguez3 · Adrienne Hoyt‑Austin3,4

Accepted: 10 December 2023 / Published online: 23 December 2023

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2023

Abstract
Introduction Adverse childhood experiences (ACEs) are common and have been associated with poor developmental out-
comes. We aimed to investigate the relationship between early ACE exposure, subsequent diagnosis of developmental delay,
and receipt of developmental delay services by young children. In addition, we aimed to assess the impact of health-promoting
behaviors such as breastfeeding and daily reading on these relationships.
Methods In this cross-sectional analysis of nationally-representative data from the 2017–2018 National Survey of Children’s
Health, we examined the relationship between ACEs, prior breastfeeding, daily reading, and developmental delay diagnosis
among 7837 children aged 3–5 years, using multivariate logistic regression to adjust for family, personal, and sociodemo-
graphic characteristics.
Results We found a dose-dependent relationship between ACEs and developmental delay diagnosis; compared to those
without ACEs, developmental delay was more common among those with either one ACE (aOR = 2.03, 95% CI 1.17–3.52)
or two or more ACEs (aOR = 2.34, 95% CI 1.25–4.37). Neither breastfeeding (exclusively breastfed for 6 months vs. never
breastfed aOR = 0.70, 95% CI 0.33–1.46) nor daily reading (no reading versus daily reading aOR = 1.15, CI 0.57–2.33) were
associated with incidence of developmental delay among study participants. There was no significant difference in receipt
of services intended to meet developmental needs between children with and without ACEs.
Discussion Children with very early ACE exposure are at increased risk for diagnosis of developmental delay. Early screen-
ing for ACEs and developmental delay may mitigate the early developmental manifestations of ACE exposure in vulnerable
children.

Significance
As poor developmental outcomes are related to ACEs, children aged 3–5 years should be routinely screened for ACE
exposure. Although breastfeeding and daily reading have multiple benefits to children, they do not adequately mitigate the
developmental delays associated with ACE exposure.

Keywords Adverse childhood experiences (ACEs) · developmental delay · breastfeeding · reading · young children

Introduction
* Adrienne Hoyt‑Austin
aehoyt@ucdavis.edu Adverse childhood experiences (ACEs) are maladaptive
1
ongoing experiences that can result in toxic stress, affect
Pediatric Residency Program, University of California San
Francisco Benioff Oakland Children’s Hospital, Oakland,
an estimated 42% of United States (US) children, and
CA, USA are associated with a range of negative health conditions
2
Department of Medicine, University of California at San
(Bright et al., 2016; Oh et al., 2018). ACEs exposure before
Francisco, San Francisco, CA, USA 5 years of age is less well-described, although ACEs have
3
Department of Pediatrics, University of California at Davis,
been associated with developmental delay in this age group
Sacramento, CA, USA (Cprek et al., 2020). Recently, the American Academy of
4
Department of Pediatrics, University of California at Davis,
Pediatrics (AAP) has advocated for an integrated approach
2516 Stockton Blvd Room 202, Sacramento, CA 95817, USA to mitigate the effects of toxic stress in childhood (Garner &

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6 Maternal and Child Health Journal (2024) 28:5–10

Yogman, 2021). The guideline advises that having engaged
and responsive caregivers, high quality education, develop-
mentally appropriate play with peers, and shared book read-
ing can improve outcomes when children experience ACEs.
It also recommends breastfeeding as a specific biological
protector against the negative impact of toxic stress because
exclusive breastfeeding is associated with decreased DNA
methylation of the glucocorticoid receptor in infants (Lester
et al., 2018).
As pediatric primary care providers give anticipatory
guidance on breastfeeding (Meek & Noble, 2022) and
shared reading (High et al., 2014), we were interested in
examining how these behaviors may ameliorate an associa-
tion between ACEs and developmental delay. Reading to
children (Weisleder et al., 2018) and breastfeeding (Belfort
et al., 2013) is beneficial for early cognitive development;
yet, little is known about how these protective behaviors
interact with ACEs and diagnosis of developmental delay.
Few studies characterize receipt of developmental services
in children with ACEs (Berg et al., 2018; Finkelhor et al.,
2021), and those that have suggest limited and delayed
access to services for this group. In this study, we exam-
ined the relationship between ACEs in young children (ages
3–5 years), diagnosis of developmental delay, and receipt
of developmental services. Additionally, we investigated
how breastfeeding and daily reading impact the associa-
tion between ACEs and developmental delay. We hypoth-
esized that young children who experienced ACEs would
have greater incidence of diagnosis of developmental delay
and reduced access to services. We also hypothesized that
those exposed to the protective behaviors of breastfeeding
and shared reading would have reduced risk of diagnosis of
developmental delay.
Methods
We conducted a secondary analysis of nationally repre-
sentative data from the 2017–2018 National Survey of
Children’s Health (NSCH) (Child and Adolescent Health
Measurement Initiative, 2019). The NSCH is administered
by the US Census Bureau online and by mail; randomly
selected non-institutionalized households across the US
are mailed invitations to fill out the survey. Respondents
initially answer a screener with the age and sex of all chil-
dren in the household. One child is then randomly selected
to be the subject of the full questionnaire. Of the 52,129
children ages 0 to 17 surveyed in the NSCH from 2017 to
2018, we limited the analysis to respondents with all data
for ACEs exposure. Further analysis was limited by age
group: (1) diagnosis of developmental delay (survey lim-
ited to children ages three and above); and (2) breastfeed-
ing history and shared reading behaviors (survey limited
to children ages five and under). This reduced the sample
to 7718 children ages 3 to 5 years old. Imputation methods
were not utilized as < 10% of data was missing from other
variables of interest (Langkamp et al., 2010). As survey
data is publicly available, this analysis was exempt from
IRB review.
We estimated developmental delay from responses to
the following: “Has a doctor, other health care provider,
or educator ever told you that this child has developmental
delay?” We estimated receipt of services using responses to
the following: “Has this child ever received special services
to meet his or her developmental needs, such as speech,
occupational, or behavioral therapy?” Respondents were
asked about eight ACEs (Fig. 1) that have validity when
reported on by caregivers/parents (Health Resources & Ser-
vices Administration, 2020) as they do not ask about child
abuse or neglect. Responses were dichotomous and limited
to “yes” and “no” and were grouped into 0, 1, and 2 or more
ACEs (Health Resources & Services Administration, 2020).
We estimated exposure to reading at home through
responses to the following: “During the past week, how
many days did you or other family members read to this
child?” Responses were “0 days,” “1–3 days,” “4–6 days,”
and “every day.” Breastfeeding history, including exclusive
breastfeeding for the first 6 months of life as recommended
(Meek & Noble, 2022), was estimated using the following:
“Was this child ever breastfed or fed breastmilk?” Responses
were dichotomous “yes” and “no.” The NSCH prompted
those answering “yes” to this question to write in their
answers to: “How old was this child when he or she was
first fed formula?” and “How old was this child when he
or she was first fed anything other than breastmilk or for-
mula?” We used the responses to group breastfeeding into

Fig. 1  Adverse childhood expe-

riences surveyed in the National 1. Parent or guardian divorced or separated
Survey of Children’s Health, 2. Parent or guardian served time in jail
2017-2018 3. Parent or guardian died
4. Saw or heard parents or adults slap, hit, kick, or punch one another in the home
5. Victim/witness of neighborhood violence
6. Lived with anyone who was mentally ill, suicidal, or severely depressed
7. Lived with anyone who had a problem with alcohol or drugs
8. Treated or judged unfairly because of his/her race or ethnic group

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Maternal and Child Health Journal (2024) 28:5–10
three exposure groups: “ever breastfed,” “never breastfed,”
and “breastfed exclusively for 6 months.”
Multivariable logistic regression was used to estimate
the relationship between ACEs, developmental delay, and
receipt of developmental support services. We controlled
for variables known to interact with ACEs exposure (Giano
et al., 2020), breastfeeding (Meek & Noble, 2022), and
developmental delay (Chen et al., 2022; Gallegos et al.,
2021; Oh et al., 2018); such as race, ethnicity, family
income, and caregiver education level, household reading,
breastfeeding, preterm birth, and birthweight. We conducted
all analyses using SAS software, Version 9.4 (SAS Software,
2017).
Results
Among US children aged 3–5 years, 18% experienced at
least one ACE, 10.8% had two or more ACEs, and 5.6%
had a diagnosis of developmental delay (see Table 1). Chil-
dren exposed to ACEs were more likely to have diagnosis
of developmental delay when compared with the non-ACEs
group. Exposure to one ACE increased the risk of devel-
opmental delay diagnosis two-fold (cOR = 1.58, 95% CI
1.06–2.35; aOR = 2.03, 95% CI 1.17–3.52). Two or more
ACEs increased the risk of developmental delay diagnosis
even further (cOR = 3.26, 95% CI 2.07–5.14; aOR = 2.34,
95% CI 1.25–4.37).
Any breastfeeding was associated with a 35% risk
reduction in diagnosis of developmental delay (cOR 0.65,
95% CI 0.43–0.97), but after adjusting for other variables
this association was not significant (aOR = 0.76, 95% CI
0.46–1.24). We did not find an association among exclusive
breastfeeding for 6 months (cOR = 0.79, 95% CI 0.40–1.54;
aOR = 0.70, 95% CI 0.33–1.46) nor being read to daily
(cOR = 1.47, 95% CI 0.62–3.51; aOR = 1.15, CI 0.57–2.33)
as protective against developmental delay in young children
with ACEs. There was no significant difference in receipt of
developmental support services between children with and
without ACEs (see Table 1).
Discussion
In this nationally representative sample of US children,
we found that young children who had experienced ACEs
were at increased risk for diagnosis of developmental delay,
regardless of exposure to protective behaviors like breast-
feeding and daily reading. Our results also demonstrate that
young children with ACEs were no less likely to receive
developmental services than those without ACEs. This
might mean that the detrimental experience of toxic stress
has significant impact on developmental outcomes before
7
children begin school, pointing to a need for comprehensive
developmental screening and referral for young children who
experience ACEs. This work contributes to a limited body of
evidence that poor developmental outcomes are associated
with ACE exposure in young children (Cprek et al., 2020;
Enlow et al., 2012; Yamaoka & Bard, 2019).
Our study results conflict with prior research in important
ways. First, we did not find any protective effect of exclusive
breastfeeding on diagnosis of developmental delay among
young children with exposure to ACEs. It is possible that
the low rates of exclusive breastfeeding in this study popula-
tion, only 8.8% at 6 months compared to US national rates
of 24.9% the same year of the study (Breastfeeding Report
Card United States, 2020), could have underestimated the
impact that exclusive breastfeeding has in young children
exposed to ACEs. This differs from prior work by Belfort
and colleagues (2013) where they found that exclusive
breastfeeding through 6 months was associated with higher
vocabulary and intelligence scores at 3 and 7 years of age.
Second, in this study, where almost half of young children
were read to daily, we did not find a protective association
among daily reading and diagnosis of developmental delay
in young children exposed to ACEs. In previous randomized
trials investigating the impact of shared reading on devel-
opmental outcomes, participants were given books along
with training sessions about the importance of reading aloud
(Mendelsohn et al., 2018; Weisleder et al., 2018). It is possi-
ble that the parental training component is of greater impor-
tance in young children exposed to ACEs. Third, we found
that young children with ACEs are no less likely to receive
services for developmental delay than those without ACEs.
This is in contrast to previous work describing an associa-
tion among ACEs, delay of diagnosis, and connection to
developmental services (Berg et al., 2018; Finkelhor et al.,
2021). Further research is needed to characterize access
to developmental services among young children at high
risk for developmental delay, with special consideration to
changes in healthcare availability and utilization related to
the COVID-19 pandemic.
Limitations
This study’s cross-sectional design precludes causal infer-
ence. Additional limitations are that ACEs exposure is self-
reported by family members, who may not be aware of all
exposures and who may be impacted by social desirability
bias. In addition, the NSCH does not ask about all possible
ACEs nor all possible protective factors against ACEs expo-
sure at the individual, family, and community level, which
could have impacted the results of this analysis. Lastly, other
medical conditions impacting cognitive development were
not considered in this analysis.
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8 Maternal and Child Health Journal (2024) 28:5–10

Table 1  Diagnosis of developmental delay and receipt of services, by adverse childhood experience (ACEs) and demographic characteristics of
children 3-5 years old, National Survey of Children’s Health 2017-2018 (N = 7718)
All participants Diagnosis of developmental delay Receipt of services
Exposure/character- N (%) % Crude OR (95% CI) Adjusted OR (95% % Crude OR (95% CI) Adjusted OR (95% CI)
istic CI)

Race & ethnicity

Hispanic 877 (11.4) 7.8 0.97 0.92 10.8 0.88 1.34
(0.62–1.51) (0.50–1.71) (0.58–1.33) (0.70–2.56)
Non-Hispanic white 5290 (68.5) 5.0 1.00 [ref] 1.00 [ref] 8.2 1.00 [ref] 1.00 [ref]
Non-Hispanic Black 460 (6.0) 8.9 2.12 1.27 10.7 0.56 1.16
(1.27–3.55) (0.64–2.51) (0.35–0.90) (0.61–2.19)
Non-Hispanic Asian 383 (5.0) 4.2 0.45 0.90 5.5 1.96 0.64
(0.22–0.92) (0.37–2.16) (1.04–3.68) (0.31–1.33)
Multi-racial 708 (9.2) 5.8 0.84 0.72 9.5 1.04 0.99
(0.53–1.34) (0.38–1.38) (0.72–1.52) (0.62–1.58)
Birthweight
Normal birthweight 6865 (88.9) 4.9 1.00 [ref] 1.00 [ref] 8.1 1.00 [ref] 1.00 [ref]
Low birthweight 519 (6.7) 9.4 1.93 1.48 11.8 0.82 0.82
(1.15–3.25) (0.67–3.28) (0.52–1.31) (0.44–1.55)
Very low birth- 83 (1.1) 27.7 6.63 2.52 25.3 0.26 1.70
weight (2.89–15.22) (1.24–5.10) (0.12–0.62) (0.86–3.36)
Prematurity
Full-term birth 6891 (89.3) 4.8 1.00 [ref] 1.00 [ref] 8.2 1.00 [ref] 1.00 [ref]
Premature birth 767 (9.9) 12.1 2.76 2.72 13.0 0.63 0.73
(1.79–4.25) (1.52–4.88) (0.41–0.95) (0.44–1.22)
Breastfeeding history
Never breastfed 1372 (17.8) 7.6 1.00 [ref] 1.00 [ref] 11.1 1.00 [ref] 1.00 [ref]
Ever breastfed 5586 (72.4) 5.0 0.65 0.76 8.0 0.72 0.82
(0.43–0.97) (0.46–1.24) (0.50–1.04) (0.51–1.34)
Exclusively breast- 682 (8.8) 5.9 0.79 0.70 8.7 0.99 1.10
fed 6 months (0.40–1.54) (0.33–1.46) (0.57–1.74) (0.56–2.16)
Household income
0-99% FPL 942 (12.2) 8.2 1.48 0.42 11.1 0.69 1.78
(0.89–2.47) (0.20–0.88) (0.44–1.08) (0.75–4.24)
100-199% FPL 1263 (16.4) 7.4 1.26 0.65 10.2 0.85 1.12
(0.77–2.08) (0.33–1.29) (0.57–1.26) (0.62–2.0)
200-399% FPL 2442 (31.6) 5.3 1.07 0.68 8.9 0.89 1.13
(0.70–1.63) (0.37–1.27) (0.65–1.23) (0.71–1.82)
400% FPL or above 3071 (39.8) 4.4 1.00 [ref] 1.00 [ref] 6.9 1.00 [ref] 1.00 [ref]
ACE exposure
0 ACEs 5493 (71.2) 4.2 1.00 [ref] 1.00 [ref] 7.2 1.00 [ref] 1.00 [ref]
1 ACE 1393 (18.0) 7.4 1.58 2.03 10.0 1.18 0.79
(1.06–2.35) (1.17–3.52) (0.78–1.77) (0.44–1.4)
2 or more ACEs 832 (10.8) 12.2 3.26 2.34 15.7 2.56 1.54
(2.07–5.14) (1.25–4.37) (1.73–3.80) (0.91–2.62)
Reading at home
Read to daily 3415 (44.2) 5.2 1.00 [ref] 1.00 [ref] 8.1 1.00 [ref] 1.00 [ref]
Read to 4-6 days/ 1803 (23.4) 4.8 0.80 0.57 8.3 0.91 1.52
week (0.52–1.25) (0.32–1.0) (0.64–1.29) (0.97–2.37)
Read to 1-3 days/ 2255 (29.2) 6.7 0.98 0.91 9.7 0.92 1.25
week (0.66–1.45) (0.54–1.55) (0.65–1.30) (0.76–2.07)
Read to 0 days/week 223 (2.9) 7.6 1.47 1.15 8.5 0.75 0.83
(0.62–3.51) (0.57–2.33) (0.34–1.66) (0.45–1.51)

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Maternal and Child Health Journal (2024) 28:5–10 9

Table 1  (continued)
All participants Diagnosis of developmental delay Receipt of services
Exposure/character- N (%) % Crude OR (95% CI) Adjusted OR (95% % Crude OR (95% CI) Adjusted OR (95% CI)
istic CI)

Parental education level

College or graduate 4932 (63.9) 4.7 1.00 [ref] 1.00 [ref] 7.8 1.00 [ref] 1.00 [ref]
degree
Some college or 1760 (22.8) 6.6 1.16 1.58 9.2 1.06 0.59
technical school (0.80–1.69) (0.89–2.83) (0.77–1.45) (0.30–1.15)
High school or GED 909 (11.8) 8.0 1.49 1.82 11.2 0.88 0.48
(0.93–2.41) (0.89–3.70) (0.57–1.35) (0.21–1.08)
Less than high 117 (1.5) 8.5 1.11 (0.48–2.56) 1.07 (0.34–3.35) 12.8 1.06 0.47
school (0.51–2.21) (0.12–1.8)

Adjusted for: prematurity of birth, birthweight, race/ethnicity, income, parental education, breastfeeding history, reading at home
OR odds ratio

Conclusions This information or content and conclusions are those of the author and
should not be construed as the official position or policy of, nor should
any endorsements be inferred by HRSA, HHS, the National Institutes
Experiencing ACEs in young childhood is associated with of Health, or the U.S. Government.
poor developmental outcomes and developmental surveil-
lance and screening tools do not universally include ACEs Data Availability National Survey of Children’s Health publicly avail-
able data set.
as risk factors for developmental delay. Screening for ACEs
provides information and connection to resources that can Code Availability SAS software, Version 9.4.
help providers and patients understand how their lived expe-
riences impact medical outcomes. This work contributes to Declarations
the emerging body of literature that ACEs can negatively
Conflict of interest The authors have no conflicts of interests to dis-
impact developmental outcomes before children begin
close.
school. However, best practices in surveilling young children
with ACEs for developmental delay is not known. Regard- Ethical Approval Not applicable.
less, it will remain important for primary care providers to
Consent to Participate Not applicable.
screen young children for both developmental delay and
ACEs and connect these vulnerable children to appropriate Consent for Publication Not applicable.
developmental services.

Author Contributions CN contributed to study design, assisted with

data analysis and interpretation of results, drafted the original manu-
script, critically revised the manuscript, and approved the final manu-
script as submitted. EBS critically revised the manuscript and approved
the final manuscript as submitted. RR critically-revised the manuscript
and approved the final manuscript as submitted. AHA designed the
study, performed the data analysis, critically revised the manuscript,
and approved the final manuscript as submitted. All authors approved
the final manuscript as submitted and agree to be accountable for all
aspects of the work.
Funding Dr. Nivens was supported by a research grant from UC Davis
School of Medicine. Dr. Hoyt-Austin was supported by the National
Institute of Health, Building Interdisciplinary Research Careers in
Women’s Health at UC Davis through Grant Number: 5K12HD051958.
This work was also supported by the National Center for Advancing
Translational Sciences within National Institutes of Health [UL1
TR001860] and the Health Resources and Services Administration
(HRSA) of the U.S. Department of Health and Human Services (HHS)
under grant number T32HP19025 for Research in Primary Care for
$1,982,060 over 5 years, 0% financed with nongovernmental sources.
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