SAN DIEGO (FRONTLINE MEDICAL NEWS)Exposure to various forms of abuse or other early adverse childhood experiences are associated with below-average literacy and attention problems in kindergartners, which in turn are strong predictors of educational trajectory, according to Dr. Manuel Jimenez.

“These findings emphasize the importance of strategies that address the developmental needs of vulnerable children, including strengthening families and early literacy promotion,” said Dr. Jimenez of the Rutgers Robert Wood Johnson Medical School in New Brunswick, N.J.

It’s well established that adverse childhood experiences (ACEs) are associated with adult disability, social problems, and engagement in health-risky behaviors. Much less is known about the impact of early ACEs on the kindergarten experience. This was the impetus for Dr. Jimenez’s analysis of data from the Fragile Families and Child Wellbeing Study . He focused on an urban cohort of 1,008 children evaluated by teacher survey and mother report at age 5 years. Forty-six percent of the children were African American, and 57% of their mothers had a high school diploma or less.

The mother-reported adverse childhood events were defined as in an earlier Centers for Disease Control and Prevention study. There were eight under consideration: exposure to maternal depression, incarceration of a household member, household substance use, the mother having been treated violently, neglect, or physical, sexual, or psychological abuse.

The prevalence of the individual ACEs was in the 10%-16% range with the exception of sexual abuse, which was reported in just 0.6% of the cohort. Forty-eight percent of the children had experienced at least one ACE and 22% two or more.

In teacher ratings conducted in the final month of kindergarten, the presence of any two or more ACEs was associated with a 1.7-fold increased likelihood of below-average literacy skills, a 1.6-fold greater likelihood of below-average math skills, a 1.8-fold increase in child disability, and a 3-fold increase in the likelihood of being in the top 10% of the class in attention problems.

Taking a more in-depth look at the teacher ratings of emergent literary skills, children with two or more ACEs were 1.9-fold more likely to be rated as “not yet” able to easily and quickly name all uppercase and lowercase letters or as “beginning to” do so; 1.8-fold more likely to not yet be able to understand or interpret a story or other text read to them; and 1.7-fold more likely not to demonstrate an understanding of some of the conventions of print.

“It’s reasonable to assume that children at the end of their kindergarten year would have mastered, or be proficient in, each of these skills,” Dr. Jimenez said at the annual meeting of the Pediatric Academic Societies.

Children with two or more ACEs were also 4.4-fold more likely to score in the top 10% for attention problems as rated by parents using the Child Behavior Checklist attention subscale.

All of these significantly increased odds ratios were adjusted for potential confounders in multivariate logistic regression analysis, including race, sex, ethnicity, maternal education at childbirth, and household income, he noted.

One audience member asked whether Dr. Jimenez thinks it’s useful to screen for ACEs in clinical practice.

“We’ve actually thought a lot about this,” he replied. “With problems as big as these, it’s often possible to feel very small. But as pediatricians we really can make an incredible difference in children’s lives because we get to see kids so often. The Bright Futures project ( is filled with tools we can use to screen for and find ACEs as well as the adverse outcomes that are associated with them. And there is an opportunity to work with families and connect them with community resources that can help build resilience and strength. In my own line of work, I’ve been fortunate to be able to partner with community groups in New Brunswick. We’re actively trying to link pediatricians in the community – the medical home – to the resources that are out there.”

The Fragile Families and Child Wellbeing Study is supported by the National Institute of Child Health and Human Development. Dr. Jimenez reported having no relevant financial disclosures.