Evaluation of Midlife Educational Attainment Among Attendees of a Comprehensive Early Childhood Education Program in the Context of Early Adverse Childhood Experiences

Key Points Question Is exposure to early adverse childhood experiences (ACEs) associated with reduced midlife educational attainment, and if so, did participation in the Child-Parent Center (CPC) comprehensive Early Childhood Education (ECE) program attenuate these associations? Findings In this cohort study of 1083 participants, early ACEs were significantly associated with reduced midlife educational attainment for the comparison group, but not for the CPC early intervention group. The CPC preschool program appeared to compensate for associations between ACEs and educational attainment; CPC attendees with early ACEs had similar educational trajectories to those of CPC attendees without early ACEs. Meaning This study suggests that comprehensive ECE can be a scalable approach for promoting long-term educational success after early experiences of ACEs.


Comprehensive Early Childhood Education for Children in Poverty
Comprehensive Early Childhood Education (ECE) programs-programs providing educational, family, and health care services to young children and their families-are effective preventive interventions for children in disadvantaged environments, [16][17][18][19] affecting broad domains of well-being and providing economic returns on investment. 19,20Longitudinal research, including investigations with the present sample, 21,22 demonstrates marked associations between ECE and educational attainment. 18reover, ECE has also been found to be most beneficial for children at highest risk, such as those with a history of maltreatment or with greater relative sociodemographic disadvantage. 21,23nsidering this evidence, ECE may also be differentially beneficial for children who are high risk due to early ACE exposure and could therefore be an effective intervention for mitigating the association of ACEs with educational attainment.

Childhood Poverty and ACEs
[26] Black people in the US are more likely than White people to experience both poverty and ACEs. 27,28e full implications of this are unknown; although ACE studies have increasingly been conducted with socioeconomically and racially and ethnically diverse samples, [29][30][31][32] large-scale longitudinal research on ACEs in low-income Black populations remains relatively scarce.
4][35][36] Such experiences, termed expanded ACEs, 30,[37][38][39] can occur in the absence of conventional ACEs 40,41 and have been associated with well-being above and beyond the effects of co-occurring conventional ACEs. 32,37Broadening the definition of ACEs could provide a more accurate picture of adversity in underserved populations and a more complete understanding of the mechanisms through which adversity is associated with poor outcomes, 37,40 but research on the consequences of a range of ACEs relevant to diverse populations is needed.

ACEs in the Present Sample
The present sample is in early midlife.When these participants were 24 years of age, research suggested that early childhood ACEs had lasting consequences for multiple dimensions of their well-being. 7Participation in the ECE program promoted resilience through later experiences and student motivation, particularly for participants with a history of ACEs. 42At the same time, participants with early ACEs were less than half as likely to graduate from high school than participants without early ACEs. 7Because few participants had earned a postsecondary degree by 24 years of age, associations between ACEs and completion of postsecondary education could not be examined.By 35 years of age, rates of participants attaining higher education had increased, presenting an opportunity to more thoroughly assess associations between ACEs and postsecondary educational attainment.
In the present study, we aim to evaluate whether ACEs and ECE intersect with regard to higher education.

Study Design
The Chicago Longitudinal Study is a prospective, matched-group multisite study investigating the association of early experiences and the Child-Parent Center (CPC) preschool through third grade intervention 22

Measures Adverse Childhood Experiences
Conventional ACEs | Conventional ACEs are defined as abuse, neglect, and household dysfunction. 1 Household dysfunction was assessed by retrospective self-report at approximately 35 years of age.Participants were asked if and when a list of events had occurred in their lives.Four of the 5 household dysfunction items from the original ACE studies were used 1 : (1) "You experienced mental illness of a parent or caregiver," (2) "You were witness to domestic abuse of mother or caregiver," (3) "One of your parents had problems with alcohol or drugs," and ( 4

Expanded ACEs |
The following items were designated as expanded ACEs based on extensive review of adverse life events among youths, as well as prior studies exploring expanded ACE scales 30,37,39,40  Participants' sex, race, risk index, CPC preschool participation, and CPC school-aged participation were entered as covariates in analyses examining the associations between ACEs and educational attainment.When examining the interaction between ACEs and preschool attendance, the covariates entered were sex, race, risk index, and CPC school-aged participation.

Outcomes: Educational Attainment
Records of attaining a bachelor's degree or higher or an associate's degree or higher and the total number of years of education were drawn from National Student Clearinghouse administrative records and interviews at 35 years of age.The measure of an associate's degree or higher was inclusive of credits beyond an associate's degree, including individuals with bachelor's degrees, master's degrees, and doctoral degrees.The measure of a bachelor's degree or higher was similarly inclusive of credits beyond a bachelor's degree. 22

Statistical Analysis
Analyses were conducted from July 1 to September 1, 2022.Outcomes were analyzed in Stata, version 14 (StataCorp LLC). 43All P values were from 2-sided tests, and results were deemed statistically significant at P < .05.44,45 Inverse probability weighting uses all available data to estimate complex adjustments independent of the outcome specification model, with weights calculated separately by sex given differential attrition. 46See eTable 2 and the eAppendix in Supplement 1 for further detail.
Direct associations of ACEs with educational attainment were estimated using both logistic (for attainment of bachelor's degree or higher or associate's degree or higher) and linear (for years of education) regression models.The ACE measures used were conventional ACEs, expanded ACEs, and a measure of either conventional or expanded ACEs, dichotomized to no ACEs or 1 or more ACEs prior to 5 years of age.Participants with no reported ACE exposure (725 of 1083 [66.9%]) served as the reference group in all analyses.Each ACE measure was entered separately with demographic covariates for each education outcome.See eTable 1 in Supplement 1 for list of covariates.
For direct associations of ACEs with the dichotomous outcomes of bachelor's degree or higher or associate's degree or higher attainment, odds ratios (ORs) with 95% CIs are presented as standardized measures of the magnitude of the findings.For the magnitude of effect for years of education, mean differences are presented.
For moderation analyses, terms testing the interaction between CPC attendance and ACE exposure were added to the model.Marginal effects indicating the proportion of participants coded as yes for the educational attainment outcome for each condition of ACE exposure and CPC preschool attendance were examined.Odds ratios indicating the magnitude of the difference in the association between ACEs and educational attainment by intervention group are also presented.For standardized measures of the magnitude of moderation findings, effect sizes for the dichotomous outcomes of bachelor's degree or higher or associate's degree or higher attainment were calculated based on differences in the proportion of participants with each binary educational attainment outcome by ACEs and then between the intervention and control groups using probit distribution transformations based on marginal effects.

Results
At the time of 30  47 See eTable 1 in Supplement 1 for full demographic and attrition information.

Direct Associations Between ACEs and Educational Attainment
ACEs were not associated with educational attainment in the full sample or in the CPC intervention subgroup.However, both the dichotomized measure of conventional or expanded ACEs and conventional ACEs alone were associated with reduced educational attainment across outcomes for the comparison group (

Interaction Between ACEs and Preschool Attendance on Educational Attainment
Overall, for participants with both early conventional and expanded ACEs, CPC preschool attendance evinced a compensatory association with educational attainment.Participants who attended CPC preschool completed similar rates of education as CPC participants without early ACEs (Table 3, Figure 1, and Figure 2).

Combined Conventional and Expanded ACEs
Bachelor's Degree or Higher | The interaction between conventional or expanded ACEs and CPC preschool was associated with attainment of a bachelor's degree or higher (OR, 4.44; 95% CI, 1.56-12.68;P = .005).Participants with either conventional or expanded ACEs who attended CPC preschool attained a bachelor's degree or higher at a similar rate as attendees without ACEs (15.4% vs 13.6%; difference, 1.8 percentage points), while comparison group participants with ACEs had lower rates of attainment of a bachelor's degree or higher than those without ACEs (3.7% vs 12.1%; difference, −8.4 percentage points) (Figure 1).
Associate's Degree or Higher | A significant interaction between conventional or expanded ACEs and CPC preschool was also associated with attainment of an associate's degree or higher (OR, 4.39; 95% CI, 1.81-10.64;P = .001).Participants with 1 or more conventional or expanded ACEs who attended CPC preschool attained an associate's degree or higher at similar rates to those without ACEs (22.4% vs 19.9%; difference, 2.5 percentage points).For participants in the comparison group, those with ACEs attained an associate's degree or higher at lower rates than those without ACEs (5.6% vs 17.1%; difference, −11.5 percentage points) (Figure 2).

Years of Education |
The interaction between conventional or expanded ACEs and CPC preschool was associated with years of education completed (β = 0.72; 95% CI, 0.20-1.24;P = .007).Among the participants in the intervention group, those with 1 or more conventional or expanded ACEs completed similar years of education as those without ACEs (12.9 vs 12.8 years; difference, 0.07   a The standardized difference for proportions was based on the probit transformation of percentages.
b The 0 ACE group serves as the reference group for all analyses.
c β Coefficient (95% CI).years).In the comparison group, participants with ACEs completed over half a year less of education than those without ACEs (11.9 vs 12.5 years; difference, −0.64 years).

Conventional ACEs
The interactions between conventional ACEs and CPC participation for attaining a bachelor's degree or higher and an associate's degree or higher (Figure 1) were significant, with similar patterns of results as those seen for the measure of conventional or expanded ACEs (OR, 4.58; 95% CI, 1.28-16.39;P = .02;and OR, 5.64; 95% CI, 1.84-17.29;P = .002,respectively) (Table 3).The association of the interaction between conventional ACEs and CPC attendance with years of education was not statistically significant.

Expanded ACEs
Interactions between expanded ACEs and CPC were significant across all 3 outcomes, with participants who had early expanded ACEs and attended CPC preschool achieving rates of educational attainment similar to or higher than their counterparts without ACEs, but with participants in the comparison group with early expanded ACEs demonstrating significantly lower educational attainment than their peers without ACEs (bachelor's degree or higher: OR, 3.42; 95% CI, 1.07-10.99;P = .04;associate's degree or higher: OR, 3.16; 95% CI, 1.18-8.49;P = .02;years of education: β = 0.72; 95% CI, 0.06-1.38;P = .03;Table 3).

Discussion
The findings of this study suggest that ACEs are associated with reduced educational attainment and that comprehensive ECE may compensate for these associations.Child-Parent Center preschool intervention attendees who had exposure to either conventional or expanded ACEs in early childhood achieved equivalent educational attainment as their counterparts not exposed to ACEs, while youths in the comparison group exposed to ACEs attained postsecondary education at lower rates than their peers without ACEs.These results contribute to the research base suggesting that youths at higher risk may benefit most from intervention and provide support for including ACEs as a standard indicator of risk.
A crossover interaction was observed for early expanded ACEs and attainment of an associate's degree or higher and a bachelor's degree or higher, wherein the group of participants exposed to ACEs who were in the CPC intervention seemed to achieve higher educational attainment than intervention participants without ACEs.It is possible that children with exposure to only expanded ACEs were able to benefit more from the intensive enrichment environment provided by CPC, but further research is needed to understand the mechanisms of this connection.These findings have clear implications for policy and practice.As evidence conclusively points to serious long-term implications of ACEs, measuring and identifying ways to mitigate these implications are crucial.Comprehensive ECE programs such as CPC preschool, which continues to serve thousands of children in the Midwestern United States, are one such mechanism.Decades of developmental science tells us that opportunities to repair and intervene are as numerous as consequences of adversity, but evidence also shows that such interventions are far more effective when started early. 48In the present study, ECE was positively associated with educational attainment for youths with the most challenging early environments, which has important implications for socioeconomic well-being and health.This study suggests that when assessing risk, clinicians and child-facing practitioners should consider not only poverty and maltreatment but also ACEs more broadly.Clinicians should screen for the presence of early ACEs so that they may refer families to comprehensive ECE and other services.

JAMA Network Open | Public Health
) "One of your parents was arrested by the police during your lifetime."The fifth household dysfunction ACE of "parent absence or divorce" was excluded given high rates of participants born into single-parent homes (75.4% of the sample [817 of 1083]).Abuse and neglect, the fifth ACE in the present study, was assessed via prospectively collected early childhood child welfare court and Department of Children and Family Services administrative records, supplemented by retrospective self-report.Participants with 1 or more affirmative indicators of any conventional ACEs prior to 5 years of age were coded as 1.

Figure 2 .
Figure 2. Percentage of Participants Attaining an Associate's Degree or Higher by Adverse Childhood Experience (ACE) and Intervention Status 25

Figure 1 .
Figure 1.Percentage of Participants Attaining a Bachelor's Degree or Higher by Adverse Childhood Experience (ACE) and Intervention Status 25

JAMA Network Open | Public Health Midlife
Educational Attainment in the Context of Early ACEs and Early Childhood Education JAMA Network Open.2023;6(6):e2319372.doi:10.1001/jamanetworkopen.2023.19372(Reprinted) June 22, 2023 2/13 Downloaded From: https://jamanetwork.com/ on 11/01/2023 To our knowledge, this is the first study to examine the association of ACEs with educational attainment in a longitudinal sample of majority Black participants, as well as the first to investigate the potential of ECE to buffer ACE-exposed youths from the deleterious effects of ACEs.
Items 1 to 6 were based on retrospective self-report, whereas item 7 was based on prospectively collected administrative records.Participants with 1 or more affirmative indicators of any expanded ACEs prior to 5 years of age were coded as 1.A dichotomized indicator was created denoting history of any conventional or expanded ACEs prior to 5 years of age.
:(1)witness to a violent crime, (2) victim of a violent crime, (3) family financial problems, (4) frequent family conflict, (5) death of a parent, (6) death of a sibling, and (7) foster care or out-of-home placement.CovariatesCPC Preschool Participation | Students who attended CPC preschool were coded as preschool participants.Child-Parent Center preschool participants comprised 64.3% of the original sample (989 of 1539) and 65.5% of the present study subsample (709 of 1083).CPC School-Age Participation | Students could attend CPC through third grade.Students who attended CPC during early elementary school, whether or not they attended for preschool, were coded as school-aged participants.In this subsample, 57.2% of participants (619 of 1083) overall (71.4% of intervention group participants [506 of 709] and 30.2% of comparison group participants [113 of 374]) had CPC school-aged participation compared with 55.2% (850 of 1539) of the original sample (69.2% of intervention group participants [684 of 989] and 30.2% of comparison group participants [166 of 550]).Sex and Race | Participants were coded 1 if female (50.3% of the original sample [774 of 1539]; 54.9% of the present subsample [594 of 1083]) and 0 if male.Participants were coded 1 if Black (92.9% of the original sample [1430 of 1539]; 93.5% of the present subsample [1013 of 1083]) and 0 if not Black.Demographic Risk Index | The risk index comprises 8 dichotomous indicators measured from birth to 3 years of age: (1) single-parent household, (2) mother younger than 18 years at child's birth, (3) 4or more children in household, (4) mother did not complete high school, (5) family income less than 185% of the federal poverty level, (6) mother unemployed, (7) welfare receipt, and (8) residence in a high-poverty neighborhood.The mean (SD) risk index score in this sample was identical to the mean (SD) risk index for the original sample (4.5[1.7]).

Table 2 )
. Comparison group participants with either conventional or expanded ACEs were approximately one-fourth as likely as comparison group participants without

Table 1 .
Prevalence of ACEs by Domain and Education in Overall Sample and by Subgroups

Table 2 .
Associations Between ACEs and Educational Attainment, in Overall Sample and by Subgroups a The 0 ACE group serves as the reference group for all analyses.

Table 3 .
Marginal Effects for Interaction Between ACEs and CPC Preschool Attendance Abbreviations: AA, associate's degree; ACEs, adverse childhood experiences; BA, bachelor's degree; CPC, Child-Parent Center; NA, not applicable; OR, odds ratio.