Adverse childhood experiences and behavioral problems in middle childhood

Abstract

Children who have been exposed to maltreatment and other adverse childhood experiences (ACEs) are at increased risk for various negative adult health outcomes, including cancer, liver disease, substance abuse, and depression. However, the proximal associations between ACEs and behavioral outcomes during the middle childhood years have been understudied. In addition, many of the ACE studies contain methodological limitations such as reliance on retrospective reports and limited generalizability to populations of lower socioeconomic advantage. The current study uses data from the Fragile Families and Child Wellbeing Study, a national urban birth cohort, to prospectively assess the adverse experiences and subsequent behavior problems of over 3000 children. Eight ACE categories to which a child was exposed by age 5 were investigated: childhood abuse (emotional and physical), neglect (emotional and physical), and parental domestic violence, anxiety or depression, substance abuse, or incarceration. Results from bivariate analyses indicated that Black children and children with mothers of low education were particularly likely to have been exposed to multiple ACE categories. Regression analyses showed that exposure to ACEs is strongly associated with externalizing and internalizing behaviors and likelihood of ADHD diagnosis in middle childhood. Variation in these associations by racial/ethnic, gender, and maternal education subgroups are examined. This study provides evidence that children as young as 9 begin to show behavioral problems after exposure to early childhood adversities.

Introduction

In 2014, the Administration on Children, Youth, and Families estimated that 702,000 children were victims of maltreatment nationwide (U.S. Department of Health and Human Services [USDHHS], 2016). Survivors of child maltreatment suffer from adverse health consequences throughout their life span, including an increased risk for chronic diseases (Danese et al., 2009), mental health disorders (Edwards, Holden, Felitti, & Anda, 2003), and overall reduced health-related quality of life (Corso, Edwards, Fang, & Mercy, 2008). Researchers have found that the long-term health effects of child maltreatment are often due to the cumulative influence of multiple forms of childhood maltreatment and adverse household characteristics in areas such as alcohol and drug abuse, domestic violence, and criminal activity (Dong, Anda, Dube, Giles, & Felitti, 2003; Dube, Williamson, Thompson, Felitti, & Anda, 2004). Collectively, these co-occurring conditions have been termed adverse childhood experiences (ACEs; Felitti et al., 1998).

The Adverse Childhood Experiences (ACE) Study, a collaboration between the Centers for Disease Control and Prevention and Kaiser Permanente’s Health Appraisal Clinic in San Diego, is one of the largest research endeavors ever conducted to examine associations between childhood adversity and adult health (Centers for Disease Control and Prevention, 2013). The original ACE questionnaire assessed 7 categories of ACEs: 3 categories of child maltreatment (psychological abuse, physical abuse, and sexual abuse) and 4 categories of household dysfunction (mother treated violently, living with a household member who was a substance abuser, mentally ill or suicidal, or was ever imprisoned). Subsequent ACE studies incorporated neglect and parental divorce or separation into the ACE index. The CDC-Kaiser ACE studies reported a strong, graded relationship between the number of ACEs a person was exposed to and the risk for cancer, ischemic heart disease, liver disease, substance abuse, depression, and chronic obstructive pulmonary disease, among other health problems (Felitti et al., 1998). Since then, numerous investigators have reported the link between ACE exposure and social and health problems, including teen pregnancy (Hillis et al., 2004); autoimmune disease (Dube et al., 2009); and use of psychotropic medications (Anda et al., 2007).

Despite this growing body of literature, the proximal effects of ACEs on behavioral outcomes during the middle childhood years have been understudied. The current study prospectively assessed ACEs and subsequent behavior problems of over 3000 children. Eight ACE categories to which a child was exposed to by age 5 were investigated: emotional neglect, physical neglect, emotional abuse, physical abuse, and parental domestic violence, anxiety or depression, substance abuse, or incarceration.

The CDC-Kaiser ACE studies have linked childhood adversity to a wide range of health problems in adulthood. Whether ACEs predict behavioral problems in childhood has received relatively less empirical attention. Internalizing (e.g., anxiety, depression) and externalizing (e.g., aggression) problem behaviors, have been observed to have a higher likelihood of emerging after exposure to childhood adversity. In a study examining ACEs among a pediatric sample, exposure to 4 or more ACEs was associated with 33 times the odds of reporting a learning or behavioral problem as compared to children without ACE exposure (Burke, Hellman, Scott, Weems, & Carrion, 2011). Other studies have found substantial increases in attention and behavioral problems among children as young as 5 after cumulative ACE exposure (Jimenez, Wade, Lin, Morrow, & Reichman, 2016; McKelvey, Whiteside-Mansell, Conners-Burrow, Swindle, & Fitzgerald, 2016). These studies advance the ACE literature by indicating that cumulative adversity is not only associated with strong effects on adulthood health outcomes but also childhood behavioral problems. Nevertheless, that most of these studies rely on cross-sectional and retrospective study designs introduces the possibility of reverse causation in regards to the associations between ACEs and child behavioral problems. A first step to overcoming this limitation involves examining these associations with a prospective lens.

Children with problem behaviors have an increased risk of developing clinical level mental illnesses and physical health problems later in life. Adults are more vulnerable to depression if they were anxious or depressed in childhood and more likely to have anxiety disorders if they experienced childhood externalizing problem behaviors (Roza, Hofstra, van der Ende, & Verhulst, 2003). Children with behavioral problems are also at risk of engaging in health risk behaviors later in childhood (Fanti & Henrich, 2010). This association between behavioral problems and health risk behaviors is significant given that the development of the disease outcomes reported in the CDC-Kaiser ACE studies is likely mediated through engagement in health risk behaviors in adolescence or early adulthood. For instance, victims of maltreatment have been found to be susceptible to numerous health risk behaviors during adolescence, such as sexual promiscuity, substance use (Repetti, Taylor, & Seeman, 2002), and obesity (Shin & Miller, 2012), behaviors that may develop into disabling diseases and premature death in adulthood. In sum, existing evidence points to the value of including middle childhood problem behaviors in the examination of childhood adversity and subsequent health problems.

Differences exist in risk of adversity in families across levels of socioeconomic advantage. Children are more likely to be victims of child maltreatment if they come from low-income or single-parent households (Berger, 2004, USDHHS, 2016), characteristics that are highly correlated with low educational attainment among parents. Parents of such households may have insufficient financial, emotional, or social resources to adequately support their children. It is also possible that increased stress resulting from socioeconomic disadvantage contributes to more punitive parenting behaviors among these families (Graham, Weiner, Cobb, & Henderson, 2001). Relatedly, risk for exposure to adversity is not evenly distributed across racial and ethnic subgroups. Hispanic and Black children have disproportionally high rates of maltreatment victimization (USDHHS, 2016) and disproportionally grow up in disadvantaged communities. The CDC-Kaiser ACE studies demonstrated that child maltreatment and adverse household characteristics are highly co-occurring phenomenon, as the presence of one ACE significantly predicting the odds of exposure to additional ACEs (Dong et al., 2003). For this reason, it is likely that children in socioeconomically disadvantaged families will not only have higher exposure to maltreatment, but will also have greater exposure to other ACE categories compared to children of higher socioeconomic advantage.

Although ACE exposure may be greater in more vulnerable families, there has been scant research dedicated to potential differences in health or behavioral problems after ACE exposure across groups of differing levels of advantage. The studies that are available portray a mixed picture. Schilling, Aseltine, and Gore (2007) observed that the negative impact of cumulative and individual ACEs on White adolescents was consistently greater than on Blacks and Hispanics in the areas of mental health and behavioral problems. For instance, White adolescents with 4 ACEs scored almost 0.5 standard deviations higher on antisocial behaviors than Whites experiencing no ACEs; there were no such associations found for Black or Hispanic adolescents. Similarly, Gerard and Buehler (2004) reported that the associations between multiple risk exposure and internalizing and externalizing behavior problems were stronger for White youth compared to Black and Hispanic youth. In contrast, using a nationally representative sample of over 15 thousand adolescents, Wickrama, Noh, and Bryant (2005) found that while White adolescents were more vulnerable to the influence of family poverty on depressive symptoms, Black adolescents were more affected by the detrimental influence of community-level poverty.

Differential susceptibility to ACE exposure across gender has also been suggested. Studies using an urban, minority sample suggests that rates of exposure to ACEs may be higher for males than for females (Mersky, Topitzes, & Reynolds, 2013); yet there is mixed evidence as to whether boys or girls are more negatively affected by ACE exposure. Some researchers report that boys are more likely to develop attention-related or externalizing behavioral problems after exposure to adversity (Cooper, Osborne, Beck, & McLanahan, 2011; Haskins, 2014). Others have found that the influences of cumulative risk are stronger for girls than for boys when it comes to internalizing behavioral problems (Gerard & Buehler, 2004). Still others find that young men are equally likely to exhibit internalizing symptoms as young women (Schilling et al., 2007). Further research examining subgroup differences in ACE exposure and susceptibility is needed to provide clarification to these findings.

A notable strength of the CDC-Kaiser ACE studies is that the link between ACE exposure and a large range of physical and mental health results was examined. However, a weakness of these studies is the reliance on retrospective reports of ACEs, which are prone to recall bias and measurement error. The ACE studies also used of a predominately White sample of higher socioeconomic advantage (Felitti et al., 1998), so less is known as to whether ACEs would have similar effects on more socially and economically diverse subgroups. Moreover, this literature overlooks the proximal effects of ACEs by primarily focusing on outcomes in adulthood. Finally, the CDC-Kaiser ACE study and many subsequent investigations rarely provide sufficient controls for confounding influences that could account for effects attributed to ACEs. Our study extends the ACE literature by using a prospective longitudinal study design to examine the association between ACE exposure by age 5 and the presence of behavioral problems in middle childhood among a diverse sample of U.S. children.

Our analyses focus on both total amounts and clinical levels of internalizing and externalizing behavioral problems. We also examine the presence of an ADHD diagnosis, given the high comorbidity between attention related problems and behavioral problems after exposure to family adversity (Biederman et al., 1995). Examining clinical levels of behavioral problems and ADHD diagnosis provides some indication as to whether early ACE exposure is associated with both the number of behavioral problems children demonstrate as well as the likelihood of more severe, diagnosable behavioral problems. We hypothesize a positive relation between ACE exposure and each of the behavioral outcomes. A second aim of the study is to examine differences in susceptibility to ACE exposure across groups of race, gender, and maternal education. We cannot provide a hypothesis about which groups would develop worse behavioral problems after ACE exposure due to inconclusive findings in prior studies. The final aim of the study is to examine whether the ACE-specific categories or cumulative exposure to ACEs is more strongly associated with worse behavioral problems in middle childhood. We hypothesize that while some ACEs may have stronger associations than others, children exposed to the highest number of ACEs will have more serious problems compared to children with fewer ACEs.