1. Adverse Childhood Experiences, Traumatic Brain Injury, and Disruptive Behavior Disorders: Results From the 2011 National Survey of Children's Health
Timothy D. McFarlane, MPH a and Matthew C. Aalsma, PhD b
a IUPUI Richard M. Fairbanks School of Public Health; b Indiana University School of Medicine
Introduction
Discussion
Results
Traumatic brain injury (TBI) is the leading cause of death and acquired disability among children and adolescents in the United States.
Behavioral difficulties following TBI injury have been well-characterized as significant TBI-related sequelae.
Adverse childhood experiences (AE), including poor family functioning, environmental factors, low socioeconomic status, emotional or sexual abuse, parental loss, and witnessing domestic violence are associated with the development negative behavioral outcomes.
We examined the joint effect of TBI and AE on prevalent childhood attention deficit or hyperactive disorder (ADD/ADHD) and oppositional defiant disorder or conduct disorders (ODCD).
The association between history of AE and prevalent ADD/ADHD and ODCD was modified by a history of TBI
Consistent, significant joint effect, increasing in strength with increasing disorder severity
Over half of children experienced an AE, most commonly financial hardship and divorce
Most experienced 1 or 2 AE (only 13% had 3+)
Taken together, TBI and AE represent forms of intrapersonal and interpersonal trauma
Many behavioral problems begin as attempts to cope, and trauma accumulation overwhelms coping capacity
Sample Demographics for Children Aged 3-17 years surveyed in the NSCH (n=71,110)
Prevalence of Behavioral Outcomes, Traumatic Brain Injury History, and Adverse Childhood Experiences
Lifetime Prevalence of Specific Adverse Childhood Experiences
Mean or % (95% CI)
Age
9.9 (9.8, 10.0)
Race/Ethnicity*
White
Black/AA
Hispanic
Multi / Other
53.2 (52.4, 54.1)
13.8 (13.2, 14.4)
22.9 (22.1, 23.8)
10.0 (9.5, 10.5)
Sex
Female
Male
49.4 (48.5, 50.2)
50.6 (49.8, 51.5)
Poverty (% FPL)
≥ 400% % %
< 100%
27.9 (27.3, 28.6)
29.3 (28.6, 30.1)
22.0 (21.3, 22.7)
20.7 (20.0, 21.5)
*Race and Ethnicity were mutually exclusive
FPL = Federal poverty line
Prevalence % (95% CI)
ADD/ADHD
Mild
Moderate
Severe
8.4 (7.94, 8.87)
3.4 (3.15, 3.73)
3.6 (3.28, 3.92)
1.4 (1.16, 1.57)
ODCD
3.2 (2.86, 3.45)
1.0 (0.83, 1.16)
1.5 (1.28, 1.70)
0.7 (0.55, 0.81)
TBI*
2.9 (2.63, 3.2)
AE*
51.1 (50.27, 51.93)
Note: Parent-reported exposures and outcomes
* Lifetime prevalence
AE Type Prevalence % (95% CI)
Financial Hardship
26.0 (25.2, 26.7)
Divorce
22.7 (22.0, 23.4)
Drugs & Alcohol
12.0 (11.4, 12.5)
Neighborhood violence
9.7 (9.2, 10.2)
Parent with mental health issue
9.5 (9.0, 10.0)
Domestic Violence
8.2 (7.7, 8.7)
Parent incarcerated
7.6 (7.1, 8.0)
Discriminated against
4.6 (4.3, 5.0)
Death in the family
3.5 (3.2, 3.8)
Note: Parent-reported adverse childhood experiences
Limitations
Methods
Parent reported exposures and outcomes
Inability to establish clear temporality
Possibility of reverse causality
Diagnostic bias and confusion
Stigma associated with AE
Lack of severity classification for TBI
Data Source and Population
Cross sectional study using the National Survey of Children’s Health for children 3 years or older (n= 71,110 parent/caregiver interviews; Child and Adolescent Health Measurement Initiative (2011) Indicator Data Set. Data Resource Center for Child and Adolescent Health.)
Parent Reported Exposures and Outcomes
Lifetime history of TBI
Nine questions for lifetime history of AE that capture socioeconomic hardship, family functioning and hardship, and suboptimal living environment
Current ADD/ADHD or ODCD diagnosis, including parent’s perception of disorder severity
Data Analysis
Joint effect operationalized by combining history of TBI (y/n) and AE (y/n), resulting in four levels – absent both exposures, No TBI with AE, TBI without AE, and TBI with AE.
Two multinomial logistic regression models for the outcomes of mild, moderate, or severe ADD/ADHD and ODCD
Results weighted to represent the demographic composition of children aged 3-17 years in each state and variance estimation accounted for complex sampling design
Strengths
Large, nationally representative sample
Good Racial/Ethnic coverage
Major AE assessed
Strong measures of association
Biological plausibility
Conclusion
Trauma accumulation from TBI and AE overwhelm coping abilities of children and adolescents, resulting in increased likelihood of behavioral disorders
Strong recommendations and training for trauma informed care from public health agencies and professional organizations are warranted
Maximizes choices for the affected and control over the healing process
Contextualizes care within life experiences and cultural background
Note: OR estimates adjusted for age, sex, race, and poverty level through multinomial logistic regression for complex survey designs
AEs = adverse childhood experiences for child; ADD/ADHD = current diagnosis of attention deficit or hyperactive disorders; ODCD current diagnosis of oppositional defiant or conduct disorders; Injury = history of traumatic brain injury; OR = odds ratio; LCL = lower confidence level; UCL = upper confidence level
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