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Links between trauma exposure and adolescent high-risk health behaviors: Findings from the NCTSN Core Data Set. (Special section paper #5)

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Although links between adverse childhood experiences (ACEs) and problems in adulthood are well established, less is known regarding links between exposure to trauma during childhood and adolescence and high-risk behavior in adolescence. We tested the hypothesis that cumulative exposure to up to 20 different types of trauma and bereavement/loss incrementally predicts high-risk adolescent behavior beyond demographic variables. Adolescents reporting exposure to at least 1 type of trauma (n � 3,785; mean age � 15.3 years; 62.7% girls) were selected from the National Child Traumatic Stress Network Core Data Set (CDS). Logistic regression analyses tested associations among both demographic variables and number of types of trauma and loss exposure as predictors, and 9 types of high-risk adolescent behavior and functional impairment (attachment difficulties, skipping school, running away from home, substance abuse, suicidality, criminality, self-injury, alcohol use, and victim of sexual exploitation) as criterion variables. As hypothesized, hierarchical logistic regression analyses revealed that each additional type of trauma exposure significantly increased the odds ratios for each problem behavior (range � 1.06–1.22) after accounting for demographic variables. Some demographic variables (female gender, public insurance eligibility, and older age) were also associated with increased likelihood for some outcomes. Study findings extend previously identified links between childhood trauma and problems later in life to include high-risk behavior and functional impairment during adolescence. The findings underscore the need for a trauma-informed public health approach to systematic screening, prevention, and early intervention for traumatized and bereaved youth in child service systems. Keywords: adverse childhood experiences, adolescence, risk factor, bereavement, child traumatic stress FULL CITATION: Layne, C.M., Greeson, J.K.P., Kim, Soeun, Ostrowski, S.A., Reading, S., Vivrette, R.L., Briggs, E.C., Fairbank, J.A., & Pynoos, R.S. (2014). Links between trauma exposure and adolescent high-risk health behaviors: Findings from the NCTSN Core Data Set. Psychological Trauma: Theory, Research, Practice, and Policy, 6(Suppl 1), 2014, S40-S49. http://dx.doi.org/10.1037/a0037799.
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Cumulative Trauma Exposure and High Risk Behavior in Adolescence:
Findings From the National Child Traumatic Stress Network Core Data Set
Christopher M. Layne
UCLA-Duke University National Center for Child Traumatic
Stress and University of California, Los Angeles
Johanna K. P. Greeson
University of Pennsylvania School of Social
Policy & Practice
Sarah A. Ostrowski
Akron Children’s Hospital and Medical Center, Akron, Ohio Soeun Kim
University of California, Los Angeles
Stephanie Reading
University of California, Los Angeles Rebecca L. Vivrette
UCLA-Duke University National Center for Child
Traumatic Stress
Ernestine C. Briggs and John A. Fairbank
UCLA-Duke University National Center for Child Traumatic
Stress and Duke University Medical Center
Robert S. Pynoos
UCLA-Duke University National Center for Child Traumatic
Stress and University of California, Los Angeles
Although links between adverse childhood experiences (ACEs) and problems in adulthood are well-
established, less is known regarding links between exposure to trauma during childhood and adolescence and
high-risk behavior in adolescence. We tested the hypothesis that cumulative exposure to up to 20 different
types of trauma and bereavement/loss incrementally predicts high-risk adolescent behavior beyond demo-
graphic variables. Adolescents reporting exposure to at least 1 type of trauma (n3,785; mean age 15.3
years; 62.7% girls) were selected from the National Child Traumatic Stress Network Core Data Set (CDS).
Logistic regression analyses tested associations among both demographic variables and number of types of
trauma and loss exposure as predictors, and 9 types of high-risk adolescent behavior and functional impair-
ment (attachment difficulties, skipping school, running away from home, substance abuse, suicidality,
criminality, self-injury, alcohol use, and victim of sexual exploitation) as criterion variables. As hypothesized,
hierarchical logistic regression analyses revealed that each additional type of trauma exposure significantly
increased the odds ratios for each problem behavior (range 1.06–1.22) after accounting for demographic
variables. Some demographic variables (female gender, public insurance eligibility, and older age) were also
associated with increased likelihood for some outcomes. Study findings extend previously identified links
between childhood trauma and problems later in life to include high-risk behavior and functional impairment
during adolescence. The findings underscore the need for a trauma-informed public health approach to systematic
screening, prevention, and early intervention for traumatized and bereaved youth in child service systems.
Keywords: adverse childhood experiences, adolescence, risk factor, bereavement, child traumatic stress
Christopher M. Layne, UCLA-Duke University National Center for
Child Traumatic Stress and Department of Psychiatry and Biobehav-
ioral Sciences, University of California, Los Angeles; Johanna K. P.
Greeson, University of Pennsylvania School of Social Policy & Prac-
tice; Sarah A. Ostrowski, NeuroDevelopmental Science Center, Akron
Children’s Hospital and Medical Center, Akron, Ohio; Soeun Kim,
Department of Medicine, University of California, Los Angeles; Steph-
anie Reading, Department of Epidemiology, University of California,
Los Angeles; Rebecca L. Vivrette, UCLA-Duke University National
Center for Child Traumatic Stress; Ernestine C. Briggs and John A.
Fairbank, UCLA-Duke University National Center for Child Traumatic
Stress and Department of Psychiatry and Behavioral Sciences, Duke
University Medical Center; Robert S. Pynoos, UCLA-Duke Univer-
sity National Center for Child Traumatic Stress and Department of
Psychiatry and Biobehavioral Sciences, University of California, Los
Angeles.
Soeun Kim is now at the Division of Biostatistics, School of Public
Health, University of Texas Health Sciences Center at Houston. Rebecca L.
Vivrette is now with the Department of Psychiatry, University of Maryland
School of Medicine.
Correspondence concerning this article should be addressed to Christo-
pher M. Layne, UCLA-Duke National Center for Child Traumatic Stress,
11150 West Olympic Boulevard, Suite 650, Los Angeles, CA 90066.
E-mail: cmlayne@mednet.ucla.edu
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2014, Vol. 6, No. S1, S40–S49 1942-9681/14/$12.00 http://dx.doi.org/10.1037/a0037799
S40
Adolescence is the principal developmental period during which
many serious health risk behaviors emerge, including substance use,
sexual behavior, self-injury, and suicidal behavior. The 2009 National
Youth Risk Behavior Survey, which monitors priority health-risk
behaviors that serve as precursors to leading causes of death, disabil-
ity, and social problems among adolescents in the 9th through 12th
grades, found that 6.3% of students reported having attempted suicide
at least once during the previous 12 months; 20.8% reported using
marijuana one or more times during the previous 30 days; and 41.8%
reported having at least one drink of alcohol on at least 1 day during
the previous 30 days (United States Department of Health and Human
Services, Centers for Disease Control and Prevention, 2009). Given
the prevalence rates of these health-risk behaviors, as well as their
many potential adverse consequences including involvement with the
juvenile justice system, school failure, and dropout (Bailey, 2009),
high-risk behaviors among the general U.S. adolescent population are
a major public health and social welfare concern. The serious social
consequences posed by adolescent health-risk behaviors have led to
their selection as targets of 11 Health Objectives in Healthy People
2020 (United States Department of Health and Human Services,
Centers for Disease Control and Prevention, 2010). These adverse
consequences have also inspired efforts to identify relevant predictors,
correlates, and risk factors in the interests of developing prevention
and early intervention programs that, by targeting multiple risk fac-
tors, reduce a range of adverse consequences while promoting posi-
tive adolescent development (Bailey, 2009).
Adolescents’ social contexts—especially their family, peer, and
school environments—have emerged as key predictors of their be-
havior (Hagan & Foster, 2001;Rutter, 1993;Steinberg & Morris,
2001). For example, findings from the National Longitudinal Study of
Adolescent Health (Resnick et al., 1997) indicate that family context
explained 5–7% of the variance in adolescent suicidality, 5–7% of the
variance in violence perpetration, 6% of the variance in alcohol use,
and 6–9% of the variance in marijuana use. The school context
accounted for a further 6–7% of the variance in adolescent violent
behavior, 4–5% of the variance in alcohol use, and 5–6% of the
variance in marijuana use depending on the metrics used. Of partic-
ular concern, trauma during developmentally sensitive periods early
in life (including child maltreatment, domestic violence, and interper-
sonal and community violence) has been found to be related to many
adverse long-term consequences. For example, childhood trauma may
negatively impact child and adolescent development through a num-
ber of different pathways including brain development (e.g., Bremner,
2003;De Bellis et al., 1999), neuroendocrinology (e.g., Heim &
Nemeroff, 2001;Lupien, McEwen, Gunnar, & Heim, 2009), psycho-
social effects (e.g., poor attachment, peer relationships; Maughan &
Cicchetti, 2002;Putnam & Trickett, 1997), and such health risk
behaviors as smoking (Dube, Felitti, Dong, Giles, & Anda, 2003),
substance abuse (Anda et al., 2006), and sexual promiscuity (Trickett,
Noll, & Putnam, 2011).
Traumatic events and other adverse childhood experiences rarely
occur in isolation; instead, they are typically interrelated and tend to
co-occur in constellations (Anda et al., 2006;Dong et al., 2004;Felitti
et al., 1998;Finkelhor, Turner, Ormrod, & Hamby, 2009;Pynoos et
al., 2008;Spinazzola et al., 2005;van der Kolk, Roth, Pelcovitz,
Sunday, & Spinazzola, 2005). Indeed, multiple episodes of trauma
exposure are more likely than not to co-occur (Kessler, 2000) and to
exert more potent predictive effects than single exposures alone
(Finkelhor et al., 2009;Kisiel et al., 2014, pp. S29–S39; Pynoos et al.,
2014, pp. S9–S17; Spinazzola et al., 2014, pp. S18–S28). For exam-
ple, multiple trauma exposures predicted youths’ increased risk for
both delinquency and psychiatric impairment in a recent study (Ford,
Elhai, Connor, & Frueh, 2010). Such findings are of particular con-
cern given the risk that trauma exposure poses for disrupting critically
important developmental tasks of adolescence (e.g., forming healthy
romantic relationships), which disruptions can “snowball” and cas-
cade into longer-term adverse negative physical and psychological
sequelae (Kerig, 2014;Layne, Briggs, & Courtois, 2014, pp. S1–S8;
Loeber, Lacourse, & Homish, 2005). In this regard, a recent longitu-
dinal study of a high-risk community sample found that female, but
not male, adolescents with higher internalizing or externalizing symp-
toms were significantly more likely to be exposed subsequently to
assaultive violence after controlling for family adversities (Haller &
Chassin, 2012). This finding is consistent with those documenting a
high risk for subsequent victimization among individuals traumatized
over the course of childhood (e.g., Duckworth & Follette, 2012).
These findings among child and adolescent populations are
buttressed by retrospective studies with adults exposed to trauma
and other severe childhood adversities. Indeed, a main information
source regarding the sequelae of severe childhood adversities in
adulthood consists of a series of retrospective studies with adult
populations commonly referred to as the Adverse Childhood Ex-
periences (ACE) studies (e.g., Felitti et al., 1998). The ACE and
related adult retrospective studies consistently report dose-
response associations between the total number of childhood ad-
versities and leading causes of death in adulthood, including heart
disease, cancer, and chronic lung disease (e.g., Appleyard, Ege-
land, van Dulmen, & Sroufe, 2005;Brown et al., 2009;Felitti et
al., 1998). Childhood adversities are also risk factors for adult
psychiatric symptoms and disorders including depression (Chap-
man et al., 2004;Dube et al., 2003;Edwards, Holden, Felitti, &
Anda, 2003;Felitti et al., 1998;Ford et al., 2010;Trickett et al.,
2011;Vythilingam et al., 2002), alcohol-related disorders (Clark,
Thatcher, & Martin, 2010;Dube et al., 2003;Felitti et al., 1998;
Ford et al., 2010), self-regulatory disturbances (Cloitre et al.,
2009), generalized anxiety disorder (Cougle, Timpano, Sachs-
Ericsson, Keough, & Riccardi, 2010), and posttraumatic stress
disorder (PTSD) (Bremner et al., 1993;Cougle et al., 2010;Ford
et al., 2010;Kendall-Tackett, Williams, & Finkelhor, 1993).
Notwithstanding their valuable contributions to the identifica-
tion of links between exposure to trauma and other severe adver-
sity in childhood, and the emergence of mental and physical health
problems in adulthood, the ACE and related adult retrospective
studies carry significant limitations. These include: (a) concerns
regarding the accuracy and validity of adult retrospective reports
of adverse events that took place many years before (Hardt &
Rutter, 2004), (b) a lack of inclusion of many known severe
childhood adversities, (c) the studies give limited attention to
proximal adverse outcomes as manifest in adolescence, and (d) the
studies provide limited information concerning the cumulative
impact of multiple adverse events. For example, many ACE-based
studies include only a limited number of adverse life events (e.g.,
emotional abuse, sexual abuse, physical abuse, domestic violence,
parental separation/divorce, mental illness in household, house-
hold substance abuse, criminal household member, emotional ne-
glect, and physical neglect) (Brown et al., 2010;Brown et al.,
2009). Other severe childhood adversities, whether common (e.g.,
bereavement) or comparatively rare (e.g., natural disaster) are
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S41
TRAUMA EXPOSURE AND ADOLESCENT HIGH-RISK BEHAVIORS
omitted although they may lead to similarly devastating conse-
quences (see Layne et al., 2010).
Although links between childhood adversities and later adult
health or mental health problems are well-established at the pres-
ent time, considerably less is known about links between histories
of exposure to multiple types of trauma and loss throughout
childhood and high-risk behaviors in adolescence. For this reason,
studies examining a diverse range of types of traumatic experi-
ences and high-risk adolescent behaviors in diverse samples are
needed to explore the proximal sequelae of trauma exposure early
in life. In particular, the study of trauma-induced developmental
derailment in adolescence (as a proximal adverse outcome) is of
great interest given that this developmental period creates three
valuable windows of opportunity. These include: (a) filling in gaps
in scientific knowledge regarding how exposure to trauma, loss,
and other severe adversities in childhood lead to subsequent social,
emotional, and cognitive impairments, as well as the adoption of
health risk behaviors—adverse proximal outcomes designated in
the ACE pyramid as precursors to disease, disability, social prob-
lems, and early death in adulthood (Felitti et al., 1998;Layne,
Briggs, et al., 2014); (b) identifying early risk markers for devel-
opmental derailment in adolescence and beyond (e.g., Loeber et
al., 2005); and (c) expanding the range of candidate targets for
prevention and early intervention efforts (Saewyc & Edinburgh,
2010) by identifying factors that practitioners can flexibly target
with the aim of interrupting causal connections (e.g., mediated
links) that lead from childhood trauma and loss to adult-era dete-
rioration and premature death (Layne, Briggs, et al., 2014;Layne,
Steinberg, & Steinberg, 2014).
The present study sought to fill in knowledge gaps regarding the
effects of childhood adversity and trauma on adolescents by ex-
amining nearly 4,000 adolescents (aged 13 to 18) with histories of
exposure to trauma and loss who were receiving mental health
services in community- or hospital-based clinics across the United
States. Data on these individuals were captured in the Core Data
Set (CDS) as collected by the National Child Traumatic Stress
Network (NCTSN) (Pynoos et al., 2008). This study design pro-
vided the opportunity to incorporate both a broader range of
adverse life events (specifically, by assessing a wide range of types
of traumatic experiences and losses in childhood through adoles-
cence), as well as a broader range of psychosocial outcomes (by
assessing nine types of high-risk adolescent behaviors and func-
tional impairment) than have been reported previously. We hy-
pothesized that each additional type of trauma exposure would
significantly increase the odds likelihood for the presence of each
type of high-risk adolescent behavior, after controlling for the
predictive effects of demographic variables.
Method
Participants
The CDS contains information on a large national sample (N
14,088) of children and adolescents who sought health services
through agencies affiliated with the National Traumatic Stress
Network (Layne, Briggs, et al., 2014). Given the focus of this
study on high-risk adolescent behavior, cases were selected for
analysis (n3,785) based on three criteria: (a) reported at least
one confirmed or suspected type of trauma, (b) completed demo-
graphic data and indicators of high-risk behavior at baseline, and
(c) were between 13 and 18 years of age at baseline.
Measures
Demographics. Clinicians completed demographic informa-
tion at baseline, including age (in years), sex (male vs. female),
race (White vs. Black vs. Other), ethnicity (Hispanic/Latino vs.
not), current primary residence (home, living with relatives, foster
care, or residential treatment center), and eligibility for public
health insurance (e.g., Medicaid, State Health Insurance) which
served as a proxy for low income.
Trauma exposure. Lifetime history of trauma exposure was
evaluated using the Trauma History Profile (THP; Pynoos et al.,
2014), the trauma exposure screening component of the UCLA
PTSD Reaction Index (PTSD RI; Steinberg, Brymer, et al., 2013).
NCTSN care providers completing the THP were provided with
standardized definitions for each trauma type (adapted from the
National Child Abuse and Neglect Data System glossary, U.S.
Department of Health and Human Services Administration for
Children & Families, 2000) as part of their training in administer-
ing the CDS. The THP assesses exposure to 20 different types of
trauma and loss across childhood and adolescence, including: (a)
sexual abuse/maltreatment; (b) sexual assault/rape; (c) physical
abuse/maltreatment; (d) physical assault; (e) emotional abuse/psy-
chological maltreatment; (f) neglect; (g) domestic violence; (h)
war/terrorism/political violence inside the United States; (i) war-
terrorism/political violence outside the United States; (j) illness/
medical trauma; (k) injury/accident; (l) natural disaster; (m) kid-
napping; (n) traumatic loss/bereavement/separation; (o) forced
displacement; (p) impaired caregiver; (q) extreme personal/inter-
personal violence; (r) community violence; and (s) other trauma.
Providers completed the THP, either at intake or early in the course
of services, by judging whether each trauma type was confirmed,
suspected,ordid not occur. Information about trauma, loss, be-
reavement, and separation experiences was obtained from multiple
informants, including the child or adolescent, parents/caregivers,
and other relatives. For purposes of the study, we created a Total
Types of Trauma and Loss exposure variable by summing the total
number of different types of trauma each youth reported experi-
encing (theoretical range 1 to 20). We then used this variable to
test hypothesized dose-response relations between exposure to a
broad range of types of trauma and loss, and various indicators of
high-risk adolescent behavior and functional impairment.
High-risk adolescent behavior. Clinicians evaluated high-
risk adolescent behavior using the Indicators of Severity of Func-
tional Problems, a quality assurance tool developed for the CDS to
assess the severity of a wide range of types of high-risk behavior,
behavioral problems, and functional impairment (Layne, Briggs, et
al., 2014). Service providers rated the presence or absence of each
problem during the previous 30 days on a 3-point scale ranging
from 0 (not a problem), 1 (somewhat a problem), to 2 (very much
a problem). We selected 9 of the 14 indicators of high-risk behav-
ior and functional impairment contained in the CDS based on their
relevance to assessing adolescent high-risk behavior. These in-
cluded: (a) criminal activity (activities that have resulted in being
stopped by the police or arrested), (b) sexual exploitation (ex-
changing sex for money, drugs, or other resources in the role of a
victim, e.g., prostitution), (c) suicidality (suicidal ideation or at-
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S42 LAYNE ET AL.
tempt), (d) other self-injurious behaviors (cutting, pulling out
one’s hair), (e) alcohol use, (f) substance use, (g) running away
from home (staying away for at least one night), (h) problems with
skipping school (skipped at least 4 days in the past month, or
skipped parts of the day for at least half of the school days), and
(i) attachment problems (difficulty forming and maintaining trust-
ing relationships with other people–conceptualized as an indicator
of interpersonal functional impairment). To improve within-cell
distributions and design parsimony, we collapsed “somewhat/
sometimes a problem” and “very much/often a problem” into one
category for each high-risk indicator, deriving a new dichotomous
variable (yes/no) for each indicator.
Results
Preparatory Analyses
We used SAS Version 9.2 (Cary, NC) to compute raw frequencies
and percentages for demographic variables, confirmed/suspected
trauma exposure, and functional impairment. We also calculated odds
ratios and confidence intervals to investigate potential relations be-
tween demographic and trauma exposure variables as predictors and
types of high-risk adolescent behavior and functional impairment as
criterion variables. To account for possible intraclass correlations
arising from youth receiving services at different NCTSN mental
health center sites, we adjusted for center-level effects using a
random-effects model, thereby controlling for the possibility that
participants within the same sites produced scores more similar to one
another compared with scores of participants from different sites.
Demographic Characteristics and Endorsement Rates
for Different Types of Trauma Exposure
Table 1 presents sample demographic characteristics. Participat-
ing adolescents had a mean age of 15.3 years (SD 1.4); a
majority were female (63%) and identified as White (64%). Inter-
viewing clinicians reported that a majority lived at home with
parents (63%); the remainder lived with other relatives (13%), in
foster care (9%), or residential care settings (9%). The subsample
contained a higher proportion of females, as well as White ado-
lescents, compared with the full CDS sample (described else-
where; see Briggs et al., 2013).
Table 2 shows endorsement rates (combined confirmed/suspected,
as noted earlier) for exposure to each of the 20 trauma types. The
mean number of reported trauma types was 4.19 (SD 2.68);
endorsement rates for a given type ranged from 1.5% (war/terrorism/
political violence) to 57.5% (traumatic loss/bereavement/separation).
Relatively common types of trauma exposure included intrafamilial
events (e.g., domestic violence, abuse), followed by various forms of
assault and violence, serious injury, and medical illness. Rarer forms
of exposure included natural disasters, kidnapping, and forced dis-
placement. The total number of trauma types reported, as well as rates
of endorsement within specific trauma types, were slightly higher in
general compared to the full (combined child and adolescent) CDS
sample (see Briggs et al., 2013). This finding served as a validity
check for the study design, given our assumption that various types of
trauma and loss co-occur, accumulate in number, and accrue in their
risks across childhood and adolescence (Layne, Briggs, & Courtois,
2014).
Endorsement Rates for Adolescent High-Risk Behavior
and Functional Impairment
Endorsement rates for specific types of high-risk adolescent
behaviors, as well as an indicator of functional impairment (at-
tachment problems) are presented in Table 3. Nearly half the
sample endorsed attachment problems (47.4%), whereas approxi-
mately one-fourth endorsed persistent suicidal ideation or attempts
(24.5%) as well as skipping school (27.2%). Most other indicators
of high-risk behaviors (e.g., alcohol and substance abuse, self-
Table 1
Demographic Characteristics (n 3,785)
Mean (SD)orN(%)
Mean age (in years) 15.3 (1.43)
Gender
Female 2,372 (62.7)
Male 1,413 (37.3)
Ethnicity
Not Hispanic or Latino 2,295 (64.6)
Hispanic or Latino 1,256 (35.4)
Race
White 2,041 (63.5)
Black 906 (28.2)
Other 268 (8.3)
Current primary residence
Home (with parents) 2,140 (62.7)
With relatives 429 (12.6)
Regular foster care 207 (6.07)
Treatment foster care 109 (3.19)
Residential treatment center 310 (9.08)
Independent 33 (0.97)
Correctional facility 30 (0.88)
Homeless 11 (0.32)
Eligible for public insurance 2,286 (60.4)
Table 2
Endorsed Types of Trauma Exposure
Mean trauma types (SD) 4.19 (2.68)
N(%)
Traumatic loss or bereavement 2,100 (57.5)
Domestic violence 1,772 (49.3)
Emotional abuse 1,619 (45.4)
Impaired caregiver 1,532 (44.7)
Physical abuse 1,288 (35.8)
Neglect 1,008 (27.9)
Sexual abuse 968 (26.8)
Community violence 952 (26.6)
Sexual assault 890 (24.9)
School violence 707 (19.9)
Physical assault 673 (18.9)
Serious injury or accident 555 (15.3)
Other 433 (12.9)
Illness or medical trauma 431 (11.9)
Interpersonal violence (not reported elsewhere) 330 (9.59)
Natural disaster 268 (7.32)
Kidnapping 106 (2.89)
Forced displacement 89 (2.43)
War or terror outside the United States 73 (1.97)
War or terror in the United States 57 (1.56)
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S43
TRAUMA EXPOSURE AND ADOLESCENT HIGH-RISK BEHAVIORS
injurious behavior) were endorsed by 15% to 20% of cases, with
the exception of sexual exploitation (1.0%).
To examine hypothesized dose-response predictive relations
between demographic variables and the Total Types of Trauma
and Loss Exposure variable (as predictors), and indicators of
adolescent high-risk behavior and functional impairment (as cri-
terion variables), we constructed a series of logistic regression
models, one model per criterion variable. The models consisted of
the predictors age (in discrete years), sex (with male as the refer-
ence group), race (with White as the reference group), ethnicity
(with non-Latino/non-Hispanic as the reference group), public
insurance status (a proxy variable for poverty, with no public
insurance as the reference group), and total types of trauma and
loss exposure (see Table 4 and 5for odds ratios and confidence
intervals). As hypothesized, odds ratios indicated that, after ac-
counting for the predictive effects of the modeled demographic
variables, a 1-unit increase in each type of trauma or loss exposure
significantly increased the odds likelihood ratios for each of the
nine types of adolescent high-risk behavior and functional impair-
ment under study. Odds ratios ranged in magnitude from 1.06 for
skipping school to 1.22 for attachment problems. These odds ratios
indicate that (after controlling for five demographic variables)
each additional type of trauma or loss exposure during childhood
or adolescence increased the odds ratios for attachment problems
by 22%; sexual exploitation by 18%; running away from home by
14%; criminal activity by 13%; suicidality by 12%; self-injurious
behavior by 11%; alcohol use by 11%; substance abuse by 8%;
and skipping school by 6%.
Also shown in Table 4 and 5, several demographic variables
also emerged as significant predictors of high-risk behavior and
functional impairment. Girls were significantly more likely than
boys to be rated as having difficulties with attachment, suicidality,
self-injurious behavior, and sexual exploitation. Further, adoles-
cents rated as eligible for public insurance were also more likely to
have problems with criminal activity and attachment. As an addi-
tional validity check (and underscoring the relevance of studying
high-risk behavior in adolescence), increasing age significantly
increased the odds ratios of several indicators of high-risk behavior
including skipping school, substance abuse, criminal activity, al-
cohol use, and running away from home.
Discussion
Adolescence is a pivotal developmental period that serves as a
passageway to adulthood (Macmillan & Hagan, 2004;Piquero,
Brame, Mazerolle, & Haapanen, 2002). Identifying risk factors for
problematic adolescent transitions to adulthood is of great impor-
tance, given that trajectories established during the transition to
early adulthood are strongly linked to mental and physical health,
quality of life, and citizenship-related outcomes in later adulthood
(Piquero, Fagan, Mulvey, Steinberg, & Odgers, 2005;Sampson &
Laub, 1993), including the risk of developmental derailment into
criminal behavior (Moffitt, 1993;Sampson & Laub, 1993). The
purpose of the present study was to replicate and extend the ACEs
and related adult retrospective studies (which examine links be-
tween severe childhood adversities and adverse outcomes in adult-
hood) by incorporating an explicit focus on high-risk behavior and
functional impairment in adolescence as proximal adverse out-
comes. Specifically, we incorporated a broad spectrum of 20
different types of trauma and loss exposure (including “other”) as
predictors, in conjunction with 9 different types of adolescent
high-risk behavior and functional impairment as outcome criterion
variables.
A sobering finding was that study participants had histories
of exposure to an average of more than four different types of
trauma and loss during childhood and adolescence. Consistent
with the concept of a risk factor caravan, characterized by a
cluster of co-occurring adversities that accumulate over time
(Layne, Briggs, & Courtois, 2014), the most frequently reported
adverse events among adolescents were traumatic loss/bereave-
ment/separation and various types of intrafamilial trauma.
Trauma-exposed adolescents also reported numerous high-risk
Table 3
Adolescent High-Risk Behavior and Functional Impairment
(n 3,785)
Variable N%
Attachment problems 1573 47.4
Skipping school 942 27.1
Substance abuse 687 20.2
Suicidality 861 24.5
Criminal activity 595 16.8
Self-injurious behaviors 577 16.3
Alcohol use 562 16.4
Running away from home 544 15.3
Sexual exploitation 36 1.0
Table 4
Odds Ratios and Confidence Intervals for Attachment, Skipping School, Substance Abuse, Suicidality, and Criminal Activity
Attachment Skipping school Substance abuse Suicidality Criminal activity
Age 1.04 (0.98, 1.11) 1.20 (1.12, 1.28)
ⴱⴱⴱ
1.36 (1.25, 1.46)
ⴱⴱⴱ
1.02 (0.96, 1.09) 1.10 (1.02, 1.19)
Female 1.25 (1.05, 1.49)
0.86 (0.72, 1.04) 0.58 (0.46, 0.72)
ⴱⴱⴱ
1.60 (1.32, 1.94)
ⴱⴱⴱ
0.41 (0.33, 0.51)
ⴱⴱⴱ
Hispanic
a
0.91 (0.70, 1.17) 1.32 (1.01, 1.71)
0.85 (0.61, 1.19) 0.98 (0.75, 1.29) 0.75 (0.53, 1.05)
Black
b
0.95 (0.75, 1.18) 0.92 (0.72, 1.17) 0.63 (0.47, 0.85)
ⴱⴱ
0.64 (0.50, 0.82)
ⴱⴱⴱ
1.03 (0.78, 1.36)
Other
b
1.09 (0.79, 1.49) 1.17 (0.84, 1.62) 0.92 (0.62, 1.36) 0.74 (0.52, 1.04) 0.83 (0.55, 1.25)
Public insurance 1.39 (1.14, 1.68)
ⴱⴱⴱ
1.17 (0.95, 1.44) 0.94 (0.73, 1.20) 0.83 (0.67, 1.02) 1.34 (1.04, 1.73)
Number of trauma types
c
1.22 (1.17, 1.26)
ⴱⴱⴱ
1.06 (1.03, 1.10)
ⴱⴱⴱ
1.08 (1.03, 1.12)
ⴱⴱⴱ
1.12 (1.08, 1.16)
ⴱⴱⴱ
1.13 (1.08, 1.18)
ⴱⴱⴱ
a
Reference ethnic category: non-Hispanic.
b
Reference race category: White.
c
ORs are associated with a 1-unit increase in total number of types of
trauma and bereavement loss.
p.05.
ⴱⴱ
p.01.
ⴱⴱⴱ
p.001.
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
S44 LAYNE ET AL.
behavior problems, as well as functional impairment (attach-
ment problems). At least 20% of participants reported difficul-
ties with attachment, skipping school, substance abuse, and
suicidality. These findings are consistent with prior ACE-
related studies reporting robust relations between adverse child-
hood events and many types of high-risk behaviors including
delinquency (Ford et al., 2010), impaired attachment (Maughan
& Cicchetti, 2002;Putnam & Trickett, 1997), substance abuse
(Anda et al., 2006), and sexual promiscuity (Trickett et al.,
2011) (see Kerig, 2014, for a review).
Our findings also contribute to the study of the adverse
consequences of cumulative developmental risks (e.g., Evans,
2003) by examining relations between the cumulative number
of types of trauma and loss exposure and behavior problems and
functional impairment in adolescence. Consistent with our hy-
pothesis, and with the findings of prior studies with adults
reporting strong relations between ACEs and maladaptive out-
comes later in life (e.g., Appleyard et al., 2005), each additional
type of trauma and loss exposure significantly increased the
odds ratios for high-risk adolescent behavior problems and/or
functional impairment by 6% to 22% in each of the nine
domains under study. Some demographic variables (e.g., gen-
der) were also significant predictors of some, but not all, types
of high-risk adolescent behavior and functional impairment.
Our finding of an increased odds likelihood for attachment
problems, suicidality, self-injury, and sexual exploitation
among trauma-exposed girls is consistent with prior research
identifying an increased risk among adolescent girls for inter-
nalizing problems (Lewinsohn, Hops, Roberts, Seeley, & An-
drews, 1993;Zahn-Waxler, 1993). In addition, our finding that
publicly insured trauma-exposed adolescents were at signifi-
cantly greater risk for criminal activity and impaired attachment
is consistent with prior research documenting the far-reaching
adverse impacts of economic disadvantage among youth
(Dodge & Pettit, 2003), and illustrates links that are theorized
to exist between socioeconomically disadvantaged “caravan
passageways,” risk factor caravans, and consequent loss cycles
(Layne, Briggs, et al, 2014).
Study Implications
These study results are useful in filling in scientific knowl-
edge gaps regarding how exposure to trauma, loss, and other
severe adversities in childhood may contribute to risk factor
caravans—the central theme of this special section (Layne,
Briggs, et al., 2014). These caravans are characterized by the
accumulation of co-occurring risk factors over time, which
accrue in their adverse effects and cascade forward into subse-
quent developmental stages. Our results are consistent with the
proposition that these “cascading effects” may manifest in
adolescence as various forms of high-risk behaviors (e.g., run-
ning away, self-injurious behavior), as well as social, emo-
tional, and cognitive impairments (particularly attachment
problems). These factors carry their own separate risks and are
theorized to serve as causal precursors that contribute to an
elevated risk for disease, disability, social problems, and early
death in adulthood (Felitti et al., 1998,Layne, Steinberg, et al.,
2014).
Findings from this study are of particular societal concern
given the cascading negative impacts, including societal costs,
that high-risk behavior and functional impairment in adoles-
cence can have on adolescent development, the transition to
young adulthood (e.g., Dodge & Pettit, 2003), and the overall
life course (Kerig, 2014;Laub & Sampson, 2003). For example,
difficulties with school and/or peer relationships are linked to
persistent physically aggressive behavior, academic failure, and
school dropout (e.g., Maguin & Loeber, 1996), which may in
turn set the stage for other negative consequences including
teen pregnancy (Maynard, 1995), substance abuse (e.g., Bryant,
Schulenberg, Bachman, O’Malley, & Johnston, 2000), and de-
linquency (e.g., Hawkins et al., 1998;Herrenkohl, Herrenkohl,
& Egolf, 1998;Huizinga & Jakob-Chien, 1998;Lipsey &
Derzon, 1998;Maguin & Loeber, 1996;Moffitt, 1993). Of
particular interest is the identification of factors within chil-
dren’s and adolescents’ physical and social ecologies that are
both causally influential and therapeutically modifiable, and
thus could play a significant role in preventing, interrupting, or
slowing the accumulation of risk factor caravans before they
“cascade” into adulthood. Such “high-value” intervention tar-
gets have been termed evidence-based intervention foci and
merit careful scrutiny (e.g., feasibility, cost-benefit analysis)
from both intervention and public policy perspectives (Layne,
Steinberg, et al., 2014). For example, youths’ caregiving envi-
ronments appear to be of key importance in preventing or
interrupting adverse cascades leading from severe childhood
adversity to adverse outcomes in adolescence and adulthood
(e.g., early loss of a mother, followed by precocious sexual
Table 5
Odds Ratios and Confidence Intervals for Self Injurious Behaviors, Alcohol Use, Running Away From Home, and Sexual Exploitation
Self-injurious behaviors Alcohol use Running away from home Sexual exploitation
Age 0.96 (0.89, 1.04) 1.42 (1.31, 1.54)
ⴱⴱⴱ
1.09 (1.00, 1.18)
0.89 (0.66, 1.19)
Female 2.27 (1.78, 2.90)
ⴱⴱⴱ
0.88 (0.70, 1.11) 1.18 (0.93, 1.50) 12.89 (1.73, 96.19)
Hispanic
a
0.80 (0.59, 1.09) 0.88 (0.63, 1.23) 1.11 (0.80, 1.56) 0.66 (0.21, 2.06)
Black
b
0.34 (0.24, 0.46)
ⴱⴱⴱ
0.46 (0.33, 0.64)
ⴱⴱⴱ
1.43 (1.07, 1.91)
1.44 (0.56, 3.72)
Other
b
0.71 (0.48, 1.06) 0.69 (0.45, 1.05) 0.86 (0.56, 1.33) 1.96 (0.62, 6.16)
Public insurance 0.95 (0.74, 1.21) 1.05 (0.81, 1.35) 1.14 (0.88, 1.49) 1.03 (0.41, 2.61)
Number of trauma types
c
1.11 (1.06, 1.15)
ⴱⴱⴱ
1.11 (1.07, 1.16)
ⴱⴱⴱ
1.14 (1.09, 1.19)
ⴱⴱⴱ
1.18 (1.03, 1.35)
a
Reference ethnic category: non-Hispanic.
b
Reference race category: White.
c
ORs are associated with a 1-unit increase in total number of types of
trauma and bereavement loss.
p.05.
ⴱⴱ
p.01.
ⴱⴱⴱ
p.001.
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
S45
TRAUMA EXPOSURE AND ADOLESCENT HIGH-RISK BEHAVIORS
behavior, followed by teenage pregnancy, followed by in-
creased risk for depression and divorce in adulthood; Brown,
Harris, & Bifulco, 1986). Such caregiving environments thus
constitute promising evidence-based intervention foci (Layne,
Briggs, et al., 2014).
Last, these findings underscore the value of screening for
exposure to a broad range of types of trauma and loss when
evaluating the developmental history of adolescents presenting
with high-risk behavior or attachment-related functional im-
pairment. Moreover, systematically assessing for both exposure
to a diverse variety of exposures to trauma and loss, in con-
junction with multiple types of high-risk behavior and func-
tional impairment, will permit researchers and clinicians to
examine more comprehensively the role that trauma and loss
exposure plays in the development and maintenance of specific
adolescent behavioral and functional problems (Kerig, 2014).
Such efforts should reflect the assumption that different types
of trauma and loss exposure at different developmental periods
can operate through different pathways of influence and may
lead to distinctly different sequelae (Layne et al., 2009;Layne,
Briggs, et al., 2014;Layne et al., 2010).
Study Strengths
Study strengths include the large size and national breadth of
the NCTSN, which spans many diverse geographic regions and
settings and ensures considerable diversity in geographic set-
tings, staff size and composition, institutional affiliations, areas
of specialization, and populations served (Pynoos et al., 2008).
In addition, the study established that a broad range of types of
traumatic and loss-related experiences during childhood and
adolescence each constitutes a risk marker (Layne et al., 2009;
Layne, Steinberg et al., 2014) for many different types of
high-risk adolescent behaviors, as well as functional impair-
ment (specifically attachment problems). Further, our study
design addressed some of the limitations of the ACEs adult
retrospective studies. Specifically, we (a) used a diverse na-
tional sample of children and adolescents referred for mental
health services at clinics specializing in trauma-focused assess-
ment and intervention, and (b) included a broader range of
trauma, losses, and other severe adversities in childhood and
adolescence (Layne, Briggs, et al., 2014;Layne et al., 2006).
We also (c) focused on adolescent-era high risk behavior and
functional impairment as proximal adverse outcomes, which we
theorized may mediate and/or moderate the causal links be-
tween childhood ACEs and adult pathology (Felitti et al., 1998;
Layne, Steinberg, et al., 2014), and (d) gave greater attention to
the cumulative impact of multiple adverse events as these may
accrue across adolescence and cascade forward into young
adulthood (Layne, Briggs, et al., 2014).
Study Limitations
This article is the first in a series of planned studies involving
the NCTSN CDS focused on “unpacking” elements of risk
factor caravans and ways in which they intersect with other
trauma-related variables (e.g., PTSD symptoms) as a function
of developmental stage. Given its foundational role of initially
testing hypothesized dose-response relations between total
number of types of trauma and loss exposure and high-risk
adolescent behavior, our study design unit-weighted (i.e., ac-
corded similar weights to) different types of trauma and loss—a
methodology that can obscure differential relations between
causal precursors and causal consequences, and predictors and
criterion variables, where they exist (see Layne, Steinberg, et
al., 2014;Layne et al., 2010). This study examined lifetime
exposure to different types of trauma and did not incorporate
different parameters of exposure to trauma and loss (e.g., age of
exposure onset, duration across years, weapon use, and devel-
opmental span). Such variables will be important to incorporate
into subsequent study designs to better unpack the social and
physical ecologies that “risk factor caravan passageways”
—passageways that give rise to trauma and loss exposure early
in life and continue to to shape ongoing risk, vulnerability, and
adjustment into early adulthood and beyond...(Layne, Briggs,
et al., 2014). Moreover, the cross-sectional study design did not
permit monitoring of changes in high-risk behavior and func-
tional impairment over time as a function of participation in
trauma-focused intervention. Notably, preliminary analyses
have yielded encouraging results in this regard, suggesting that
participation in trauma-focused treatment is linked to signifi-
cant reductions in a variety of such “high risk” indicators
(Layne, Ostrowski, et al., 2010). Last, although the CDS facil-
itates exploration of questions within “real world” clinical
settings, it was primarily established as a quality improvement
initiative; thus, CDS data should not be presumed to be nation-
ally representative. Rather, these findings can be reasonably
expected to generalize to programs in child service settings that
are similar to the diverse array of NCTSN sites that participated
in this study (e.g., community- and school-based mental health,
juvenile justice).
Directions for Further Study
Planned studies include utilizing the CDS to “unpack” differ-
ential predictive effects of different constellations of trauma ex-
posure and distress symptom clusters in relation to specific types
of adolescent high-risk behavior and functional impairment (Layne
et al., 2010)—a line of inquiry that has yielded promising initial
findings (Ostrowski, Greeson, Briggs-King, Fairbank, & Layne,
2010). Other planned studies will examine the effectiveness of
trauma-focused intervention in reducing the likelihood of these
same problem outcomes, as a function of treatment sessions, in an
innovative approach to defining and evaluating “clinically signif-
icant change” (Layne, Ostrowski, et al., 2010) as gauged using a
variety of “real world” metrics that carry direct relevance for
consumers (see Kazdin, 2006). The broad range of assessment
tools making up the CDS will also permit studies examining
differential associations linking specific constellations and differ-
ent parameters of trauma and loss exposure, including age of onset,
duration, and sequencing of specific trauma types within and
across childhood and adolescence, to specific sequelae (see Stein-
berg et al., 2014, pp. S50–S57).
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Received December 19, 2012
Revision received July 29, 2014
Accepted July 29, 2014
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TRAUMA EXPOSURE AND ADOLESCENT HIGH-RISK BEHAVIORS
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