Area-level deprivation and adverse childhood experiences among high school students in Maryland

Although adversity has long been a focus of research on the etiology of behavioral problems, much of the scientific thinking on the link between adversity and health comes from the 1998 “Adverse Childhood Experiences Study,” which investigated health in association with childhood exposure to substance use, mental illness, violence, criminal behavior, and child maltreatment (including psychological, physical, and sexual abuse) [1, 2]. The study demonstrated that there are strong associations between adverse childhood experiences (ACEs) and a broad array of problems spanning physical health, mental and behavioral health, and psychosocial functioning [3‐8]. The link between ACEs and health problems has been attributed to prolonged activation of the stress-response system, leading to maladaptive coping, impulsivity, and impairments in learning, attention, and decision-making [9, 10]. Current research indicates that nearly one-half of Americans have at least one ACE before turning 18 years old, and that the annual costs to society exceeds a billion dollars [8, 11].

It has now been two decades since the ACE Study, and a strong body of work demonstrates that adversity is a critical factor in adolescent risk behaviors, including violence, school failure, and substance use [11‐15]. Broader recognition of how adversity shapes adolescent behavioral health has led to an increased focus on preventing risk behaviors by attending to underlying trauma [8, 16‐18], typically through interventions and services at the community and organizational levels. Interventions include strategies such as connecting youth to supportive adults through mentoring programs, implementing mindfulness training in schools, and screening for ACEs by pediatricians and other health care providers [2, 17, 18]. Although important, these types of psychosocial interventions do not address societal factors that increase risk for youth adversity [19]. Initiatives that target structural factors have the potential to prevent children from experiencing ACEs. For example, policies to reduce deportations, replace incarceration with alternate criminal sanctions, and broaden the economic safety-net could decrease the number of children who face adverse experiences such as parental separation and food insecurity [1, 20, 21]. The combination of structural interventions to prevent youth adversity and psychosocial approaches to attend to youth who have experienced adversity could be powerfully effective at ensuring the health and well-being of adolescents. Therefore, an important next step for preventing ACEs – and the focus of this study – is to identify whether societal factors increase risk for ACEs.

Living in an area characterized by socioeconomic disadvantage increases risk for a range of health and social problems [22, 23] and may also increase risk for youth adversity. Research shows that individuals living in areas of greater deprivation are more likely to experience morbidity and mortality, even after adjusting for individual-level sociodemographic factors [23, 24]. Several studies indicate that low socioeconomic position is associated with increased risk for ACEs [25‐29]. People from low-income households are at greater risk for experiencing specific types of ACEs [26] and for overall greater numbers of ACEs [29]; low socioeconomic position is also a positive moderator of the association between ACEs and health outcomes [28]. However, studies investigating whether area-level socioeconomic disadvantage is associated with increased risk for ACEs are surprisingly sparse. It is not known whether the deprivation-adversity link would hold if disadvantage were conceptualized as a feature of the social environment, versus an individual or family characteristic. Understanding the relationship between area-level disadvantage and adversity would provide clues about how structural factors influence risk for ACEs.

The purpose of this study is to investigate the association between county-level disadvantage and ACEs among a representative, population-based sample of Maryland high school students. We explored five ACEs: food insecurity, parental substance use/gambling, parental mental illness, family member in jail/prison, and caregiver verbal abuse. This set of ACEs is common and strongly associated with later problems in life, including mental disorders [30, 31]. Given that risk for negative outcomes is higher among those who reported more ACEs, we also examined how many of the ACEs students reported [30]. We used the area deprivation index (ADI) to measure county-level disadvantage; ADI is a validated, composite indicator of socioeconomic disadvantage that spans four domains: income, housing, employment, and education [32]. Our findings will provide needed information about area-level disadvantage and youth adversity, and may provide a foundation for research to contextualize the drivers of disparities in ACEs.

For all six samples (i.e., each of the 5 ACEs and a sixth sample measuring 1 or more ACEs versus none), approximately 45% of the students were White, 30% were ≥ 17 years of age, 50% were girls, and 18% were SGM (Table 1). The most commonly reported ACE among White and Latinx students was parental mental illness, whereas having a family member in jail/prison was the most commonly reported ACE among Black students (Table 2). With each increase in age category, respondents were more likely to report having experienced any of the five ACEs. Girls had a higher prevalence than boys of four of the five ACEs; boys were more likely than girls to report having a family member in jail/prison. SGM students had a higher prevalence of all five ACEs relative to cisgender, heterosexual students. The most commonly reported ACE reported among SGM students was parental mental illness.

One-fourth of the students reported just one ACE, whereas 15% reported two and 15.6% reported three or more (Table 3). Black and Latinx students had the lowest prevalence of reporting zero ACEs, ~ 37% for both groups. Boys were more likely than girls to report zero ACEs (47.9% vs. 39.7%), and heterosexual, cisgender students were more likely than their SGM peers to report zero ACEs (47.9% vs 27.1%). Twenty-six percent of SGM students reported 3 or more ACEs, an estimate higher than all other demographic groups.

Multiple regression analyses show that, after adjustment for demographic factors, students in more deprived counties were at an increased likelihood of reporting at least one ACE (Table 4). County-level ADI was associated with increased odds of food insecurity (OR = 1.10, 95% CI: 1.07–1.13), parental substance use/gambling (OR = 1.05, 95% CI: 1.02–1.07), and having a family member who had been to prison/jail (OR = 1.14, 95% CI: 1.09–1.19). Rural county status was associated with increased odds of reporting parental substance use/gambling (OR = 1.24, 95% CI: 1.05–1.47), having a family member in jail/prison (OR = 1.35, 95% CI: 1.04–1.76), and caregiver verbal abuse (OR = 1.25, 95% CI: 1.08–1.46).

Associations between ACEs and race/ethnicity held even after adjustment for county-level ADI and rural status. Compared to White students, Black students were 183% more likely to experience food insecurity, 129% more likely to have a family member in jail/prison, and 16% more likely to experience caregiver verbal abuse. By contrast, Black students were 40% less likely to report parental mental illness than their White peers. Compared to White students, Latinx students had greater odds of reporting food insecurity (OR = 2.75, 95% CI: 2.21–3.42), parental substance use/gambling (OR = 1.40, 95% CI: 1.25–1.58), family member in jail/prison (OR = 2.03, 95% CI: 1.80–2.29), and caregiver verbal abuse (OR = 1.43, 95% CI: 1.33–1.55).

The odds of reporting all five ACEs were particularly high among SGM students relative to heterosexual, cisgender students, and there were also noteworthy associations between ACEs and age, sex, and rural county status. SGM students were 131% more likely to report at least one ACE and were at least 50% more likely to report each of the five ACEs. Living in a rural county was associated with increased risk for reporting parental substance use/gambling (OR = 1.24, 95% CI: 1.05–1.47), family member incarceration (OR = 1.35, 95% CI: 1.04–1.76), and caregiver verbal abuse (OR = 1.25, 95% CI: 1.08–1.46), Compared to those aged 14 or younger, students aged 15, 16, or 17 or older had significantly higher odds of reporting four of the five ACEs (the exception being caregiver verbal abuse). Compared to boys, girls were less likely to report having a family member in jail/prison (OR = 0.89, 95% CI: 0.80–0.99), but more likely to report parental mental illness (OR = 1.44, 95% CI: 1.30–1.59), caregiver verbal abuse (OR = 1.21, 95% CI: 1.06–1.37), and at least one ACE (OR = 1.25, 95% CI: 1.17–1.34).

To examine how social factors shape risk for adversity, we investigated county-level socioeconomic disadvantage in association with ACEs among a statewide sample of Maryland high school students. We found that ADI – an indicator of county-level socioeconomic deprivation – was associated with significantly higher odds of reporting three ACEs (i.e., food insecurity, parental substance use/gambling, and having a family member in jail/prison), but was not associated with the other two ACEs (i.e., parental mental illness and caregiver verbal abuse). ADI was also associated with significantly higher odds of reporting at least one ACE. As described in more detail below, the prevalence of specific types of ACEs was higher among youth in rural counties, Black and Hispanic/Latinx youth, and SGM youth. Increased likelihood of ACEs among youth in more disadvantaged counties, in rural counties, and in marginalized populations suggests that social and structural factors shape risk for experiencing adversity.

Rural county status was associated with increased risk for parental substance use/gambling, family member in jail/prison, and caregiver verbal abuse. The fact that it was not associated with increased odds for reporting at least one ACE suggests rural status is linked to specific types of adversity, rather than to adversity in general. Increased risk for these three ACEs could relate to the fact that rural communities have been especially hard hit by substance use problems, especially opioids [45‐49]), as well as by child abuse and neglect, and mass incarceration [50, 51]. Compounding the problem, rural parents and families face isolation and have limited access to social support, family services, and treatment for substance use problems [52‐54].

Black and Latinx students were significantly more likely than White students to report having experienced at least one ACE, highlighting the racialized nature of exposure to adversity among Maryland adolescents. Compared to their White peers, Black and Latinx students were more likely to report food insecurity, that a family member had been to jail/prison, and caregiver verbal abuse. Latinx students were 40% more likely than White students to report parental substance use/gambling; although there was no difference among Black versus White students. Disparities in ACEs likely stem from race-based inequities in social institutions, including education, criminal justice, and workplaces [55, 56]. Notably, Black youth were less likely to report parental mental illness compared to White youth, which could reflect cultural differences in what constitutes mental illness and lower help-seeking behaviors, or an actual difference in prevalence [57].

SGM status was the only demographic factor that was strongly and significantly associated with each of the 5 ACEs and with number of ACEs. These findings are consistent with previous literature in adult [58] and adolescent [59, 60] samples, and there are several explanations for this phenomenon. Given the enduring cultural stigma surrounding their identity, many SGM adolescents may experience rejection and abuse from their parents [61, 62]. SGM adolescents may be kicked out of their home or run away because of abuse [63]. Those youth who attempt to preserve the parental relationship by not disclosing may experience anxiety, isolation, and limited support in navigating peer relationships. Parental rejection of SGM youth may contribute to their increased likelihood for caregiver verbal abuse, parental mental illness, and food insecurity, but it is not entirely clear why SGM adolescents report higher levels of family member incarceration or parental substance use/gambling than their heterosexual, cisgender peers.

Setting the county as the contextual unit of analysis is a strength of our study. Maryland is different from many US states in that counties represent a meaningful unit of the lived experience and the municipal jurisdiction for public school systems, in addition to being a geographic unit for data on population statistics. The MD YRBS/YTS is unique among adolescent health surveillance systems in that it is powered to be representative at the county level, and it includes items on ACEs. Thus, we leveraged a unique opportunity to investigate the association between county-level socioeconomic disadvantage and adversity in a population-based sample of adolescents. Given that data are from a single year in one state, additional studies are required to draw more definitive conclusions about socioeconomic disadvantage and adversity in adolescence. It will also be important to determine how the nature of our observations might change with more detailed measurement of ACEs, such as asking about additional ACEs or clarifying chronicity of experiences.

ACEs can have negative, long-lasting effects on development and can lead to maladaptive coping mechanisms, including substance use [5‐7, 9, 10, 64]. Given the substantial public health burden of ACEs, primary prevention is a key national priority. We demonstrate that area-level socioeconomic disadvantage is linked to the adversity that youth experience, and we also show that there are disparities in adversity among Black, Latinx, rural, and SGM youth. Our findings suggest that strategies for the primary prevention of ACEs should address structural factors such as food access, family financial support, imprisonment as a sanction for criminal behavior, strategies to change cultural attitudes toward LGBT youth and to support their families, and access to family services and behavioral health care.

Importantly, identifying specific structural targets that will move the needle on youth adversity requires careful consideration of the mechanisms through which macro-level phenomena effect families and youth. States and other municipal agencies should prioritize comprehensive assessment of ACEs and how to prevent them. In Maryland, Governor Hogan recently signed an Executive Order proclaiming that it is the State’s policy to promote the understanding of the impacts of adversity, toxic stress, and trauma on development, and to promote resilience through protective factors and programs. Efforts such as this will enable locales to develop trauma-informed programming, interventions, surveillance and screening, and have great potential for reducing the disparate burden of ACEs.