Adverse Childhood Experiences, Traumatic Brain Injuries, and Modifying Effects of Parental Aggravation and Bullying-Victimization Among Children and Adolescents

Abstract

Previous research has shown an association between Adverse Childhood Experiences (ACEs) and traumatic brain injuries (TBIs). Our study seeks to assess the effect of parental aggravation and bullying-victimization on the association between ACEs and TBIs. The sample was 6–17-year-old participants in the 2019 National Survey of Children’s Health (NSCH). Descriptive and multivariate analysis was conducted in SAS 9.4, to examine the association between ACEs and TBIs, and to test for effect modification by parental aggravation and bullying-victimization. Of 19,883 children, 1,188 had a TBI. About 23.0% of children had reported one ACE, followed by 10.3% with two ACEs, 6.1% with three ACEs, and 7.0% with four or more ACEs. Those with four or more ACEs were 1.79 times more likely to have experienced a TBI compared to those with zero ACEs (95% confidence interval (CI) = 1.03–3.13, p-value = 0.04) in adjusted analysis. Those who experienced four or more ACEs and whose parents expressed more frequent aggravation had 2.73 times the odds of having had a TBI, compared to those with zero ACEs and rare parental aggravation. Additionally, those who had four or more ACEs and were victims of bullying were 2.68 times more likely to have experienced a TBI compared to those with zero ACEs. Intervention efforts to reduce parental aggravation and bullying-victimization among children and adolescents may mitigate the association between ACEs and TBIs. Further research is needed to understand the relationship between ACEs and TBIs, emphasizing the role of bullying involvement.

Adverse childhood experiences (ACEs) are events of abuse, neglect, and household dysfunction among 0–17-year-old children and adolescents (Guinn et al., 2019). The first widely used ACE scale included questions assessing physical abuse, emotional abuse, sexual abuse, physical neglect, emotional neglect, substance abuse in household, mental illness in household, parental detention, domestic violence in household and parental separation (Felitti et al., 1998; Guinn et al., 2019; Petruccelli et al., 2019). Newer ACE scales have supplemented the base ACE scale with additional adverse events (Petruccelli et al., 2019). For example, studies have included experiences of violence, economic hardship, parental/caregiver’s loss, and racial discrimination (Bernstein et al., 1995; Ma et al., 2017). Furthermore, exposure to ACEs is associated with adverse outcomes such as chronic diseases, negative behaviors, anxiety and depression, and poor oral health outcomes among children and adolescents(Elmore et al., 2020; Felitti et al., 2019; Ong et al., 2021; Simon et al., 2021).

Our interest in exploring the association between ACEs and traumatic brain injuries (TBIs) grew through understanding mechanisms of ACEs in triggering extended periods of stress and negatively impacting child’s brain development, attention, learning and decision-making abilities, which can also contribute to TBIs (Shonkoff et al., 2012). For example, a study shows that having greater count of ACEs (four or more ACEs) is associated with 70% odds of having head and neck injuries, especially with ACEs such as sexual abuse, domestic violence and parent mental illness specifically associated with higher odds of those injuries(Saadi et al., 2024). Another study using 2016–2018 National Survey of Children’s Health (NSCH) data found an association between ACEs and TBIs (Jackson et al., 2022). According to the case definition, TBI is a type of acquired brain injury (ABI) that may occur as a result of unexpected blow, hit and trauma to the head, that has the ability to damage the brain and interferes with normal brain functioning (National Academies of Sciences and Medicine, 2019). TBIs among children often occur during falls, sports injuries, and violence (Richmond & Rogol, 2014). Consequently, these can result in chronic school absenteeism, dysfunctional school engagement and decreased emotional regulation among children and adolescents (Richmond & Rogol, 2014; Rozbacher et al., 2017; Safar et al., 2021). Collectively, research is beginning to identify patterning in exposure to ACEs and TBIs (Guinn et al., 2019).

Research has also considered bullying-victimization as a co-occurring event with ACEs, and victims of bullying were reported to have higher likelihood of facing childhood adversity than those who did not experience bullying (Reisen et al., 2019). The term bullying-victimization refers to those who have been involved in bullying victimization and/or perpetration (Lereya et al., 2013). Victimization has also been associated with TBIs in a population-based study from Ontario, which found that victims of verbal and cyber-bullying had a higher likelihood of experiencing TBIs (Ilie et al., 2014). Those with TBIs were associated with higher odds of being victimized by bullying (AOR = 1.70) and were at increased likelihood of reporting psychological distress (AOR = 1.52) and being prescribed antidepressants (AOR = 2.45) compared to those without TBI (Ilie et al., 2014).

Lastly, studies have begun to examine the role of parental aggravation in the relationship between ACEs and adverse health outcomes. Parental emotional distress and aggravation have acted as joint mediators between parental ACE score and behavioral problems among children (Schickedanz et al., 2018). Parental aggravation has been defined as the measurement of stress faced by parents in nurturing and caring for their child. It has been associated with several other child-level characteristics such as obesity, learning disabilities, autism and parent-level attributes including paternal alcoholism and psychopathology involving depression, maternal long-term illness, and immigrant families (Altarac & Saroha, 2007; Annunziato et al., 2007; Barlow & Chang, 2007; Eiden & Leonard, 2000; Schieve et al., 2007; Yu & Singh, 2012).

Existing literature shows an association between ACEs and TBIs. However, considering the expanding role of parental aggravation, and bully-victim status contributing to ACEs, we found that prior studies have not specifically investigated parental aggravation, and bully-victim status as effect modifiers of the association between ACEs and TBIs among children and adolescents. Our study seeks to address that gap in the literature.

Methods

Survey Characteristics and Study Population

Our study utilized the 2019 National Survey of Children’s Health (NSCH), directed by the Health Resources and Services Administration affiliated with U.S. Department of Health and Human Services. The survey was conducted from June 2019 through January 2020. The 2019 NSCH includes a total of 184,000 unique addresses in 50 states and the District of Columbia (D.C). Of these addresses, 68,500 households completed screener questionnaires and 36,196 households were identified as those with children of 0–17 years old. The screeners were followed by age-specific topical questionnaires including questions on child, family, community, and neighborhood characteristics. One child from each household was sampled to be the subject of the topical questionnaire. Finally, a total of 29,433 topical questionnaires were completed by parents/caregivers living in the same household as the child and has knowledge of the experiences of the selected child. The estimates are all weighted to be representative of the United States (U.S.) population. We restricted the study sample to participants 6–17 years old (n = 21,259) to examine the association between ACEs and TBIs and the effect modification of parental aggravation. The justification for choosing this grouping is based on the relevance of ACEs, TBIs and parental aggravation across broader developmental range, as these are likely to occur throughout childhood and adolescence with younger children being more sensitive and vulnerable to high stress and aggravation in parents (Suh & Luther, 2020). The non-response or missing responses for each of the ACE variables (1,295) and TBI (81) were excluded, leaving the final study sample (n = 19,883). To test for effect modification by bully-victim exposure, the study sample for sub-population analysis was then restricted to adolescents of 12–17 years old, since the questions in the survey ascertaining exposure to bullying were only administered to this age group (n = 11,480) indicating justification of choosing this grouping to highlight peer-related bullying becoming more prevalent during adolescence. Additionally, we removed missing values for the bully-victim exposure, further reducing our sub-population (n = 11,347). More information about survey characteristics and instruments have been previously described www.childhealthdata.org.

Exposure Characteristics – Adverse Childhood Experiences (ACEs)

The 2019 NSCH included nine questions on ACEs, which ascertained information on parental separation/divorce, economic hardship, mental illness in household, domestic violence in household, parental incarceration, parental death, experiencing and/or witnessing neighborhood violence, racial discrimination, and substance abuse in household. The ACE module includes questions on events which were experienced by others in the household and witnessed by the sampled child; except racial discrimination, which reflects the child’s own experience. Our study utilized cumulative number of reported events as a measure of ACEs. ACEs were categorized as 0 ACEs, one ACE, two ACEs, three ACEs and four or more ACEs.

Outcome Characteristics – Traumatic Brain Injury (TBI)

The outcome of our study is child’s TBI status reported by parent/caregiver. We created a consolidated dichotomous variable that represented occurrence of TBI. The dichotomous measure has two levels: No TBI and TBI. The TBI category was created by incorporating both past only TBI and current TBI, which indicates the occurrence of TBI in child’s lifetime.

Covariates

Our study used child-level characteristics as individual level covariates which include basic sociodemographic such as child’s race/ethnicity, age, and sex (Fig. 1). We also included sports involvement and epilepsy status as individual level covariates (Fig. 1). Prior literature suggests that out of 1.7 million TBI cases occurring each year, 10% have been estimated to be attributed to participation in sports and recreational activities (Sahler & Greenwald, 2012). Epilepsy causes seizures; and fall-related head and brain injuries are more likely to occur among epileptic patients ascribed to seizures than others(Zwimpfer et al., 1997).

Fig. 1.

Concept map: individual level covariates

Age (years) was used continuously in our study. For race/ethnicity, we utilized a categorical variable with four levels: White non-Hispanic, Black non-Hispanic, Other/Multiracial non-Hispanic, Hispanic. For all other individual level covariates, we have used dichotomous variables such as sex (male, female), epilepsy status (epilepsy, no epilepsy), and sports involvement (yes, no). Our analysis included two interpersonal and household level covariates as measures of socioeconomic status: percent federal poverty level (% FPL) and parental/caregiver’s education level (Fig. 2). The measure of parental/caregiver’s education has three levels: less than high school, high school or some college, and college degree or higher. FPL is the measure annually issued by the U.S. Department of Health and Human Services (HHS). It is utilized to determine eligibility for Medicaid and other assistances based on the household size. We based our categorization of % FPL on prior literature, which used four levels to capture poverty level: 0–99% FPL, 100–199% FPL, 200–399% FPL and 400% FPL or greater (Crouch et al., 2019; Kerns et al., 2017; Loria & Caughy, 2018).

Fig. 2.

Concept map: interpersonal level covariates

Testing for Effect Modification and Interaction

Our study utilized interaction terms to assess if the association between ACEs and TBIs is modified by parental aggravation and bully-victim status. (Fig. 3). The 2019 NSCH has three items indicating parental aggravation, including “if parents felt child is much harder to care for than most children”, “if parent felt that child does things that bothers them”, and “if parent felt angry with child during the past month”. The final parental aggravation measure is described as the number of usually or always responses to these three forms of stress reported by parents. Therefore, this measure represents the frequency of aggravation experienced by parents in caring for their child. Some researches may have used the terms parenting stress and parental aggravation interchangeably for the same measure. While we used the term ‘parental aggravation’ which is alignment with the term originally used in the survey. A dichotomous variable was created that grouped “usually/always” into one level labeled as “aggravation” and “rarely, never, sometimes” were grouped into “no or less frequent aggravation”.

Fig. 3.

Concept map: effect modifiers

Our study included sub-population analysis on the subset of children 12–17 years old for the measure of bully-victim as the survey provided this instrument only for this specific age group. A consolidated measure was created using separate items of victims and perpetrators of bullying available in the survey. The combined measure is categorical and has four levels (victim only, perpetrator only, perpetrator and victim, none).

Analytic Plan

Firstly, we conceptualized the association between ACE score and TBI status through creating Concept maps (Figs. 1, 2, 3 and 4). These concept maps assisted us in effective decision-making about which covariates to include in the final models. We reviewed existing literature and selected covariates which relate to both ACE score and TBI status. Concept maps were created in Microsoft PowerPoint.

Fig. 4.

Concept map: community level covariates

Secondly, we computed weighted percentages and unweighted frequencies of individual ACEs as well as cumulative ACE score. Additionally, we calculated weighted prevalence with 95% confidence intervals (CI) for all categorical variables included in our study. Mean and standard deviation were computed for the continuous age variable.

Finally, we created logistic regression models which tested main effects, adjusted effect without interaction term, and adjusted effect with interaction term for parental aggravation and ACE score among children 6–17 years old. Adjusted effect with and without interaction term for bully-victim and ACE score in the smaller subset of adolescents 12–17 years old were also tested in separate models respectively. Descriptive statistics, and adjusted odds ratios (AORs) were used to assess associations. Our study used survey procedures (SURVEYFREQ and SURVEYLOGISTIC) in SAS 9.4, to account for clustering across various strata and to adjust for the complexities of NSCH sampling design.

Results

Our initial sample consisted of children and adolescents 6–17 years old. The sample was 51.4% male and 48.6% female (Table 1). Moreover, 50.8% of children and adolescents were white, non-Hispanic. The average age of children and adolescents in our initial sample was 12.1 years old (SD = 3.43). Among adolescents 6–17 years old, 4% of the sample reported previous or current TBI, while 96% of the sample did not report experiencing a TBI. Additionally, 22% had at least one ACE, 10.3% experienced two ACEs, 6.18% experienced three ACEs, and 7% experienced four and more ACEs (Table 1).

Table 1.

Descriptive statistics, children and adolescents 6–17 years old, 2019 National survey of children’s health

Overall (n = 19,964)	n		% (95% CI)
Sex
Male	10,336		51.0 (49.4, 52.5)
Female	9,628		49.0 (48.5, 52.1)
Race/Ethnicity
Hispanic	2,312		25.1 (23.4, 26.8)
White, non-Hispanic	14,003		50.8 (49.3, 52.4)
Black, non-Hispanic	1,266		13.2 (12.1, 14.2)
Other/Multi-racial, non-Hispanic	2,383		10.8 (10.0, 11.7)
TBI Status
No TBI	18,695		96.0 (95.6, 96.5)
TBI	1,188		4.0 (3.5,4.9)
ACE Composite Score
0 ACE	11,126		53.6 (52.0, 51.2)
1 ACE	4,542		21.9 (21.6, 24.2)
2 ACEs	1,972		10.3 (9.4, 11.28)
3 ACEs	1,045		6.2 (5.3, 7.1)
4 and More ACEs	1,279		7.0 (6.1, 7.7)
% FPL
0–99% FPL	2,078		17.7 (16.2, 18.9)
100–199% FPL	3,229		21.3 (20.0, 22.7)
200–399% FPL	6,328		29.6 (28.2, 31.0)
400% FPL or Greater	8,329		31.1 (30.1, 32.8)
Epilepsy Status
No Epilepsy	19,757		99.4 (99.2 99.5)
Current Epilepsy	147		0.6 (0.5, 0.8)
Caregiver’s Education
Less than high school	471		10.0 (8.55, 11.52)
High school or some college	7,341		40.5 (38.9, 42.0)
College degree or higher	12,152		49.4 (47.9, 51.0)
Sports Involvement
Yes	12,474		55.4 (53.8, 57.0)
No	7,304		44.5 (42.9, 46.1)
Parental Aggravation
Aggravation	1,136		5.6 (4.8, 6.3)
No Aggravation	18,800		94.4 (93.7, 95.1)
Bully-Victim (12–17 Years)
Perpetrator	242		2.4 (1.5, 3.3)
Victim	3,233		26.7 (24.8, 28.5)
Perpetrator & Victim	1,722		14.1 (12.6, 15.9)
None	6,150		57.0 (55.0, 59.0)
Age (Years)	Mean		SD
	12.1		3.43

In our initial sample, we found that most children and adolescents were living in household at 400% FPL. Similarly, considering caregiver’s education as a measure of socioeconomic status, the majority of children had parents or caregivers with high school diploma or some college and college degree or higher compared to those whose education was less than high school (Table 1).

Nearly 6% of children’s parents felt frequent aggravation. Moreover, in the subset of adolescents 12–17 years old, the majority were reported not being a bully or victim (57.0%), followed by being victims of bullying (26.7%), followed by both perpetrators and victims of bullying (14.1%), and perpetrators only (2.4%) (Table 1).

Figure 5 illustrates the relative prevalence of individual ACEs. The most frequently reported ACE among children and adolescents in 2019 NSCH was parental separation/divorce (28.6%), while the least reported was parental death (4.1%).

Fig. 5.

Prevalence of individual ACEs

The unadjusted analysis shows no significant association between frequency of ACEs and TBIs among children and adolescents (Table 2, Model 1). The odds ratio (OR) estimates of TBIs among children with four or more ACEs leans towards significant but is still not statistically significant (OR = 1.54, 95% CI = 0.94–2.51).

Table 2.

Unadjusted, adjusted, and interaction effects on odds of TBIs of children 6–17 years old

	Initial Sample Analysis (Ages 6–17 Years)			Sub-population Analysis (Ages 12–17 Years)
	Unadjusted	Adjusteda	Interaction Effect with Parental Aggravation	Adjustedb	Interaction Effect with Bully-Victim
Predictors	Model 1 OR** (95% CI)c	Model 2 AOR*** (95% CI)	Model 3 AOR (95% CI)	Model 4 AOR (95% CI)	Model 5 AOR (95% CI)
ACE Score			N/A		N/A
0 ACE (REF)	1 (1)	1 (1)		1 (1)
1 ACE	1.17 (0.89–1.55)	1.29 (1.00-1.82)		1.14 (0.80–1.60)
2 ACEs	1.31 (0.93–1.83)	1.67 (1.18–2.35)		1.71 (1.15–2.55)
3 ACEs	0.76 (0.50–1.17)	0.89 (0.58–1.40)		0.77 (0.46–1.30)
4 or More	1.54 (0.94–2.51)	*1.79 (1.03–3.13)		1 (0.52–1.96)
Parental Aggravation	N/A		N/A		N/A
No/Less Frequent Aggravation (REF)		1 (1)		1 (1)
Aggravation		*1.73 (1.21–2.47)		*1.53 (1.02–2.33)
ACE Score * Parental Aggravation	N/A	N/A		N/A	N/A
0 ACE * No/Less Frequent Aggravation (REF)			1 (1)
1 ACE * Aggravation			*2.41 (1.41–4.14)
2 ACE * Aggravation			*2.91 (1.14–7.47)
3 ACE * Aggravation			1.78 (0.60–5.27)
4 and More ACEs * Aggravation			*2.73 (1.19–6.25)
ACE Score * Bully-Victim	N/A	N/A	N/A	N/A
0 ACE * None					1 (1)
1 ACE * Perpetrator					0.62 (0.16–2.44)
1 ACE * Victim					1.28 (0.71–2.32)
1 ACE * Perpetrator & Victim					*3.27 (1.77–6.04)
2 ACE * Perpetrator					1.35 (0.34–5.37)
2 ACEs * Victim					1.8 (0.95–3.40)
2 ACEs * Perpetrator & Victim					*3.21 (1.59–6.48)
3 ACE * Perpetrator					*0.03 (0.004–0.29)
3 ACE * Victim					1.38 (0.69–2.77)
3 ACE * Perpetrator & Victim					1.61 (0.65–3.94)
4 and More ACEs * Perpetrator					1.78 (0.34–9.25)
4 and More ACEs * Victim					*2.68 (1.0–7.0)
4 and More ACEs * Perpetrator & Victim					0.88 (0.42–1.83)
Race/Ethnicity	N/A
Black, Non-Hispanic (REF)		1 (1)	1 (1)	1 (1)	1 (1)
Hispanic		1.78 (0.94–3.38)	1.78 (0.94–3.37)	1.18 (0.58–2.41)	1.13 (0.56–2.28)
Other/Multiracial		*2.91 (1.56–5.42)	*2.91 (1.55–5.44)	*2.93 (1.43-6.0)	2.68 (1.33–5.39)
White, Non-Hispanic		*4.13 (2.48–6.86)	*4.14 (2.49–6.88)	*3.77 (2.11–6.7)	2.47 (1.97–6.13)
Age (Years)	N/A
		1.18 (1.13–1.23)	1.18 (1.13–1.23)		1.28 (1.19–1.38)
Sex	N/A
Female (REF)		1 (1)	1 (1)	1 (1)	1(1)
Male		*1.52 (1.19–1.93)	*1.52 (1.20–1.92)	*1.36 (1.04–1.78)	*1.36 (1.05–1.77)
Sports Involvement	N/A
No (REF)		1 (1)	1(1)	1(1)	1 (1)
Yes		*1.7 (1.32–2.21)	*1.71 (1.33–2.20)	2.2 (1.65–2.93)	2.12 (1.59–2.83)
Caregiver’s Education	N/A
High School or Some College (REF)		1 (1)	1 (1)	1 (1)	1 (1)
College Degree or Higher		1.1 (0.84–1.44)	1.1 (0.83–1.44)	1.0 (0.75–1.41)	1.0 (0.76–1.44)
Less than High School		0.82 (0.34–1.97)	0.82 (0.34–1.98)	0.3 (0.11–0.78)	0.3 (0.11–0.80)
Epilepsy Status	N/A
No Epilepsy (REF)		1 (1)	1 (1)	1 (1)	1 (1)
Epilepsy		*11.29 (5.66–22.5)	12.1 (0.05–24.1)	9.35 (3.88–22.5)	10.36 (4.52–23.7)
% FPL	N/A
0–99% FPL (REF)		1 (1)	1 (1)	1 (1)	1(1)
100–199% FPL		1.13 (0.63–2.03)	1.12 (0.62–2.03)	1.51 (0.76–2.97)	1.53 (0.79–2.99)
200–399% FPL		1.22 (0.72–2.07)	1.22 (0.72–2.06)	1.24 (0.67–2.29)	1.28 (0.70–2.31)
400% FPL or Greater		1.49 (0.89–2.50)	1.48 (0.88–2.49)	1.52 (0.83–2.76)	1.54 (0.86–2.77)

* Statistically Significant Odd Ratios

** Odds Ratio

*** Adjusted Odds Ratio

^a Model adjusted for child’s sex, race/ethnicity, age, epilepsy status, sports involvement, % FPL, parental aggravation, caregiver’s education

^b Model adjusted for child’s sex, race/ethnicity, age, epilepsy status, bully-victim status, sports involvement, % FPL, parental aggravation, caregiver’s education

^C 95% Confidence Interval

However, after adjusting for covariates, children, and adolescents with four or more ACEs have 1.79 times the odds of having had a TBI than those with zero ACE (AOR = 1.79, 95% CI = 1.03–3.13) (Table 2, Model 2). Additionally, the model with interaction term shows that children and adolescents with four or more ACEs and whose parent felt aggravation frequently had 2.73 times the odds of having had a TBI compared to those with zero ACEs and whose parents did not feel aggravation or rarely felt aggravation. (AOR = 2.73, 95% CI = 1.19–6.25) (Table 2, Model 3). Children and adolescents who had one and two ACEs and whose parent felt frequent parental aggravation were more likely to experience TBI compared to those with zero ACEs and no or less frequent parental aggravation (Table 2, Model 3). However, those with three ACEs and whose parents felt frequent aggravation were not significantly associated with higher odds of having had a TBI, possibly due to low sample count in this category.

Table 2, Model 4 shows the results of the adjusted logistic regression for the subpopulation analysis of adolescents 12–17 years old. Those with two ACEs had higher odds of having had a TBI compared to those with zero ACE (AOR = 1.71, 95% CI = 1.15–2.55). Adolescents who were both perpetrators and victims of bullying were more likely to have had a TBI than those who are not involved in bullying-victimization (AOR = 1.86, 95% CI = 1.26–2.77) (Table 2, Model 4). Furthermore, adolescents who were reported to be perpetrators of bullying were 2.38 the odds of having had a TBI than those who were not involved in bullying-victimization (AOR = 2.38, 95% CI = 1.04–5.45) (Table 2, Model 4). No significant association was observed between those who reported to be victims of bullying and having experienced a TBI in the adjusted subpopulation analysis.

In analysis of effect modification by bully-victim, those who experienced four or more ACEs, and were reported to be victims of bullying, were more likely to have had a TBI compared to those with zero ACEs and no involvement in bullying-victimization (AOR = 2.68, 95% CI = 1.0–7.0) (Table 2, Model 5).

Moreover, the results of the interaction term model show that adolescents who had one ACE and were both perpetrators and victims of bullying were 3.27 times more to have experienced a TBI compared to those with zero ACEs and no involvement in bullying-victimization (AOR = 3.27, 95% CI = 1.77–6.04) (Table 2, Model 5). Additionally, those who experienced two ACEs and were both perpetrators and victims of bullying had higher odds of experiencing TBI than those with zero ACEs and no involvement in bullying-victimization (AOR = 3.21, 95% CI = 1.49–6.48) (Table 2, Model 5).

Discussion

Our results expand upon prior research on ACEs and TBIs. Like prior studies, we observed an association between children and adolescents who had four or more ACEs and increased likelihood of TBI (Guinn et al., 2019; Jackson et al., 2022). In examination of joint effects, odds of having experienced TBI was higher among those who had four or more ACEs and whose parents felt frequent aggravation compared to children with zero ACEs and whose parents did not feel frequent aggravation. Our study utilized the cumulative ACE score and did not seek to identify individual ACEs and how they might have influenced parental aggravation leading to TBI. However, evidence from prior literature suggests the role of economic hardship in contributing to parenting stress (Crouch et al., 2019). Certain individual level ACE components may be drivers of the association between ACEs, parental aggravation, and TBIs. Similarly, a study has shown the negative influence of parental separation on socioeconomic status, academic performance, social connectedness and network, psychological health, and increased likelihood of gender-based violence among children and adolescents (Seijo Martínez et al., 2016). Moreover, literature has also demonstrated the association between early childhood adversity and later-stage violence (Salo et al., 2021). Even though TBIs mostly occurs because of other factors such as falls and sports-related injuries, factors leading to violence which ultimately result in TBIs should also be considered while developing interventions and examining and/or screening children and adolescents for TBIs.

We also found that bullying-victimization modified the association between ACEs and TBIs in adjusted subpopulation analysis of adolescents 12–17 years old. The interaction effect reveals that the adolescents who had four or more ACEs and reported being victims of bullying had higher likelihood of having had a TBI relative to those without ACEs and engagement in bullying-victimization. Moreover, no significant association was seen among those who were perpetrators of bullying and had four or more ACEs in the interaction effect. However, the main effects adjusted analysis found the highest likelihood of having had a TBIs among those who were perpetrators of bullying followed by those who were both perpetrators and victims. While, having four or more ACEs concurrently increased the likelihood of TBIs among adolescents who were being victimized by bullying in the interaction effect with four or more ACEs. This may build on the existing evidence that adolescents in this age subset (12–17 years old) are more likely to have been exposed to victimization as they get more time to experience childhood adversity and consequent health impacts (Seijo Martinez et al., 2016). Along these lines, our study also corroborates the findings from prior literature that victims of bullying were at increased likelihood of having exposed to ACEs followed by perpetrators of bullying (Ilie et al., 2014).

To our knowledge, prior studies have not examined how parental aggravation and bullying-victimization modify the association between ACEs and TBIs. Thus, our study sought to fill in the gap with novel findings on the effect of interaction between ACEs and parental aggravation, ACEs, and bully-victim on the odds of TBIs among children and adolescents of 6–17 years old. As our study is a snapshot analysis, the focus on the association of ACEs and TBIs and other events which may be co-occurring or have preceded or followed the TBIs is a bit unclear. Therefore, our findings emphasize the need for the initiatives which can prevent the occurrence of the events which may be associated with TBIs in children and adolescents in one way or the other. Since the most reported ACE was parental divorce/separation, and we also found the association of frequent parental aggravation with TBIs, there may be hidden evidence that points towards the effect of parental attitudes and behaviors on subsequent TBIs among those children and adolescents. ACEs have also been associated with child psychopathology including depression, anxiety, and headaches (Anda et al., 2010; Chapman et al., 2004; Elmore & Crouch, 2020). Such factors might not lead to TBI, may have the potential to affect the recovery from TBI as evident from the existing literature (Ponsford et al., 2012). We recommend pediatricians to evaluate children and adolescents having TBIs for both current and past exposure to ACEs, parental aggravation and involvement in bullying perpetration and victimization.

This study has limitations. The measure of TBI (including both past and current TBI) used in our study was reported by parents/caregivers and does not represent any sort of medical confirmation, such as reports from neurological exam or diagnostic imaging tests. Also, the study design is cross-sectional, so we cannot establish temporality. Therefore, we do not know if ACEs preceded TBIs in our sample. Additionally, we were not able to measure important events which may drive associations between ACEs and adverse health events. The NSCH module excludes items on child abuse and neglect due to responses being reported by parents/caregivers, who may fear the non-confidentiality of the population-based surveys. Also, child abuse and neglect are stigmatized events. The absence of questions on abuse (sexual, emotional, and physical) limits the ability of analysis which utilizes the survey to find associations with outcomes that may arise as a result of abuse among children and adolescents. Our study also presents the limitation of reporting bias due to parents/caregivers being the respondents of this survey. Selective suppression and disclosure of information may have occurred due to personal opinions and judgements related to events that the selected child may have experienced.

Researchers are increasingly focused on how psychosocial and behavioral factors act jointly to contribute to adverse health outcomes. Our study highlights the importance and need for interventions which reduce parental aggravation and bullying-victimization. Further research is needed to understand the relationship between ACEs and TBIs, emphasizing the role of bullying involvement among adolescents 12–17 years old. Reducing the occurrence of ACEs, parental aggravation, and bullying-victimization may mitigate the risk of TBIs among adolescents.

Author Contributions

Shaiza Bushra conceptualized the study, conducted data analyses, drafted the original article, and managed the submission and revision process. Emilia Pawlowski provided subject matter input, guided analysis, and manuscript development, and contributed to correspondence with the journal. Michael Bauer was engaged in interpretation of data and reviewed the manuscript.

Funding

Centers for Disease Control and Prevention: Nu17CE010055.

Data Availability

https://www2.census.gov/programs-surveys/nsch/technical-documentation/methodology/2019-NSCH-Methodology-Report.pdf. https://www.childhealthdata.org/learn-about-the-nsch/nsch-codebooks.

Declarations

Ethical Approval

This study was exempt from ethical approval as this used publicly accessible and de-identified data from the National Survey of Children’s Health (NSCH).

Competing Interests

No competing interests to disclose.