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Journal of Child & Adolescent Trauma logoLink to Journal of Child & Adolescent Trauma
. 2019 Feb 28;12(4):447–456. doi: 10.1007/s40653-019-00251-7

The Association between Caregiver Substance Abuse and Mental Health Problems and Outcomes for Trauma-Exposed Youth

Briana Woods-Jaeger 1,✉, Ernestine C Briggs 2, Rebecca L Vivrette 3, Robert C Lee 2, Liza Suarez 4, Harolyn M E Belcher 5,6
PMCID: PMC7163816  PMID: 32318214

Abstract

Trauma-exposed youth with impaired caregivers (i.e., due to substance use and/or mental health problems) may be at particular risk for negative outcomes. This study utilized data from the National Child Traumatic Stress Network Core Data Set to examine the impact of caregiver impairment on youth outcomes. Trauma-exposed youth with an impaired caregiver due to either: substance use (n = 498), mental health problems (n = 231), or both substance use and mental health problems (n = 305) were compared to youth without a reported impaired caregiver (n = 2282) to determine if impaired caregiver status is independently associated with increased likelihood of negative behavioral and mental health outcomes and service utilization after accounting for demographics and exposure to traumatic events. Youth with impaired caregivers compared to those without were more likely to display PTSD, emotional and behavioral problems, suicidality, self-injury, and substance abuse and had higher rates of service utilization (p < 0.05). Differential patterns were observed based on the type of caregiver impairment. Findings support the importance of family-centered assessment and intervention approaches for youth affected by trauma.

Keywords: Adolescent, Caregiver impairment, Mental health, Risk behavior, Trauma

Over two-thirds of youth in the United States are exposed to a traumatic event during childhood, and the majority of those youth experience multiple types of trauma (Copeland et al. 2007; Costello et al. 2002). Youth with trauma histories are at risk for a variety of negative outcomes, including: mental health disorders such as posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and substance abuse disorder (Copeland et al. 2007; Kilpatrick et al. 2003; Suarez et al. 2012), increased suicidal ideation and attempts (Lipschitz et al. 1999; Waldrop et al. 2007), impaired academic performance and outcomes (Coohey et al. 2011; Slade and Wissow 2007), and increased risk for physical illness in adulthood (Felitti et al. 1998; Lanius et al. 2010).

Youth with trauma exposure and impaired caregivers (i.e., caregivers impaired due to substance use and/or mental health problems) are particularly at risk for negative outcomes (Vivrette et al. 2016). Caregiver substance use (i.e., drug and alcohol use) increases the risk of negative outcomes for youth exposed to violence (Ryan et al. 2000) and moderates the association between multiple types of violence exposure and youth PTSD and substance use outcomes (Hanson et al. 2006). Similarly, caregiver mental health problems also increase the likelihood of emotional and behavioral problems for children exposed to trauma (Chemtob et al. 2010) and have been shown to moderate (Proctor 2006) and mediate (Aisenberg et al. 2007; Koverola et al. 2005; Levendosky et al. 2006; Proctor 2006) the association between trauma exposure and child mental and behavioral health outcomes. Moreover, caregiver’s exposure to violence can affect their child’s behaviors above and beyond the child’s own exposure (Mitchell et al. 2011). In addition to these consequences on children’s emotional and behavioral development, caregiver impairment is a risk factor for child maltreatment and child removal (Correia 2013; Kohl et al. 2011).

There are several potential pathways that may explain these findings. Caregiver substance use is associated with a variety of negative parenting factors including poor parental monitoring, inconsistent discipline practices, and a lower quality of the parent-child relationship (Mayes and Truman 2002) increased physiological and environmental risks (Chatterji and Markowitz 2001) and child behavioral dysregulation (Fisher et al. 2011). Parental psychopathology, particularly depression, is associated with harsh parenting, poor parent-child relationship, decreased parental responsiveness (Koenen et al. 2009), a shared genetic diathesis (Fisak Jr. and Grills-Taquechel 2007), and modeling and reinforcement of anxious or avoidant behaviors by caregivers (Fisak Jr. and Grills-Taquechel 2007). Further, impaired caregivers may experience numerous other contextual risks (e.g., low social support, poverty, history of child trauma and violence exposure) that may have an influence on the caregiver as well as their child(ren). For instance, depression in mothers typically occurs in the context of marital discord, paternal psychopathology, stressful economic and work difficulties, and/or negative interactions with their children (Cummings and Davies 1994; Goodman and Gotlib 1999; Hammen 1992; Lovejoy et al. 2000). Caregiver substance use is often associated with economic challenges (Chatterji and Markowitz 2001), which increase the risk of children’s mental health and behavioral difficulties.

There is growing recognition of the importance of parental emotion and cognitive control capacities in relation to positive and negative parenting behaviors (Crandall et al. 2015), and parents with substance use and/or mental health problems may have challenges in these areas. In addition, models of cumulative trauma (Kisiel et al. 2014; Ford et al. 2010) and empirical findings demonstrating the increased risk for negative health and behavioral outcomes among those experiencing multiple early adversities and traumas including parental substance use and mental health problems (Felitti et al. 1998) highlight the importance of better understanding these additive and multiplicative effects.

Taken together, theory and research suggest caregivers play a significant role in the outcomes of trauma-exposed children and youth. In particular, caregiver substance use and mental health problems are potential risk factors for negative outcomes among these youth. Further research that delineates the specific associations between caregiver mental health problems, caregiver substance use, and behavioral and mental health outcomes for trauma-exposed youth is important to develop effective strategies for intervention. The current study compared youth with trauma exposure and an impaired caregiver due to either: substance use, mental health problems, or both substance use and mental health problems to youth without a reported impaired caregiver to determine if type of impaired caregiver status is associated with (1) increased likelihood of PTSD, depression, and behavioral and emotional problems; (2) increased likelihood of suicidality, self-injury, and substance abuse; and (3) increased service utilization (i.e., number and type of services used).

Methods

Sample and Procedures

The study sample was drawn from the National Child Traumatic Stress Network (NCTSN) Core Data Set (CDS). The NCTSN is a congressionally mandated initiative funded by the Substance Abuse and Mental Health Administration (SAMHSA) designed to enhance access to and improve the standard of care for children and families exposed to trauma across the United States (US). The larger quality improvement initiative based on the CDS included 14,088 children and adolescents (infancy-21 years), referred for assessment and mental health treatment. The CDS included information on demographic characteristics, domestic and family environment, service use, trauma exposure, functioning, clinical evaluation, treatment, and standardized assessments of emotional symptoms/behavioral problems. Data were collected at baseline, every 3 months, and/or at the end of treatment from 56 sites across the US, between 2004 and 2010. The present study utilized the baseline data for analysis. All procedures were approved by the Duke University Health System Internal Review Board (IRB), as well as the IRB of all participating NCTSN centers.

The current study included a subsample of youth aged 12–18 (n = 5746) who reported experiencing caregiver impairment or at least one other lifetime traumatic event (n = 4584). Those without information concerning exposure to an impaired caregiver, or who had an impaired caregiver due to reasons other than mental health or substance use, were excluded (n = 1268) resulting in a final sample of 3316. This subsample was comprised of four comparison groups defined by their type of exposure to an impaired caregiver as reported in the trauma history profile. The four groups included youth whose caregiver’s impairment was due (1) only to “drug use/abuse/addiction” (n = 498), (2) only to mental health /psychiatric disorder(s) (n = 231), (3) “drug use/abuse/addiction and mental health /psychiatric disorder” (n = 305), and (4) youth who did not endorse having an impaired caregiver (n = 2282).

Measures

Demographic Characteristics

Demographics examined in the present study included gender, age, race (White/Black/Other), ethnicity (Hispanic/Latino), current primary residence (home with parents, home with relatives, regular foster care, treatment foster care, residential treatment center, other), and eligibility for public insurance (e.g., Medicaid, State Health Insurance) which served as a proxy for socio-economic status.

Services

Services utilized 30 days prior to treatment entry were identified by the child, child’s family, or clinician. Approximately 19 different types of services representing an array of youth service systems were included in this measure (e.g., child welfare, schools, juvenile justice). In the present study, services were grouped into the following categories: educational, social services, mental health services, juvenile justice, and healthcare and were examined across impaired caregiver subgroups. A variable was also computed to indicate the endorsement of use of two or more of the five service categories.

The Trauma History Profile

The THP includes questions from the General Trauma and Trauma Detail Forms of the NCTSN CDS. Clinicians used these forms to gather information from the child, parents/caregivers, and other collaterals (e.g., caseworkers) about traumatic experiences. Supplemental information on the child’s trauma history (e.g., case records), when available, was also used to inform responses. Impaired caregiver in the CDS was defined as a history of exposure to caregiver mental health/psychiatric disorders; other medical illness; or substance (alcohol/drug) use. The forms also included 18 specific types of trauma (e.g., physical abuse, sexual abuse, domestic violence). Respondents were able to rate whether the event was suspected to occur or confirmed, frequency of exposure (single vs. multiple exposures), age(s) of exposure, as well as salient details about each trauma type (e.g., perpetrator).

The UCLA Post-Traumatic Stress Disorder Reaction Index

The PTSD-RI (Steinberg et al. 2004) was used as a self report or clinician-administered instrument to assess the frequency and severity of PTSD symptoms occurring in the past month. Symptoms assessed were derived from DSM-IV (American Psychiatric Association 1994) criteria for Posttraumatic Stress Disorder (PTSD). Frequency of occurrence of PTSD symptoms during the past month was rated on a 5-point scale from 0 (none of the time) to 4 (most of the time). The present study used the Total Severity Score to create a dichotomous variable that signifies whether PTSD symptoms were in the clinical range (i.e., scores ≥38). Psychometric properties of the PTSD-RI are robust and have been described previously (Elhai et al. 2013; Steinberg et al., 2013). Here, internal consistency for each scale was good (PTSD Total Severity Score: α = 0.86, Criterion B: α = 0.92, Criterion C: α = 0.92, and Criterion D: α = 0.94).

The Child Behavior Checklist 6–18

The CBCL (Achenbach and Rescorla 2000) a standardized parent/caregiver-reported measure, was used to rate 113 behavioral and emotional problems of children. Caregivers who knew the child well (e.g., non-offending biological parents, other family members, foster parents, residential treatment staff) were asked to complete this form. The respondent used a three-point scale to rate each problem from 0 (not true) to 2 (often true) to reflect the child’s behavior over the past 6 months. The CBCL includes two broadband scales: internalizing behavioral problems and externalizing behavioral problems; and a total behavioral problems scale. T-scores greater than 63 were used as clinical cut-scores to indicate the presence or absence of internalizing and externalizing behavioral problem scores in the clinical range. The CBCL has reliable psychometric properties across diverse racial and ethnic populations. In the present study, the CBCL yielded Cronbach alphas of α = 0.92 for the total score and α = 0.90 and 0.93 for externalizing and internalizing, respectively.

Indicators of Severity

The Indicators of severity included 14 functional impairments or problems the child may have displayed within the past month as reported by the child, parent/caregiver, or other collaterals. Respondents indicated whether these were present and/or if they were reported to be 1 (somewhat a problem) or 2 (very much a problem). The current study examined the percentage of youth that endorsed the following indicators of severity as present: suicidality, self-injurious behaviors, and substance abuse.

Data Analysis

We used chi-square tests to examine the associations between demographic characteristics, services, and types of trauma exposure for each of the study groups. Mean differences between age and number of trauma types by impaired caregiver status groups were assessed with a Student’s T test. Associations between binary outcomes representing indicators of severity and the independent variables were assessed with mixed logistic models (estimated using generalized estimating equations (GEE) in SAS (PROC GLIMMIX) with clinical site level random effects that account for potential correlations for participants nested within NCTSN Centers. In sum, each equation was adjusted for site, child demographic factors, including age, gender, race/ethnicity, and the total number of trauma types experienced.

Results

Sample Characteristics

As noted in Table 1, participants in the impaired caregiver subgroups were disproportionally white, particularly in the substance use only (46.8%) and the substance use and mental health problems impaired caregiver subgroups (58.1%). A higher proportion of female compared to male youth had caregivers with a history of substance use only and substance use and mental health problems (65.5% and 63.9%, respectively). Youth in the impaired caregiver subgroups were also less likely to be residing at home with their parents, especially those whose impairment was due to substance use (49.7%) or substance use and mental health problems (33.8%). Additional details on the sample characteristics can be found in Table 1. Mean ages for subgroups ranged from 14.8 to 15.1 years and there were no statistically significant differences with respect to average age.

Table 1.

Demographic characteristics by impaired caregiver subgroups (N = 3316)

Substance use only Mental health problems only Substance use & Mental health problems None indicated
N = 498 N = 231 N = 305 N = 2282
Age, M (SD) 14.8 (1.6) 14.9 (1.7) 15.1 (1.8) 14.9 (1.7)
Gender, N (%)a
Male 172 (34.5%) 88 (38.1%) 110 (36.1%) 966 (42.3%)
Female 326 (65.5%) 143 (61.9%) 195 (63.9%) 1316 (57.7%)
Race/Ethnicitya
White 230 (46.8%) 94 (41.8%) 175 (58.1%) 589 (26.4%)
Black 98 (19.9%) 44 (19.6%) 42 (14.0%) 515 (23.1%)
Hispanic/Latino 132 (26.8%) 74 (32.9%) 62 (20.6%) 998 (44.8%)
Other 32 (6.5%) 13 (5.8%) 22 (7.3%) 126 (5.7%)
Insurance Typea
Public Insurance 349 (70.1%) 160 (69.2%) 241 (79.0%) 1189 (52.1%)
Private Insurance 41 (8.2%) 31 (13.4%) 21 (6.9%) 349 (15.3%)
Primary Residencea,b
With Parents 237 (49.7%) 150 (65.5%) 103 (33.8%) 1605 (78.0%)
With Relatives 99 (20.8%) 15 (6.6%) 57 (18.8%) 181 (8.8%)
Foster Care 64 (13.4%) 24 (10.5%) 57 (18.8%) 84 (4.1%)
Residential Treatment 50 (10.5%) 32 (14.0%) 66 (21.7%) 112 (5.4%)
Other 27 (5.7%) 8 (3.5%) 21 (6.9%) 76 (3.7%)

Number of Traumaa,b

Types (M, SD)

 5.2 (2.4) 5.1 (2.2) 6.3 (2.6) 2.8 (1.8)
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aIndicates a significant relationship between demographics and all subgroups at the p < 0.001 level. bIndicates significance between the three impaired caregiver subgroups at the p < 0.001 level

Service Utilization

Services used 30 days prior to the start of treatment by impaired caregiver subgroups are outlined in Table 2. Case management showed the most notable utilization gap between those with impaired caregivers and those without. Here, even the minimum difference between groups with reported impaired caregiver (“Substance Use only”) and those without (“None Indicated”) was substantial (35.1% vs. 20.6%, respectively). Moreover, those with an impaired caregiver, for any reason, were also more likely to utilize outpatient therapy services.

Table 2.

Services utilized prior to treatment entry by impaired caregiver subgroups

Substance use only Mental health problems only Substance use & Mental health problems None indicated
N = 498 N = 231 N = 305 N = 2282
Educational
School counselor 114 (23.6%) 67 (29.1%) 104 (34.7%) 604 (27.4%)
Special class 106 (21.9%) 70 (30.4%) a,d 105 (34.8%) a,d 409 (18.5%) b,c
Social services
Treatment foster care 36 (7.4%) 13 (5.7%) 21 (7.0%) 80 (3.6%) a,b,c
Child welfare 204 (42.1%) 100 (43.5%) 170 (56.3%) a,b,d 474 (21.5%) a,b,c
Foster care 107 (22.1%) a,d 29 (12.6%) a,c,d 80 (26.5%) b,d 149 (6.7%) a,b,c
Mental health services
In-home counseling 62 (12.8%) 34 (14.8%) 39 (12.9%) 184 (8.3%) a,b,c
Inpatient psychiatric 29 (6.0%) b,c 27 (11.7%) a,d 43 (14.2%) b,d 140 (6.3%) b,c
Outpatient therapy 186 (38.4%) d 80 (34.8%) d 116 (38.4%) d 629 (28.5%) a,b,c
Psychiatrist 93 (19.2%) d 50 (21.7%) d 75 (24.8%) d 290 (13.1%) a,b,c
Residential treatment 56 (11.5%) d 38 (16.5%) d 72 (23.8%) d 161 (7.3%) a,b,c
Case management 170 (35.1%) d 85 (37.1%) d 142 (47.0%) d 454 (20.6%) a,b,c
Group home 20 (4.1%) d 16 (7.0%) d 13 (4.3%) d 47 (2.1%) a,b,c
Day treatment program 31 (6.4%) 9 (3.9%) 12 (4.0%) 83 (3.8%)
Self-help groups 29 (6.0%) 12 (5.2%) 16 (5.3%) 83 (3.8%)
Juvenile Justice
Detention center 40 (8.3%) 8 (3.5%) 17 (5.6%) 147 (6.7%)
Probation officer 89 (18.4%) 28 (12.2%) 47 (15.6%) 266 (12.0%)
Healthcare
Primary care physician 65 (13.4%) 43 (18.7%) 54 (17.9%) 270 (12.2%)
Emergency room 26 (5.4%) 23 (10.0%) 27 (8.9%) 161 (7.3%)
Service utilization (2+ service types of 5) 297 (59.6%) c,d 149 (64.5%) d 222 (72.8%) a,d 967 (42.4%) a,b,c
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Those with an impaired caregiver on average had higher service utilization from multiple areas (2 or more services of 5)—in particular those with an impaired caregiver due to both substance use and mental health problems (72.8% reported more than two services used)—compared to those without an impaired caregiver (42.4% reported more than two services used). Differences across groups in child welfare and foster care involvement were also pronounced. While only 21.5% of those without an impaired caregiver were involved with the child welfare system, the impaired caregiver subgroups ranged from 42.1% (substance use only) to 56.3% (substance use and mental health problems). Those whose caregiver impairments were due only to mental health problems had the lowest rate of foster care involvement among the impaired caregiver subgroups (12.6%); however, this rate was still nearly twice that seen in the caregiver group with no impairment indicated (6.7%). By contrast, caregiver with impairments due to substance use or substance use and mental health problems had much higher utilization of foster care (22.1% and 26.5%, respectively).

In contrast, there were no statistically significant differences with respect to several types of service. Though use of school counselors was common, this did not differ significantly between groups. While use of day treatment programs and self-help groups was rare, there were also no significant differences between groups. There were also no significant differences with respect to juvenile justice involvement or general healthcare (primary care physicians and emergency department visits).

Impaired Caregiver Status and Indicators of Clinical Severity

There were also significant differences across the impaired caregiver subgroups on the problems, symptoms, and disorders noted on the Indicators of Severity forms (see Table 3). Those with caregivers impaired due to mental health problems and substance use were more likely to display posttraumatic stress symptoms than those without impaired caregivers (36.2% compared to 22.9%). Furthermore, children who had a caregiver with both substance and mental health problems were significantly more likely to display these symptoms than the substance use only group (21.9%). Children with an impaired caregiver due to mental health problems and substance were more likely to display problems with suicidality compared to those without an impaired caregiver (34.7% compared to 21.2%). Similarly, children whose caregiver’s impairment was due to both substance use and mental health problems (34.7%) were more likely to display problems with suicidality than those with an impaired caregiver due to only substance use, with 20.0%.

Table 3.

Indicators of severity and clinical evaluation of problems, symptoms, and disorders by impaired caregiver subgroups

Substance use only Mental health problems only Substance use & Mental health problems None indicated
N = 498 N = 231 N = 305 N = 2282
N (%) N (%) N (%) N (%)
Indicators of severity
Suicidality 96 (20.0%) b,c 65 (28.1%) a,d 105(34.7%) a,d 464 (21.2%)b,c
Self-injurious behaviors 66 (13.8%) b,c 46 (19.9%) a,d 76 (25.1%) a,d 312 (14.3%) b,c
Substance abuse 112 (23.3%) d 41 (17.7%) 77 (25.4%) d 341 (15.6%) a,c
PTSD-RI total score, M (SD) 25.6 (14.0) b,c 28.9 (15.1) a,d 29.4 (15.7) a,d 25.3 (15.0) b,c
PTSD total§ 97 (21.9%) b,c 61 (29.9%) a,d 94 (36.2%) a,d 468 (22.9%) b,c
Behavior problems (CBCL) scores§ n = 310 n = 149 n = 198 n = 1348
Internalizing 153 (44.0%) b,c 99 (57.9%) 147 (63.9%) 704 (46.6%) b,c
Externalizing 188 (54.0%) 101 (59.1%) 145 (63.0%) 685 (45.4%)
Total 206 (59.2%) b,c 116 (67.8%) a,d 166 (72.2%) a,d 775 (51.3%) b,c
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There was a similar pattern of results for self-injurious behaviors, with the highest prevalence of self-injurious behaviors in the substance use and mental health problems group (25.1%) followed by the mental health problems group (19.9%). Both of these are notably higher than either those with impairment only due to substance use (13.8%) and those without an impaired caregiver (14.3%). There was, however, no notable difference in prevalence of self-injurious behaviors between those without an impaired caregiver and those where the impairment was due only to substance use.

Odds of Clinical Severity Associated with Caregiver Impairment

Examining the modeled odds ratios provides additional insight into these relationships. The results of the mixed logistic regression models are presented in Table 4. First, all outcomes were associated with increasing odds of occurrence as the overall exposure to different trauma types increased. Female youth had over twice the odds (OR 2.73, 95% CI 1.93, 2.88) of having scores in the clinically significant range on PTSD measures and significantly higher odds of having scores in the clinical range on other behavioral problems (OR 1.34, 95% CI 1.12, 1.60). Females also had significantly higher odds of displaying suicidal (OR 1.73, 95% CI 1.39, 2.15) or self-injurious behavior (OR1.75, 95% CI 1.40, 2.17).

Table 4.

Odds ratios for clinical outcomes

Independent variable PTSD-RI total estimated odds ratio CBCL total estimated odds ratio Suicidality estimated odds ratio Substance abuse estimated odds ratio Self-injurious behaviors estimated odds ratio
[95% CI] [95% CI] [95% CI] [95% CI] [95% CI]
Number of trauma types 1.15 b 1.15 b 1.11 b 1.14 b 1.10 b
[1.10, 1.19] [1.09, 1.20] [1.06, 1.16] [1.09, 1.18] [1.05, 1.15]
Female vs. Male 2.36 b 1.34a 1.73 b 0.88 1.75 b
[1.93, 2.88] [1.12, 1.60] [1.39, 2.15] [0.72, 1.06] [1.40, 2.17]
Impaired caregiver subgroups
Substance Use vs. None 0.64 a 0.97 0.65 a 1.38 a 0.72 a
[0.48, 0.84] [0.74, 1.26] [0.48, 0.89] [1.06, 1.79] [0.53, 0.99]
Mental Health vs. None 1.05 1.48 a 1.33 0.94 1.19
[0.75, 1.48] [1.03, 2.12] [0.93, 1.88] [0.66, 1.34] [0.82, 1.71]
Both vs. None 1.11 1.55 a 1.37 a 1.21 1.40 a
[0.81, 1.54] [1.10, 2.20] [1.01, 1.91] [0.88, 1.66] [1.00, 1.95]
Both vs. Substance use 1.75 a 1.61 a 2.11 a 0.88 1.93 a
[1.22, 2.51] [1.11, 2.33] [1.45, 3.07] [0.62, 1.23] [1.32, 2.82]
Both vs. Mental health 1.06 1.05 1.04 1.29 1.18
[0.7, 1.61] [0.67, 1.64] [0.69, 1.56] [0.85, 1.96] [0.77, 1.81]
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Estimated Odds Ratios are adjusted for clinical site and age. Given the lack of significance, race was not adjusted for in these models. a Indicates statistical significance at the p < 0.05 level, bp < 0.001 level.

Among the impaired caregiver subgroups, children of caregivers with substance use only had lower odds of a clinically significant PTSD score (OR = 0.64, 95% CI, 0.48, 0.84) and lower odds for displaying suicidal or self-injurious behavior than when compared to traumatized children without an impaired caregiver (OR 0.65, 95% CI 0.48, 0.89) and (OR 0.72, 0.53, 0.99) respectively. The odds that youth would use substances were 1.38 (95% CI 1.06, 1.79) times higher for youth whose caregiver had a history of substance use compared to youth without caregiver substance use.

Those with a caregiver impaired due to mental health problems only had significantly higher odds of having behavior problems in the clinical range than those without an impaired caregiver (OR = 1.48, 95% CI 1.03, 2.12). Those with an impaired caregiver due to both substance use and mental health problems had significantly higher odds of self-injurious and/or suicidal behavior when compared to traumatized children without impaired caregiver (ORs 1.40, 95% CI and 1.37, 95% CI respectively). This group also had significantly higher odds of behavioral problems (i.e., CBCL Total scores in the clinical range; OR = 1.55, 95% CI).

Among those with an impaired caregiver, significant differences existed between the group with both impairments over the substance use only group. The substance use and mental health group had higher odds of scores in the clinical range for both the PTSD-RI (OR = 1.75, 95% CI) and the CBCL Total scores (OR = 1.61, 95% CI). Additionally, this group had significantly higher odds than the substance use only group of displaying both suicidality (OR = 2.11, 95%CI) and self-injurious behavior (OR = 1.93, 95%CI).

Discussion

Findings from this clinical sample of youth demonstrate significant associations between caregiver impairment due to substance use, mental health problems, or both substance use and mental health and health risk behavior outcomes among their adolescent children. The current study builds on previous findings of Vivrette et al. (2016) on impaired caregiving in the NCTSN Core Data Set by examining an adolescent sample and common psychiatric concerns for this age group (e.g., suicidal ideation and behavior, substance use), as well as, service use patterns related to impaired caregiving. As hypothesized, youth with a history of impaired caregivers demonstrate increases in service utilization, suicidality, self-injury, substance use, PTSD, emotional and behavioral problems. Importantly, differential associations based on the type of caregiver impairment suggest interventions to improve outcomes for trauma-exposed youth may need to be tailored to meet the needs of those with impaired caregivers due to substance use only, mental health problems only, or both substance use and mental health problems.

Youth of caregivers who had histories of both substance use and mental health problems had the highest rates of negative mental health and health risk behavior outcomes and a greater likelihood of emotional and behavior problems, suicidality and self-injurious behavior compared to youth whose caregivers did not have a history of co-occurring mental health and substance use problems. This is consistent with the findings of Vivrette et al. (2016), which also demonstrated high frequencies in PTSD symptoms, internalizing and externalizing, attachment, and behavioral problems for co-occuring impaired caregiving groups. The confluence of these findings indicate that youth whose caregivers have both mental health problems and substance use are at increased risk for a myriad of adverse psychosocial outcomes. In the current study, youth of caregivers who had mental health problems had a higher prevalence of suicidality and self-injurious behaviors compared to adolescents whose parents had a history of substance use or no history of impairement and had greater odds of emotional and behavioral problems compared to adolescents whose parents had no history of impairment.

Youth of caregivers who had substance use histories only had increased odds of substance use, but interestingly had a decreased likelihood of PTSD symptoms, suicidality, and self-injurious behaviors when compared to youth whose parents had no history of impairment. This was a surprising finding that supports the importance of specifically identifying the type of impairment the caregiver is experiencing given various psychosocial, genetic, and trauma exposures associated with the type of caregiver impairment and how that may relate to youth outcomes. Perhaps through social learning children of caregivers with substance use problems learn to cope with negative emotions with substance use/self-medication rather than through other maladaptive behaviors such as self-injury. Another possibility is that youth feel responsible for caring for their caregiver and thus are less likely to report their own internalizing mental health concerns. These and other plausible explanations support the importance of conducting comprehensive and sensitive assessments of trauma-exposed youth that include assessing caregiver impairment; as youth may be at decreased risk for certain mental health outcomes and increased risk for other adverse health behaviors given caregiver impairment type.

Impaired caregiving was prevalent for trauma-exposed youth in this study, with nearly one-third exposed to a primary caregiver with mental health and/or substance use problems. Findings from the current study reveal unique associations between type of caregiver impairment and trauma-exposed youth health outcomes, adding support for calls to carefully examine characteristics of caregiver impairment. Given that impaired caregiving is associated with increased rates of mental and behavioral health symptoms and service utilization for youth, the results of this study highlight the importance of addressing caregiver functioning through family-focused assessment and intervention. Following existing models of family-focused practice (Foster et al. 2012) family-focused assessment and intervention would expand the focus and service provision beyond the child to the larger caregiving system including direct inclusion of caregiver mental health and/or substance use problems within a treatment plan (Foster et al. 2016). Further, due to the complexities of impaired caregiving and its consequences including the potential of adolescents with impaired caregivers to be cared for by non-biological parents, it is critical that family and caregiver is defined by the client (Osher and Osher 2002) and could include extended family, foster parents, and/or others who provide caregiving to the trauma-exposed adolescent. Although an increasing number of investigations demonstrate associations between impaired caregiving and child trauma exposure and symptoms (Ackerson and Venkataraman 2003; Hinden et al. 2005; Kohl et al. 2011), this type of family-focused practice continues to be limited.

Our finding that impaired caregiving is associated with increased rates of service utilization for youth may not necessarily reflect an additional risk factor as help-seeking and greater access to supportive services can be protective. Whether increased service utilization is a risk or protective factor, findings from this study support the importance of ensuring services are responsive to impaired caregivers. Caregivers with mental health and substance use problems encounter many barriers to care, including a fragmented system of support that does not adjust to the needs of individuals and families, an emphasis on deficits rather than strengths, and lack of key information on specialized services and supports for all family members (Tunnard 2004). Practice and policy recommendations to address these needs include: 1) provision of specialized services ranging from early intervention, home-based and residential programs; 2) delivery of family-focused services that are strength-based and incorporate families as partners; 3) care coordination among youth and caregiver providers; 4) offering services aimed at building skills in youth and caregivers to improve community functioning; and 5) the development of a workforce that is well prepared to provide these services (National Academies of Sciences, Engineering, and Medicine 2017a, b; Tunnard 2004).

Existing therapeutic frameworks propose several core processes to support caregivers with mental health and/or substance use problems, including treatment that is family-centered, strengths-based, non-judgmental, emotionally supportive, and comprehensive (Hinden et al. 2005). These core processes may be achieved both through reduction of logistical barriers (e.g., co-location of child and adult services, coordinated appointment times) as well as promotion of clinical facilitators (e.g., adult and child provider collaboration with parent permission, increasing parent engagement and trust). For youth with impaired caregivers, comprehensive treamtent could include individual adult treament, individual child treament, caregiver-child treatment, and family-systems treatment. Importantly, an expert panel of parent mental illness researchers outlined a number of tenants for effective family-focused assessment and intervention, including: (1) emphasizing functional, rather than diagnostic, assessment of caregiver impairment and how it may affect parenting capacity, (2) tailoring assessments and interventions to the unique context of the parent, (3) utilizing a strengths-based approach by identifying existing skills and supports and (4) increasing caregiver capacity to support children, rather than perpetuating stigma and isolation (Ackerson and Venkataraman 2003; National Academies of Sciences, Engineering, and Medicine 2017a, b).

In the context of the results of the current study, secondary prevention of childhood trauma and traumatic stress should involve identification of parents who are at risk for impaired caregiving. Assessing parent functioning across children’s development, beginning in pregnancy, through postpartum, early childhood, and beyond may provide robust opportunities to reduce adverse youth outcomes in adolescence. In addition, considering a range of both mental and behavioral health outcomes is important when assessing trauma-exposed adolescents, as absence of mental health diagnosis does not necessarily equate to absence of severe health risk behaviors (e.g., self-injury, substance abuse).

There are several limitations to consider when interpreting these findings. The study is cross sectional in nature, which limits causal inferences among the associations found. The CDS is a quality improvement initiative consisting of a large sample of trauma treatment-seeking youth, and therefore it is not nationally representative or probability-based, and this may limit the study’s generalizability to clinical samples of trauma-exposed children. Data regarding caregiver trauma histories or specific mental health diagnoses were not available, and thus it was not possible to explore possible differences based on differential diagnoses within the mental health problems group. Furthermore, caregiver functioning categories were created using clinician and collateral rated data, which may have underestimated or overestimated potential caregiver impairment. Finally, the limitations inherent to self-report data also apply to this study. In particular, bias could have been introduced through caregiver reports in circumstances where caregivers under-or over-reported caregiver impairment/trauma exposures, symptoms of behavioral problems, or use of services. This study, however, has many strengths. The population is a large and diverse clinical cohort that utilized comprehensive measures of child trauma exposure elicited from caregiver, collateral, and child reports. Moreover, there are very few investigations that have studied the differences in odds of youth emotional and behavioral outcomes and health services utilization associated with two of the most prevalent caregiver risk behaviors (i.e., substance use and mental health).

The increased risk among youth with impaired caregivers for a variety of negative health outcomes highlights the importance of family-focused assessment and intervention as well as policies aimed at promoting collaboration and coordination among youth and adult service sectors and family-centered services that are tailored to meet each families’ unique needs. Directly assessing parent and youth mental health symptoms, trauma history, and substance use as it relates to youth functioning deserves more careful attention in future studies. Further, examining cultural differences in future studies is recommended to ensure the family-focused assessment and intervention is culturally responsive and addresses values, beliefs, and practices related to caregiving and family roles. Our results underscore the importance of considering caregiver functioning in the assessment and treatment of youth, particularly those affected by trauma, and directly addressing the multigenerational transmission of the impact of trauma exposure, mental health and substance use problems.

Acknowledgments

This manuscript was developed (in part) under grant numbers 2U79SM054284 from the Center for Mental Health Services (CMHS), Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS). The views, policies, and opinions expressed are those of the authors and do not necessarily reflect those of SAMHSA or HHS. We would like to acknowledge the 56 sites within the NCTSN that have contributed data to the Core Data Set as well as the children and families that have contributed to our growing understanding of child traumatic stress.

Compliance with Ethical Standards

Conflict of Interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Ethical Standards and Informed Consent

All procedures were approved by the Duke University Health System Internal Review Board (IRB), as well as the IRB of all participating NCTSN centers.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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