Addictive Behaviors 68 (2017) 30–34

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Addictive Behaviors

journal homepage: www.elsevier.com/locate/addictbeh

Short Communication

Associations between adverse childhood experiences, student-teacher

relationships, and non-medical use of prescription medications
among adolescents
Myriam Forster ⁎, Amy L. Gower, Iris W. Borowsky, Barbara J. McMorris
Division of General Pediatrics and Adolescent Health - Department of Pediatrics, University of Minnesota, MN, United States

H I G H L I G H T S

• The strong, graded relationship between ACE and NMUPM needs further consideration in prevention program design.
• Positive and caring student-teacher relationships are inversely associated with NMUPM.
• Students’ positive perceptions of teachers and belief that teachers care about them can buffer the ACE-NUMPM relationship, especially among students
experiencing multiple ACE.

a r t i c l e i n f o a b s t r a c t

Article history: Objective: Few studies have investigated associations between adverse childhood experiences (ACE) and non-
Received 17 July 2016 medical use of prescription medication (NMUPM) in population-based samples of adolescents, and even fewer
Received in revised form 5 December 2016 have examined whether promotive factors might buffer these effects. The present study assesses the direct ef-
Accepted 4 January 2017 fects of ACE and positive student-teacher relationships on NUMPD and whether positive student-teacher rela-
Available online 06 January 2017
tionships moderate this association.
Design: Data were from the 2013 Minnesota Student Survey (MSS), an in-school survey administered every three
years to students throughout Minnesota. The analytic sample (n = 104,332) was comprised of 8th, 9th, and 11th
graders.
Results: Approximately 3% of students acknowledged past year NMUPM, the majority of whom reported at least
one ACE. The most frequently used prescription drug was Ritalin/ADHD medications (1.71%) followed by opiate-
based painkillers (1.67%), tranquilizers (0.92%), and stimulants (0.75%). Students who reported any use tended to
use more than one medication. For every additional ACE, there was a 56%, 51%, 47%, and 52% increase in the odds
of past year stimulant use, ADHD medication, pain reliever, and tranquilizer use, respectively. The estimated rate
of the number of prescription drugs used increased by 62% for every additional ACE. Positive student- teacher re-
lationships buffered the association between ACE and NMUPD, especially at higher levels of ACEs.
Conclusion: Our findings have important implications for prevention work. Training educators to recognize trau-
ma symptomology and cultivating strong student-teacher relationships are important considerations for future
school-based substance use prevention initiatives.
© 2017 Published by Elsevier Ltd.

Nonmedical use of prescription medication (NMUPM) among ado-
lescents has become a serious health issue linked to delinquency
(Catalano, White, Fleming, & Haggerty, 2011), school dropout (Ford,
2009), and future addiction (McCabe, West, Teter, & Boyd, 2014). De-
spite a general decrease in adolescent substance use over the past
20 years (Volkov, 2014), rates of prescription drug overdoses have qua-
drupled in that same period, and young people now abuse prescription
drugs second only to marijuana, the leading drug of abuse (Centers for
⁎ Corresponding author.
E-mail address: mforster@umn.edu (M. Forster).
Disease Control and Prevention, 2015). The potency and accessibility
of prescription medications increase danger for adolescents and high-
lights the need for timely prevention services.
Adverse childhood experiences (ACE) are traumatic stressors that,
when experienced during childhood, negatively impact numerous be-
havioral health outcomes among adults (Anda, Felitti, Bremner, et al.,
2006; Anda, Felitti, & Croft, 1999). ACE include verbal, physical and sex-
ual abuse by a caregiver, parental substance misuse or abuse, parental
intimate partner violence, and parental incarceration, often co-occur
and have a strong, graded relationship to health behavior problems
(e.g. the likelihood of poorer outcomes increases as the number of ACE

http://dx.doi.org/10.1016/j.addbeh.2017.01.004
0306-4603/© 2017 Published by Elsevier Ltd.
 M. Forster et al. / Addictive Behaviors 68 (2017) 30–34
experienced increases) (Anda et al., 2006; Shonkoff & Garner, 2011).
Studies using retrospective, self-report data have identified ACE as a
key factor in the etiology of illicit substance use (Anda et al., 2006)
and indicate ACE account for one half to two thirds of serious problems
with drug use in adulthood (Dube et al., 2003). However, research has
yet to fully describe the relationship between child-reported ACE and
adolescent substance use. To date, investigations of the association be-
tween ACE and NMUPM patterns in larger, representative samples of
adolescents are extremely limited (Anda et al., 2008; Young, Glover, &
Havens, 2012) and even fewer have examined factors that may buffer
these effects.
The long-term consequences of ACE and drug use prior to age 18 call
for research that examines factors within extra-familial contexts that
foster positive youth outcomes and could offset familial stressors
(Tremblay & Rinaldi, 2010). Supportive relationships with adults out-
side the family have been shown to help youth cope with adverse cir-
cumstances, both physiologically and psychologically (Thompson &
Ron, 2014; Werner, 1996). This is critical given that youth who have ex-
perienced ACE within the family may rely heavily on non-family rela-
tionships for support. Schools, where youth spend a majority of their
day and attendance is compulsory, provide an opportunity for the de-
velopment of bonds between students and teachers/staff. In fact, posi-
tive student-teacher bonds have demonstrated benefits for
psychosocial adjustment (Birch & Ladd, 1998; Greenberger, Chen, &
Beam, 1998; Muller, 2001) and academic achievement (Baker, Grant,
& Morlock, 2008) and are inversely associated with disciplinary events
(Rudasill, Reio, Stipanovic, & Taylor, 2010) and substance use initiation
(McNeely & Falci, 2004). However, whether positive, caring student-
teacher relationships can mitigate the association between ACE and
NMUPM remains unknown.
The present study aimed to assess the main effects of ACE and posi-
tive student-teacher relationships on NMUPM, but we were also inter-
ested in protection: whether a potential promotive factor, student-
teacher relationships, moderates the impact of ACE on NMUPM. We ex-
amined the association between cumulative ACE and past year use of
four commonly abused prescription drugs [e.g. stimulants (speed, up-
pers or diet pills); ADHD medication or Ritalin; opioid-based pain killers
(OxyContin, Percodan, Vicodin, or others); tranquilizers (Valium,
Xanax, barbiturates)] and poly-prescription drug use among a popula-
tion-based sample of 8th, 9th, and 11th graders. We hypothesized that
1) a greater number of ACE would be positively associated with misuse
of each type of prescription drug, 2) that a greater number of ACE would
increase the estimated rate of the number of prescription drugs used
and 3) that positive, caring student-teacher relationships would buffer
the effects of ACE on NMUPM.
1. Methods
Data were from the 2013 Minnesota Student Survey (MSS), an anon-
ymous, in-school survey administered every three years to students
throughout Minnesota to monitor risk and protective factors. Of the
334 operating public school districts that were invited to participate in
the survey, 280 (84%) agreed. Student participation was voluntary,
with approximately 69% of parents providing passive consent and stu-
dents participating (Minnesota Student Survey Interagency Team,
2013). School administration coordinated whether they would use
paper and pencil or electronic surveys; 65% of schools used paper and
pencil surveys and 35% administered online versions. Using list-wise
deletion, approximately 6% of students were removed from the sample
due to non-response/missing data. The final analytic sample (n =
104,332) was comprised of 8th, 9th, and 11th graders.
1.1. Measures
Adverse childhood experiences: Six questions assessed individual ACE
(Felitti et al., 1998). Household substance use was two questions; “Do
31
you live with anyone who drinks too much alcohol?” and “Do you live
with anyone who uses illegal drugs or abuses prescription drugs?” An
affirmative response to one was classified as living in a household
where someone uses substances. Verbal abuse was one item: “Does a
parent or other adult in your home regularly swear at you, insult you
or put you down?” Physical abuse was assessed with: “Has a parent or
other adult in your household ever hit, beat, kicked or physically hurt
you in any way?” One item measured parental intimate partner violence:
“Have your parents or other adults in your home ever slapped, hit,
kicked, or punched or beat each other up?” Familial sexual abuse was
assessed with “Has any older or stronger parent or member of your fam-
ily ever touched you or had you touch them sexually?” The having an in-
carcerated parent item asked, “Have any of your parents or guardians
ever been in jail or prison?” Response options were coded no = 0 or
yes = 1. The composite index ranged from 0 to 6.
Positive teacher relationships were measured with four items from
Appleton, Christenson, Kim, & Reschly's (2006) Teacher-Student Rela-
tionships scale from the Student Engagement Instrument. Sample
items included: “At my school teachers care about me”, and “Most
teachers at my school are interested in me as a student.” Students
responded on a four-point scale from strongly agree (4) to strongly dis-
agree (1). Responses were summed with higher scores indicating more
positive teacher-student relationships (Cronbach's alpha = 0.84).
Past year NMUPM was measured with one item: “During the last 12
months, on how many occasions (if any) have you used any of the fol-
lowing prescription drugs NOT prescribed for you or that you took
ONLY to get high?” Endorsement of any use in the past year for each
drug category (stimulants, medication for ADHD or ADD, opiate-based
pain relievers, tranquilizers) was coded 0 = no use and 1 = past year
use. Responses for each drug category were summed to calculate the
number of medications used in the past year, ranging from 1 to 4.
Covariates: Age was calculated in years, sex was coded female = 1
and male = 0, race/ethnicity was defined as Hispanic/Latino, non-His-
panic Black/African American/African, non-Hispanic Asian/Pacific Is-
lander, non-Hispanic American Indian/Native American, multiple race/
ethnicities, with non-Hispanic white as the reference group. Family
structure classification was living with 2 biological parents (coded 1)
versus any other adults (coded 0). Poverty status was operationalized
as having two or more poverty indicators (homelessness, qualifying
for free/reduced price lunch, skipping meals due to lack of money) vs.
less than two. School district size was a categorical variable and past
30-day alcohol use was defined yes (coded 1) or no (coded 0).
1.2. Analyses
Separate logistic regression models and a negative binomial regres-
sion model assessed the associations between ACE and use of each pre-
scription medication and ACE and polyprescription drug use. All models
adjusted for age, sex, race/ethnicity, family structure, past 30-day alco-
hol use, poverty status, and school district size. An interaction term
was calculated (ACE ∗ student-teacher relationships) to assess whether
student-teacher relationships moderated the association between ACE
and NMUPM. To control for Type I errors, p-values b 0.001 for main ef-
fects and p b 0.01 for moderation effects were considered statistically
significant. Results are reported as odds ratios (OR) incident rate ratios
(IRR), and 95% confidence intervals (95% CI).
2. Results
In this sample, 2.8% of respondents were engaged in past year
NMUPM and over a quarter (28%) acknowledged at least one ACE. The
prevalence of ACE among youth misusing prescription medications
however was substantially higher than the general population with
nearly 70% of these youth acknowledging some form of maltreatment
or family dysfunction and 30% contending with three or more ACE
(Table 1).
32 M. Forster et al. / Addictive Behaviors 68 (2017) 30–34

Table 1 The significant, positive buffering effect of positive student-teacher

Descriptive statistics for 8th, 9th and 11th graders participating in the 2013 Minnesota relationships on all types of NMUPM and polyprescription drug use im-
Student Survey (N = 104,332) and NMUPM engaged students (n = 2921).
plies a greater protective effect on prescription drug use at higher levels
Variables Full sample NMUPM-engaged of ACE. For example, among students not exposed to ACE, a shift from
frequency (%) frequency (%) the lowest to highest score on student-teacher relationships reduces
Female 53,279 (49%) 1461 (50%) the probability of polyprescription drug use by 15%, whereas a shift
Race/ethnicity from lowest to highest student-teacher relationship score for students
American Indian 1147 (1%) 29 (1%)
with 6 ACE is associated with a 45% lower probability of polyprescription
Black 4319 (4%) 88 (3%)
Asian Pacific Islander 5357 (5%) 88 (3%) drug use (Fig. 1).
Hispanic/Latino 7020 (7%) 117 (4%)
Mixed 6779 (7%) 204 (7%) 3. Discussion
White 79,710 (76%) 2395 (82%)
Family structure
Two biological parents 71,057 (68%) 1490 (51%)
Consistent with national prevalence estimates, nearly 3% of the sam-
Poverty status ple reported past month NMUPM (National Institute on Drug Abuse,
2 or 3 poverty indicators 4531 (4%) 204 (7%) 2016), with the overwhelming majority (69%) of prescription medica-
School district location/size tion using youth exposed to at least one ACE. ACE exposure can nega-
Twin cities metropolitan area 52,896 (51%) 1694 (58%)
tively affect areas of the brain responsible for mood and behavioral
Greater MN district N 5000 7885 (8%) 204 (7%)
Greater MN district 2000–4999 15,746 (15%) 409 (14%) self-regulation (Anda et al., 1999, 2006; Ford, Steinberg, Hawke,
Greater MN district 1000–1999 13,262 (13%) 321 (11%) Levine, & Zhang, 2012; McEwen, 2005, 2006) and the ability to form
Greater MN district b 999 14,453 (14%) 292 (10%) positive social bonds (Bowlby, 1973; Dieperink, Leskela, Thuras, &
Adverse childhood experiences Engdahl, 2001; Gamble & Roberts, 2005; Sroufe, 2005), disrupting pro-
Having an incarcerated parent 5659 (5%) 906 (31%)
cesses that reduce risk for maladaptive coping behaviors, such as sub-
Parent substance use 10,675 (10%) 993 (34%)
Exposure to parental intimate 6907 (7%) 168 (24%) stance use. The high number of ACE-exposed youth involved in
partner violence NUMPM is further evidence that addressing the behavioral and emo-
Sexual abuse 2297 (2%) 321 (11%) tional consequences of childhood trauma should be a central compo-
Physical abuse 12,461 (12%) 168 (24%)
nent of public health prevention efforts. Our finding that strong
Verbal abuse 14,218 (14%) 1110 (38%)
Cumulative ACE student-teacher relationships can offset the negative effects of harmful
1–2 ACE 22,953 (22%) 1110 (38%) family environments for NMUPM behaviors, especially among youth
≥3 6260 (6%) 906 (31%) experiencing multiple ACE has important implications for prevention
Past year NMUPM work.
Stimulants 787 (0.75%)
Although caring bonds with adults support healthy development
Ritalin, ADHD or ADD medications 1779 (1.71%)
Opioid based pain killers 1741 (1.67%) (Eisenberg, Ackard, & Resnick, 2007; Masten & Reed, 2002), there is
Tranquilizers 958 (0.92%) scant research investigating whether positive, caring student-teacher
N1 prescription medication used 1556 (1.49%) relationships have compensatory effects for youth raised in dysfunc-
Note. MN = Minnesota. NMUPM = nonmedical use of prescription medications. tional familial environments. The present study provides compelling ev-
idence that the benefits of students' positive view of teachers, and a
belief that teachers care about them as individuals, can mitigate risk.
The most frequently used prescription drugs for non-medical pur- That intergenerational relationships within the school context foster re-
poses were ADHD medications, followed by opiate-based painkillers, silience among disadvantaged youth, even during mid to late adoles-
tranquilizers, and stimulants, with the majority of students engaged in cence when school engagement tends to decline (Barber & Olsen,
NMUPM using multiple medications. Multivariable logistic regression 1997; Eisenberg, Ackard, & Resnick, 2007) and substance use increases,
models demonstrated that for every additional ACE a student experi- is promising. Reducing the rates of NMUPM will depend not only on in-
enced there was a 56%, 51%, 47%, and 52% increase in the odds of past terventions aimed at improving home environments and strengthening
year stimulant use, ADHD medication, pain reliever, and tranquilizer individual level factors, but programs that maximize protective factors
use, respectively. Similarly, the estimated rate of polyprescription drug available in school and community contexts. Although studies have
use increased by 62% for every additional ACE (Table 2). identified individual characteristics (e.g. intelligence, personality) that

Table 2
Results of logistic and negative binomial regression models assessing associations between ACE, student-teacher relationships and NMUPM.

Source Stimulants OR Medications for ADHD, ADD Pain Relievers OR Tranquilizers OR Polyprescription drug use
(95% CI) n = 868 OR (95% CI) n = 1957 (95% CI) n = 1917 (95% CI) n = 1067 IRR (95% CI) n = 1556

ACE 1.56 (1.49, 1.64)⁎⁎⁎ 1.51 (1.46, 1.56)⁎⁎⁎ 1.47 (1.42, 1.52)⁎⁎⁎ 1.52 (1.45, 1.59)⁎⁎⁎ 1.62 (1.56, 1.68)⁎⁎⁎
Student-teacher relationships 0.56 (0.50, 0.62)⁎⁎⁎ 0.60 (0.55, 0.64)⁎⁎⁎ 0.43 (0.32, 0.56)⁎⁎⁎ 0.55 (0.50, 0.61)⁎⁎⁎ 0.53 (0.48, 0.58)⁎⁎⁎
Age 1.21 (1.14, 1.28)⁎⁎⁎ 1.43 (1.37, 1.49)⁎⁎⁎ 1.34 (1.29, 1.39)⁎⁎⁎ 1.37 (1.30, 1.44)⁎⁎⁎ 1.38 (1.33, 1.44)⁎⁎⁎
Sex 1.12 (0.95, 1.03) 0.95 (0.86, 1.06) 0.92 (0.83, 1.02) 0.89 (0.77, 1.02) 0.87 (0.79, 0.99)
American Indian 1.23 (0.73, 2.10) 1.02 (0.68, 1.47) 1.18 (0.82, 1.71) 1.15 (0.72, 1.85) 1.52 (1.04, 2.13)
Black 0.69 (0.47, 0.99) 0.42 (0.31, 0.56)⁎⁎⁎ 0.52 (0.39, 0.69)⁎⁎⁎ 0.64 (0.46, 0.89) 0.55 (0.42, 0.72)⁎⁎⁎
Hispanic 1.25 (0.97, 1.49) 0.83 (0.69, 1.01) 0.83 (0.69, 1.01) 0.88 (0.69, 1.13) 0.90 (0.75, 1.09)
Asian/Pacific Islander 0.58 (0.36, 0.88) 0.28 (0.20, 0.41)⁎⁎⁎ 0.27 (0.18, 0.40)⁎⁎⁎ 0.30 (0.18, 0.49)⁎⁎⁎ 0.36 (0.26, 0.48)⁎⁎⁎
Biracial 1.29 (0.97, 1.59) 1.07 (0.89, 1.27) 1.36 (1.14, 1.60)⁎⁎⁎ 1.22 (0.98, 1.52) 1.10 (0.99, 1.28)
Two biological parents 0.65 (0.55, 0.76)⁎⁎⁎ 0.67 (0.60, 0.74)⁎⁎⁎ 0.70 (0.63, 0.78)⁎⁎⁎ 0.65 (0.56, 0.74)⁎⁎⁎ 0.61 (0.55, 0.68)⁎⁎⁎
Past 30-day alcohol use 1.94 (1.86, 2.83)⁎⁎⁎ 1.97 (1.91, 2.03)⁎⁎⁎ 2.01 (1.95, 2.08)⁎⁎⁎ 1.94 (1.86, 2.02)⁎⁎⁎ 2.60 (2.48, 2.72)⁎⁎⁎
School district size 1.16 (0.99, 1.35) 1.81 (1.63, 2.01)⁎⁎⁎ 1.47 (1.32, 1.64)⁎⁎⁎ 1.05 (0.98, 1.17) 1.42 (1.28, 1.56)⁎⁎⁎
ACE ∗ student-teacher relationships 0.09 (0.03, 0.14)⁎⁎⁎ 0.06 (0.02, 0.10)⁎⁎⁎ 0.11 (0.06, 0.15)⁎⁎⁎ 0.12 (0.07, 0.16)⁎⁎⁎ 0.14 (0.09, 0.20)⁎⁎⁎

Notes: All models adjust for age, sex, race/ethnicity, poverty status, family structure, past 30-day alcohol use, and school district location/size.
ACE = adverse childhood experiences. NMUPM = nonmedical use of prescription medications.
⁎⁎⁎ p b 0.001.
 M. Forster et al. / Addictive Behaviors 68 (2017) 30–34
Fig. 1. The graded association between ACE, student-teacher relationships, and
polyprescription drug use.
can mitigate the harmful effects of adversity, (Brown, Barbarin, & Scott,
2013; Coifman, Bonanno, Ray, & Gross, 2007; Friborg, Barlaug,
Martinussen, Rosenvinge, & Hjemdal, 2005) the present study high-
lights the opportunity that developing teachers as key points of inter-
vention offers for schools. Training teachers is advantageous in that
the approach relies less on individual level characteristics but rather le-
verages school assets, potentially reaching many more students than
family-based interventions can.
3.1. Limitations
These findings should be considered in light of several limitations.
First, generalizability is limited to youth sharing similar characteristics
as those enrolled in schools participating in the MSS. Second, results
are based on cross sectional analyses and do not support any causal
claims. Third, although socially desirable responding may bias self-re-
port responses, studies that rely on self-reports have yielded reliable re-
sults (Bradburn, 1983; Rutherford, Cacciola, Alterman, McKay, & Cook,
2000). Fourth, we cannot report the extent of variability in the ACE-
NMUPM relationship by frequency or severity of ACE or anchor expo-
sure to a specific time frame. Lastly, due to the large sample size there
is a risk of Type I errors; however, reducing the alpha levels for the anal-
yses limited the number of findings reported as statistically significant.
4. Conclusion
Although there is a growing awareness of the high prevalence and
toll of ACE exposure and the clear benefits of early prevention in school
settings, most schools do not screen for ACE and are not prepared to ad-
dress issues related to child maltreatment or family dysfunction
(Chafouleas, Riley-Tillman, Jaffery, Miller, & Harrison, 2015; Substance
Abuse and Mental Health Services Administration, 2014). Based on
our analyses, training educators to recognize trauma symptomology, ac-
knowledging the significant role that teachers can have in student de-
velopment, and cultivating strong student-teacher relationships in
conjunction with traditional prevention programming are important
considerations for future school-based substance use prevention
initiatives.
Role of funding sources
This study was partially supported by the Health Resources and Services Administra-
tion (HRSA) of the U.S. Department of Health and Human Services (HHS) under National
Research Service Award in Primary Medical Care grant number T32HP22239, Bureau of
Health Workforce. HHS had no role in the study design, collection, analysis or interpreta-
tion of data, writing the manuscript, or the decision to submit the manuscript for
publication.
33
Contributors
Myriam Forster and Amy Gower conducted literature searches and provided summa-
ries of previous research studies. Myriam Forster conducted the statistical analysis.
Myriam Forster and Amy Gower wrote the first draft of the manuscript and all authors
contributed to and have approved the final manuscript.
Conflict of interest
All authors declare that they have no conflict of interest.
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