The impact of family function as a moderating variable on the association between adverse childhood experiences (ACEs) and behavioral problems in male adolescents aged 10–17 Years in Indonesia

Introduction

Behavioral problems during adolescence are a growing concern. These problems encompass persistent disruptive, aggressive, or antisocial behaviors that interfere with an adolescent’s social, academic, and family functioning [1], [2], [3], [4]. Adolescence is a critical developmental stage characterized by significant physiological, psychological, and social transitions, which can heighten vulnerability to emotional and behavioral disturbances [5]. The global prevalence of behavioral issues among adolescents was estimated at 5.3 % in 2021, with a higher occurrence in males (7.2 %) compared to females (3.37 %) [6]. Similarly, data from the Indonesia National Mental Health Survey (I-NAMHS) indicate a national prevalence of 2.4 % among adolescents aged 10 to 17, with a higher prevalence in males (3.5 %) than females (1.2 %) [7].

The development of behavioral problems in adolescence is influenced by a complex interplay of individual, familial, and environmental factors [1], 2]. Among these, adverse childhood experiences (ACEs) have been identified as a significant risk factor, encompassing exposure to abuse, neglect, and household dysfunction, all of which contribute to an increased likelihood of developing behavioral disorders [3], 8]. Adolescents who experience ACEs are at a substantially higher risk of mental health issues, including post-traumatic stress disorder (PTSD), anxiety, depression, suicidal behavior, and externalizing problems such as antisocial behavior, interpersonal violence, delinquency, and impulsivity [9], [10], [11]. A large-scale study involving over 64,000 adolescents engaging in rule-breaking behaviors found that those exposed to four or more ACEs were four times more likely to develop behavioral problems compared to those with fewer or no ACEs [10]. These findings underscore the profound and long-term impact of ACEs on adolescent psychological and behavioral health.

Nevertheless, some adolescents can overcome the negative impacts of ACEs and avoid engaging in risky behaviors. A well-functioning family is a key element that can serve as a protective factor in this context [12]. The family is considered the primary environment where adolescents learn, grow, and form their identity [13]. Good family function includes aspects such as emotional support, open communication, parental involvement, and the formation of positive norms and values [12], 14], 15].

Consistent emotional support from family members can serve as a robust pillar for the emotional well-being of adolescents. When adolescents perceive support and acceptance within the family setting, they are likely to enhance their resilience against stress and trauma linked to ACEs [16]. Moreover, transparent communication among family members can help adolescents express and understand their emotions, thereby reducing the likelihood of behavioral issues arising from unhealthy emotional expression [17].

Although global studies have explored the association between ACEs, family functioning, and adolescent behavioral problems, evidence from Indonesia remains scarce. The I-NAMHS provides the first nationally representative dataset on adolescent mental health in Indonesia [18]. This dataset is essential for understanding the prevalence and determinants of behavioral problems within the Indonesian context, given the cultural and socio-economic differences that may influence adolescent mental health outcomes. This study aims to examine the relationship between ACEs and adolescent behavioral problems while exploring the moderating role of family functioning in this association. Specifically, it aims to evaluate how various dimensions of family functioning – such as communication, affective involvement, cohesion, and control – impact the effects of ACEs on adolescent behavioral outcomes.

Materials and methods

Results

Table 1 shows that the majority of respondents were in late adolescents (58.6 %), lived in urban areas (68.4 %), and were from Java-Bali (61.6 %). Most were in junior high school (44.9 %), followed by senior high school (33.5 %) and primary school (21.6 %).

Table 2 summarizes the homogeneity test between the case and control groups. There were no significant differences in education level (p=0.97), age group distribution (p=1.00), or regional representation (p=0.43), indicating that the groups were well-matched. The majority of adolescents experiencing behavioral problems were late adolescents (58.6 %), had completed junior high school (45.7 %), and were from the Java-Bali region (49.5 %).

The bivariate analysis (Unadjusted) in Table 3 revealed a dose-response relationship between ACEs and behavioral problems in male adolescents. Among adolescents with behavioral problems, the odds of having experienced 1–2 ACEs were 5.96 times higher compared to those in the control group (OR=5.96, 95 % CI [2.29, 15.15], p<0.001). The odds further increased among those with three or more ACEs (OR=8.65, 95 % CI [3.21, 23.3], p<0.001).

The multivariate analysis (adjusted) in Table 3 examined the impact of family function on the relationship between ACEs and behavioral problems. The results indicate that positive family function reduces the negative effects of ACEs on behavioral problems. After adjusting for family function, the risk of behavioral problems among adolescents with 1–2 ACEs decreased from OR=5.96 to OR=4.94, remaining statistically significant. A similar pattern was observed for adolescents with three or more ACEs; before considering family function, the odds ratio was OR=8.65, which decreased to OR=6.95 after adjustment (p<0.001). These findings highlight the crucial role of family function as a protective factor, mitigating the impact of ACEs on behavioral problems in male adolescents.

The multivariate analysis in Table 4 further investigates the role of family function components as potential protective factors in the relationship between ACEs and behavioral problems. Among the family function components, positive family communication demonstrated a protective effect. Adolescents who reported positive communication within their family were significantly less likely to exhibit behavioral problems (OR=0.33–0.41, p<0.05). Similarly, positive family cohesion showed a potential protective effect, although the confidence intervals suggest variability in its impact (OR=0.47, p>0.05). Family affective function and control did not demonstrate a statistically significant protective effect, as their odds ratios remained close to 1. These findings suggest that while family function plays a role in buffering the impact of ACEs on behavioral problems, certain aspects – particularly family communication – may have a stronger influence in mitigating risk.

Table 5 measures the mediating role of family function between ACEs and behavioral problems. The results of the analysis showed that the direct effect of ACEs on behavioral problems was significant (OR=2.92, p<0.001), whereas the indirect effect through family function was not significant (OR=2.73, p>0.05). Although about 23.7 % of the total effect was mediated, the wide confidence interval suggests that the mediation role is not strong enough. The total effect remained significant (OR=7.97, p<0.001), confirming that ACEs contribute greatly to behavioral problems, especially through direct pathways. These results suggest that family function may not be the primary mediator in these relationships, so it is necessary to explore other factors, such as coping strategies or social support, to better understand the mechanisms that link ACEs to behavioral problems.

Discussion

This study examined the moderating role of family function in the association between ACEs and behavioral problems in male adolescents aged 10–17 years in Indonesia. The findings indicate that adolescents with behavioral problems were significantly more likely to have been exposed to 1–2 ACEs compared to those in the control group. These findings are consistent with previous research highlighting the long-term adverse effects of childhood adversity on adolescent psychosocial outcomes [8], 24]. ACEs often result in trauma and impose a significant burden on adolescents, both globally and in Indonesia [25]. Such trauma involves emotional and psychological strain caused by negative or violent experiences, leading to heightened stress responses. These adversities are strongly associated with symptoms such as depression, anxiety, and various behavioral problems, which collectively undermine adolescents’ overall mental and social well-being [2].

The bivariate analysis revealed a strong dose-response relationship between ACEs and behavioral problems, in which adolescents exposed to 1–2 ACEs had nearly six times the risk of developing behavioral problems, and those exposed to three or more ACEs had an even higher risk (OR=8.65). These findings align with existing literature demonstrating that cumulative exposure to ACEs is associated with an increased likelihood of engaging in risky behavior [24], 26]. The study conducted by [24] suggests that adolescents with one or more ACEs have an increased risk of behavioral problems. Negative parental behaviors, such as child abuse and substance abuse, have been shown to increase the risk of behavioral problems and are strong risk factors for subsequent violence, including violent behavior in young adulthood and child abuse when they become parents [27], 28]. Additionally, childhood abuse is a predictor of later criminality [29].

The multivariate analysis demonstrated that family function reduces the negative impact of ACEs on behavioral problems. When family function was considered, the odds ratios for behavioral problems among adolescents with ACE exposure decreased significantly, indicating that a supportive family environment can buffer against the detrimental effects of early adversity. Specifically, positive family communication emerged as the most stable and significant protective factor, reducing the likelihood of behavioral problems (OR=0.33–0.41, p<0.05). This finding is in line with research suggesting that open and supportive communication within families fosters emotional regulation and resilience in adolescents facing adversity [30].

Previous studies have shown that family support plays a protective factor against the adverse effects of ACEs [31]. The parent-child relationship has been identified as a mediator in the association between childhood abuse and adolescent behavioral problems [32]. Specifically, there is a well-documented link between maternal violence victimization and behavioral issues in adolescents, wherein children subjected to maternal abuse exhibit higher levels of both externalizing and internalizing problems [33]. Furthermore, paternal violence victimization has been found to predict violent behavior in adolescents [34].

The relationship between ACEs and family function is complex, as they often coexist. ACEs are associated with family instability, particularly in precarious living conditions [35]. Dysfunctional family environments further exacerbate mental health issues stemming from ACEs [36]. Additionally, the intergenerational effects of ACEs can shape family functioning over time [37]. However, ACEs do not always lead to family dysfunction – some individuals develop resilience through external support or adaptive coping mechanisms [38].

Despite the protective effects of family function, the mediation analysis revealed that family function did not fully mediate the relationship between ACEs and behavioral problems. Although approximately 23.7 % of the total effect was mediated, the indirect effect was not statistically significant. This suggests that while family function plays a role in moderating the impact of ACEs, other factors, such as peer support, school environment, and individual coping strategies, may also contribute to adolescent behavioral outcomes [39], 40]. Future research should explore these alternative pathways to provide a more comprehensive understanding of the mechanisms linking ACEs to behavioral problems.

These findings have significant implications for interventions aimed at reducing behavioral problems among adolescents exposed to ACEs. Strengthening family cohesion and enhancing communication skills within families may serve as key strategies to mitigate the adverse effects of ACEs, especially when integrated with broader social support systems such as school-based counseling and community resilience programs. The results are particularly relevant for stakeholders in Indonesia, including the Ministry of Population and Family Development, whose existing programs could incorporate evidence-based components to foster emotional bonding and family communication, making interventions more preventive and contextually relevant. Beyond Indonesia, these insights may also inform family-centered policies and practices in other low- and middle-income countries, contributing to global efforts to promote child and adolescent mental health.

Conclusions

This study reinforces the significant impact of adverse childhood experiences (ACEs) on behavioral problems among male adolescents and highlights the protective role of family functioning. Although family functioning did not fully mediate the relationship between ACEs and behavioral problems, it remains an important buffering factor. Strengthening family-based strategies – particularly those that promote emotional cohesion and effective communication – may help reduce the risk and severity of behavioral problems among adolescents exposed to adversity. Future studies should consider other potential mediators, including peer support and coping strategies, to develop more targeted interventions aimed at reducing the negative effects of childhood adversity on adolescent behavioral outcomes.