Prevalence of Adverse Childhood Experiences and Long-Term Associations With Mental Health Among Adults: A Nationwide Cross-Sectional Study in China

Abstract

This study aimed to estimate the prevalence of adverse childhood experiences (ACEs) and explore their associations with mental health among Chinese adults. This population-based, cross-sectional survey was conducted in China in 2023. Data on participants' ACEs, depressive symptoms, anxiety symptoms, suicidal ideation, and other information were collected among participants who were selected using multi-stage stratified quota random sampling. Of 30,054 participants, 26.0% (7809/30,054) reported at least one ACE. The prevalence of major depression symptoms, moderate or severe anxiety symptoms, and suicidal ideation were 19.5%, 12.7%, and 21.7%, respectively. There was a dose‒response relationship between the cumulative number of ACEs and mental health among Chinese adults. Compared to those with no ACEs, the adjusted odds ratios (ORs) and 95% confidence interval for major depression symptoms were 1 ACE: 1.340 (1.226‒1.465), 2 ACEs: 1.769 (1.588‒1.971), 3 ACEs: 2.172 (1.909‒2.472), and ≥4 ACEs: 3.084 (2.712‒3.507). The ORs for anxiety symptoms of 1, 2, 3, and ≥4 ACEs were 1.262 (1.135‒1.403), 1.714 (1.513‒1.942), 2.119 (1.831‒2.452), and 2.890 (2.512‒3.325). The ORs for suicidal ideation were 1.056 (0.966‒1.154), 1.324 (1.188‒1.477), 1.470 (1.287‒1.679), and 3.134 (2.761‒3.557). Sexual abuse survivors were at great risk for mental health problems. Comprehensive measures are needed to support populations affected by ACEs.

Keywords

adverse childhood experience (ACE) / anxiety / depression / suicidal ideation

References

[1] National Center for Injury Prevention and Control of United States, Preventing Adverse Childhood Experiences (ACEs): Leveraging the Best Available Evidence (2019), https://stacks.cdc.gov/view/cdc/82316.

[2] Q. Fan and H. Chen, “The “Long Arm” of Adverse Childhood Experiences on Adult Health Depreciation in China,” Child Abuse & Neglect 143 (2023): 106234.

[3] A. Danese and J. R. Baldwin, “Hidden Wounds?,” Annual Review of Psychology 68 (2017): 517-544.

[4] C. A. Nelson, Z. A. Bhutta, N. Burke Harris, A. Danese, and M. Samara, “Adversity in Childhood is Linked to Mental and Physical Health Throughout Life,” The BMJ 371 (2020): m3048.

[5] L. Thaler and H. Steiger, “Eating Disorders and Epigenetics,” Advances in Experimental Medicine and Biology 978 (2017): 93-103.

[6] A. Danese and C. S. Widom, “Objective and Subjective Experiences of Child Maltreatment and Their Relationships With Psychopathology,” Nature Human Behaviour 4, no. 8 (2020): 811-818.

[7] M. A. Reinhard, S. V. Rek, T. Nenov-Matt, et al., “Association of Loneliness and Social Network Size in Adulthood With Childhood Maltreatment: Analyses of a Population-Based and a Clinical Sample,” European Psychiatry 65, no. 1 (2022): e55.

[8] E. Kuzminskaite, A. W. Gathier, P. Cuijpers, et al., “Treatment Efficacy and Effectiveness in Adults With Major Depressive Disorder and Childhood Trauma History: A Systematic Review and Meta-Analysis,” The Lancet Psychiatry 9, no. 11 (2022): 860-873.

[9] G. Turecki, D. A. Brent, D. Gunnell, et al., “Suicide and Suicide Risk,” Nature Reviews Disease Primers 5, no. 1 (2019): 74.

[10] S. Alter, C. Wilson, S. Sun, et al., “The Association of Childhood Trauma With Sleep Disturbances and Risk of Suicide in US Veterans,” Journal of Psychiatric Research 136 (2021): 54-62.

[11] D. Lu, W. Wang, X. Qiu, et al., “The Prevalence of Confirmed Childhood Trauma and Its' impact on Psychotic-Like Experiences in a Sample of Chinese Adolescents,” Psychiatry Research 287 (2020): 112897.

[12] T. Zhang, L. Kan, C. Jin, and W. Shi, “Adverse Childhood Experiences and Their Impacts on Subsequent Depression and Cognitive Impairment in Chinese Adults: A Nationwide Multi-Center Study,” Journal of Affective Disorders 323 (2023): 884-892.

[13] J. Li, Z. Liu, M. Li, et al., “Associations of Adverse Childhood Experiences With Common Psychiatric Disorder in Later Life: Results From the China Mental Health Survey,” BMC Geriatrics 23, no. 1 (2023): 706.

[14] W. Xiao, S. Li, H. Xu, et al., “Population Attributable Fractions of Adverse Childhood Experiences for Emotional Problems and Self-Harming Behaviors Among Middle School Students in China,” Asian Journal of Psychiatry 85 (2023): 103621.

[15] D. Sun, R. Zhang, X. Ma, et al., “The Association Between Childhood Trauma and the Age of Onset in Drug-Free Bipolar Depression,” Psychiatry Research 310 (2022): 114469.

[16] X. Fang, D. A. Fry, and K. Ji, “The Burden of Child Maltreatment in China: A Systematic Review,” Bulletin of the World Health Organization 93, no. 3 (2015): 176-185C.

[17] A. C. Kallstrom-Fuqua, R. Weston, and L. L. Marshall, “Childhood and Adolescent Sexual Abuse of Community Women: Mediated Effects on Psychological Distress and Social Relationships,” Journal of Consulting and Clinical Psychology 72, no. 6 (2004): 980-992.

[18] T. Rechenberg, T. Fleischer, C. Sander, and G. Schomerus, “Gender-Related Stigma Toward Individuals With a History of Sexual or Physical Violence in Childhood,” BMC Public Health [Electronic Resource] 24, no. 1 (2024): 2396.

[19] J. E. Lansford, L. Chang, K. A. Dodge, et al., “Physical Discipline and Children's Adjustment: Cultural Normativeness as a Moderator,” Child Development 76, no. 6 (2005): 1234-1246.

[20] L. Liu and M. Wang, “Parental Harsh Discipline and Adolescent Problem Behavior in China: Perceived Normativeness as a Moderator,” Child Abuse & Neglect 86 (2018): 1-9.

[21] R. Gilbert, C. S. Widom, K. Browne, D. Fergusson, E. Webb, and S. Janson, “Burden and Consequences of Child Maltreatment in High-Income Countries,” The Lancet 373, no. 9657 (2009): 68-81.

[22] M. T. Merrick, D. C. Ford, K. A. Ports, and A. S. Guinn, “Prevalence of Adverse Childhood Experiences from the 2011-2014 Behavioral Risk Factor Surveillance System in 23 States,” JAMA Pediatrics 172, no. 11 (2018): 1038-1044.

[23] T. W. Viola, G. A. Salum, B. Kluwe-Schiavon, B. Sanvicente-Vieira, M. L. Levandowski, and R. Grassi-Oliveira, “The Influence of Geographical and Economic Factors in Estimates of Childhood Abuse and Neglect Using the Childhood Trauma Questionnaire: A Worldwide Meta-Regression Analysis,” Child Abuse & Neglect 51 (2016): 1-11.

[24] R. H. Salk, J. S. Hyde, and L. Y. Abramson, “Gender Differences in Depression in Representative National Samples: Meta-Analyses of Diagnoses and Symptoms,” Psychological Bulletin 143, no. 8 (2017): 783-822.

[25] L. Gu, J. Xie, J. Long, et al., “Epidemiology of Major Depressive Disorder in Mainland China: A Systematic Review,” PLoS ONE 8, no. 6 (2013): e65356.

[26] R. Chen, J. An, and J. Ou, “Suicidal Behaviour Among Children and Adolescents in China,” The Lancet Child & Adolescent Health 2, no. 8 (2018): 551-553.

[27] J. Zhang, Y. Liu, and L. Sun, “Psychological Strain and Suicidal Ideation: A Comparison Between Chinese and US College Students,” Psychiatry Research 255 (2017): 256-262.

[28] C. Bethell, J. Jones, N. Gombojav, J. Linkenbach, and R. Sege, “Positive Childhood Experiences and Adult Mental and Relational Health in a Statewide Sample,” JAMA Pediatrics 173, no. 11 (2019): e193007.

[29] J. Lian, K. M. Kiely, B. L. Callaghan, and K. J. Anstey, “Childhood Adversity is Associated With Anxiety and Depression in Older Adults: A Cumulative Risk and Latent Class Analysis,” Journal of Affective Disorders 354 (2024): 181-190.

[30] L. Lin, H. H. Wang, C. Lu, W. Chen, and V. Y. Guo, “Adverse Childhood Experiences and Subsequent Chronic Diseases Among Middle-Aged or Older Adults in China and Associations With Demographic and Socioeconomic Characteristics,” JAMA Network Open 4, no. 10 (2021): e2130143.

[31] Y.-R. Wang, J.-W. Sun, P.-Z. Lin, H.-H. Zhang, G.-X. Mu, and F.-L. Cao, “Suicidality Among Young Adults: Unique and Cumulative Roles of 14 Different Adverse Childhood Experiences,” Child Abuse & Neglect 98 (2019): 104183.

[32] T. O. Afifi, M. W. Enns, B. J. Cox, G. J. G. Asmundson, M. B. Stein, and J. Sareen, “Population Attributable Fractions of Psychiatric Disorders and Suicide Ideation and Attempts Associated With Adverse Childhood Experiences,” American Journal of Public Health 98, no. 5 (2008): 946-952.

[33] E. S. Howe and E. R. Dworkin, “The Day-to-Day Relationship Between Posttraumatic Stress Symptoms and Social Support After Sexual Assault,” European Journal of Psychotraumatology 15, no. 1 (2024): 2311478.

[34] S. E. Ullman and M. Relyea, “Social Support, Coping, and Posttraumatic Stress Symptoms in Women Sexual Assault Survivors: A Longitudinal Analysis,” Journal of Traumatic Stress 29, no. 6 (2016): 500-506.

[35] E. N. Satinsky, B. Kakuhikire, C. Baguma, et al., “Adverse Childhood Experiences, Adult Depression, and Suicidal Ideation in Rural Uganda: A Cross-Sectional, Population-Based Study,” PLoS Medicine 18, no. 5 (2021): e1003642.

[36] V. J. Felitti, R. F. Anda, D. Nordenberg, et al., “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study,” American Journal of Preventive Medicine 14, no. 4 (1998): 245-258.

[37] J. Radley, C. Grant, J. Barlow, and L. Johns, “Parenting Interventions for People With Schizophrenia or Related Serious Mental Illness,” The Cochrane Database of Systematic Reviews 10, no. 10 (2021): CD013536.

[38] M. L. Gunlicks and M. M. Weissman, “Change in Child Psychopathology With Improvement in Parental Depression: A Systematic Review,” Journal of the American Academy of Child and Adolescent Psychiatry 47, no. 4 (2008): 379-389.

[39] P. Ip, R. S. Wong, S. L. Li, K. L. Chan, F. K. Ho, and C.-B. Chow, “Mental Health Consequences of Childhood Physical Abuse in Chinese Populations: A Meta-Analysis,” Trauma, Violence & Abuse 17, no. 5 (2016): 571-584.

[40] National Bureau of Statistics of China, Chinese Statistical Yearbook 2023 (2023), https://www.stats.gov.cn/sj/ndsj/2023/indexeh.htm.

[41] K. Kroenke, R. L. Spitzer, and J. B. Williams, “The PHQ-9: Validity of a Brief Depression Severity Measure,” Journal of General Internal Medicine 16, no. 9 (2001): 606-613.

[42] Y. H. Lee, Z. Liu, D. Fatori, et al., “Association of Everyday Discrimination With Depressive Symptoms and Suicidal Ideation During the COVID-19 Pandemic in the All of Us Research Program,” JAMA Psychiatry 79, no. 9 (2022): 898-906.

[43] Y. Feng, W. Huang, T.-F. Tian, et al., “The Psychometric Properties of the Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR) and the Patient Health Questionnaire-9 (PHQ-9) in Depressed Inpatients in China,” Psychiatry Research 243 (2016): 92-96.

[44] R. L. Spitzer, K. Kroenke, J. B. W. Williams, and B. Löwe, “A Brief Measure for Assessing Generalized Anxiety Disorder: The GAD-7,” Archives of Internal Medicine 166, no. 10 (2006): 1092-1097.

[45] H. W. Fung, H. M. Chung, and C. A. Ross, “Demographic and Mental Health Correlates of Childhood Emotional Abuse and Neglect in a Hong Kong Sample,” Child Abuse & Neglect 99 (2020): 104288.

[46] K. Hughes, M. A. Bellis, K. A. Hardcastle, et al., “The Effect of Multiple Adverse Childhood Experiences on Health: A Systematic Review and Meta-Analysis,” The Lancet Public Health 2, no. 8 (2017): e356-e366.

RIGHTS & PERMISSIONS

2025 The Author(s). MedComm published by Sichuan International Medical Exchange & Promotion Association (SCIMEA) and John Wiley & Sons Australia, Ltd.