Childhood adversity in a youth psychiatric population: prevalence and associated mental health problems

ABSTRACT

Background: Childhood adversity can have lasting negative effects on physical and mental health. This study contributes to the existing literature by describing the prevalence rates and mental health outcomes related to adverse childhood experiences (ACEs) among adolescents registered for mental health care.

Methods: Participants in this cross-sectional study were youths (aged 12–18 years) who were referred to outpatient psychiatric departments in the Netherlands. Demographic information was collected from the medical records. The Child Trauma Screening Questionnaire (CTSQ) was used to examine the presence of ACEs and posttraumatic stress symptoms (PTSS). To assess mental health problems, we used the Dutch translation of the Youth Self Report. Descriptive statistics and frequencies were used to calculate prevalence rates across the various ACEs domains. ANOVA and chi-square tests were used to explore the relationship between ACEs and mental health.

Results: Of the 1373 participants, 69.1% reported having experienced at least one ACE and 17.1% indicated exposure to four or more ACEs in their lives. Although there was substantial overlap among all ACE categories, the most frequently reported were bullying (49.2%), emotional abuse (17.8%), physical abuse (12.2%), and sexual abuse (10.1%). Female adolescents (72.7%) reported significantly more ACEs than their male counterparts (27.0%). Furthermore, a higher number of ACEs was associated with significantly more self-reported general mental health problems, an elevated prevalence of both mood and post-traumatic stress disorders, and a greater presence of two or more co-existing psychiatric diagnoses (comorbid psychiatric classification).

Conclusions: This cross-sectional study on childhood adversity and its association with mental health showed that ACEs are highly prevalent in youth registered for mental health care. This study provides support for a graded and cumulative relationship between childhood adversity and mental health problems.

HIGHLIGHTS

• This study investigated the prevalence of adverse childhood experiences and associated mental health problems among Dutch youth registered for mental health care. Almost seven out of ten patients reported having been exposed to childhood adversity, and two out of ten patients reported exposure to four or more adverse childhood experiences.

• The results indicated a significant association between exposure to childhood adversity and mental health problems.

• Analysis of the data showed a cumulative effect of adverse childhood experiences, meaning that patients who reported exposure to more childhood adversity also showed more severe internalizing and externalizing mental health problems, a significant increase in both posttraumatic stress disorder and mood disorder diagnoses, and a general increase in psychiatric comorbidities.

Antecedentes: La adversidad infantil puede tener efectos negativos a largo plazo en la salud física y mental. Este estudio contribuye a la literatura existente mediante la descripción de las las tasas de prevalencia y los resultados de salud mental asociadas a experiencias infantiles adversas (ACEs por sus siglas en inglés) entre adolescentes registrados por atención en salud mental.

Método: Los participantes de este estudio transversal fueron jóvenes (Edad 12–18 años), que fueron remitidos a departamentos psiquiátricos ambulatorios de los Países Bajos. La información demográfica fue recolectada desde su historial médico. El Cuestionario de Detección de Trauma Infantil (CTSQ por sus siglas en inglés) fue utilizado para evaluar la presencia de ACEs y de síntomas de estrés postraumático (PTSS, por sus siglas en inglés). Para evaluar los problemas de salud mental, utilizamos la traducción holandesa del Youth Self Report. Se utilizaron estadísticas descriptivas y de frecuencias para calcular las tasas de prevalencia entre los distintos dominios de ACEs. Se utilizaron test de ANOVA y Chi-cuadrado para explorar la relación entre ACEs y la salud mental.

Resultados: De los 1.373 pacientes, 69,1% reportaron haber experimentado al menos una ACEs y un 17,1% señaló haber estado expuesto a cuatro o más ACEs en sus vidas. Aunque existió una sustancial sobreposición entre las categorías de ACEs, aquellas reportadas con mayor frecuencia fueron el bullying (49.2%), abuso emocional (17.8%), abuso físico (12.2%), y abuso sexual (10.1%). Las Adolescentes mujeres (72.7%) reportaron significativamente más ACEs que sus contrapartes masculinas (27.0%). Además, un mayor número de ACEs se asoció con un número significativamente mayor de problemas de salud mental auto informados, con una alta prevalencia de trastornos del ánimo y de trastorno de estrés postraumático, y con una mayor presencia de dos o más diagnósticos psiquiátricos coexistentes (clasificación psiquiátrica de comorbilidad).

Conclusiones: Este estudio de corte transversal sobre la adversidad infantil y su asociación con la salud mental, demostró que las ACEs son altamente prevalentes en los jóvenes registrados para el cuidado de la salud mental. Este estudio respalda una relación gradual y acumulativa entre la adversidad infantil y los problemas de salud mental.

KEYWORDS:

• Childhood adversity
• ACE
• childhood trauma
• PTSD
• mental health
• adolescences
• outpatient psychiatric sample

PALABRAS CLAVES:

• Adversidad infantil
• trauma infantil
• TEPT
• salud mental
• adolescentes
• muestra psiquiátrica ambulatoria

1. Background

Adverse childhood experiences (ACEs), such as abuse, neglect, or maltreatment, can have serious perpetual effects on a child's development and physical and mental health (Felitti et al., 1998). Studies have shown that ACEs are common, but their prevalence rates vary widely across studies, ranging from 41% to 97% (Carlson et al., 2020), which may be due to differences in methodology and characteristics of participants as well as inconsistencies in operational definitions of ACEs. Although the term ACEs cannot be operationalized unambiguously, the most common definition of ACEs is ‘potentially traumatic events in childhood’ (CDC, 2022). Furthermore, studies have shown notable parallels in the impact of ACEs on individual development, with combined and cumulative effects contributing to an increased risk of poor health outcomes (Hughes et al., 2017; Lanier et al., 2018). However, most studies have been conducted on adults in the general population.

The high prevalence of ACEs is a major public health concern that negatively affects development and increases the risk of mental health conditions and chronic diseases in later life (Gardner et al., 2019; Hughes et al., 2017; Scott et al., 2023). A systematic review by Petruccelli et al. (2019), which included 96 articles on health outcomes associated with ACEs, showed that ACEs were associated with significantly poorer medical health outcomes, such as respiratory disease, ischemic heart disease, sleep problems, gastrointestinal disease, and somatic pain. This review also found poorer psychosocial/behavioral outcomes, such as alcohol problems, risky sexual behaviour, depressed mood, suicidal ideation, and anxiety problems. Furthermore, Petruccelli and colleagues concluded that ACEs are related to lower Quality of Life, and that the association showed a graded response to the number of ACEs to which a person was exposed. Previous studies have suggested that ACEs impair the development of endocrine, immune, and nervous systems (McCrory et al., 2011). Altogether, these health outcomes can also have intergenerational effects (Zhang et al., 2023), affecting not only individuals who experience ACEs themselves but also their families and communities. Therefore, ACEs are associated with major health and financial costs in European countries (Hughes et al., 2021).

Despite numerous studies on the impact of ACEs, little progress has been made in preventing their occurrence or in addressing their mental health consequences (McLaughlin et al., 2019; Rith-Najarian et al., 2021). It is crucial to promptly identify and acknowledge the impact of ACEs early in life to minimize their detrimental effects on children's physical and mental well-being. Early identification and recognition of ACEs play a vital role in facilitating timely intervention and support for both children and their families. This could involve granting access to mental health services, social and legal services, and other resources to address the underlying causes of adversity and mitigate its negative impact. Although there is still room for improvement in the care of individuals experiencing the aftermath of ACEs, there are promising results in reducing mental health problems associated with ACEs (Lorenc et al., 2020), highlighting the importance of early recognition and treatment.

Despite a well-established body of evidence on ACEs in the general population, studies on the prevalence of these events in psychiatric populations are limited. Several studies among adults have shown that the prevalence of ACEs in the psychiatric population is higher than that in national community samples (Jiang et al., 2022; van der Feltz-Cornelis et al., 2019). However, the prevalence of ACEs among youth registered for mental health care remains largely unknown, and knowledge of the mechanisms underlying its impact is scarce. Given that ACEs play a substantial role in the onset of mental health problems and can affect the efficacy of treatment, it is imperative to comprehensively understand the characteristics, occurrence rates, and potential ramifications of ACEs in youth psychiatric populations. This understanding is fundamental for devising targeted prevention and intervention approaches tailored to meet distinct requirements.

Therefore, the purpose of the present study was to determine the prevalence and impact of ACEs in youth registered for mental health care. We explored the associations between ACEs and important demographic variables, ACEs and their co-occurrence, and ACEs and several mental health conditions.

2. Methods

2.1. Design

A descriptive cross-sectional study was conducted at Karakter Child and Adolescent Psychiatry, an organization specializing in child and adolescent psychiatry in the Netherlands. The data utilized in this study form were part of the screening procedure in an ongoing clinical trial (Knipschild et al., 2023) and aimed at assessing the trauma history of all adolescents (aged 12–18 years) registered for mental health care. Approval for the study and its screening procedure was granted by the Medical Research Ethics Committee East Netherlands (MREC Oost-Nederland) under reference number 2017–3732.

2.2. Procedure

For this cross-sectional study, data were gathered from adolescents who were referred to one of the 13 outpatient psychiatric departments. Data collection spanned from May 2018 to April 2023. Upon referral and after providing consent, all patients along with their parents or legal guardians received standard digital questionnaires designed to collect information about the child's development, current symptomatology, and various variables, including age and sex. Additionally, validated questionnaires, such as the Youth Self Report (YSR; Verhulst et al., 1997) and the Child Trauma Screening Questionnaire (CTSQ) (Kenardy et al., 2006), were administered. The completed questionnaires were incorporated into the patient files. In this study, a dataset was obtained through anonymized and non-identifiable coding procedures to ensure the confidentiality and privacy of the participants.

2.3. Population

Adolescents eligible to participate in this study were recruited between May 2018 and May 2023. All eligible adolescents were sequentially referred by primary, secondary, and tertiary health care services to Karakter Child and Adolescent Psychiatry, with 13 departments spread over the central, eastern, and southern regions of the Netherlands. During this period, a total of 4569 patients were referred for mental health care and received invitations to complete the standard digital questionnaires including trauma screening (CTSQ). Individuals were excluded from the analyses in the current study for various reasons, including missing YSR forms (n = 926), age outside the range of 12–18 years (n = 113), non-disclosure of the questionnaire by parents or legal guardians or when parents or legal guardians did not share the questionnaire with the participant (n = 794), and refusal or failure to complete the questionnaires on time (n = 1363). Analyses were conducted on the complete datasets, resulting in a final sample size of 1373 participants.

2.4. Measures

2.4.1. Demographic variables

Information on the participants’ age, sex (0 = male, 1 = female), and educational level was collected. We categorized and coded educational levels as follows: 0 = Low (pre-vocational secondary education, 4 years of post-elementary education), 1 = Intermediate (senior general secondary education, 5 years of post-elementary education) and 2 = High (pre-university education, 6 years of post-elementary education).

2.4.2. Adverse childhood experiences and posttraumatic stress symptoms

The Child Trauma Screening Questionnaire (CTSQ) was used to examine the presence of ACEs (Kenardy et al., 2006) and posttraumatic stress symptoms (PTSS). The CTSQ is a self-report measure that contains a 14 items list of traumatic life events. The list of life events was categorized using the following types of events: sexual abuse, physical abuse, emotional abuse, neglect, accidents/disaster/war, parental loss, and bullying. Each life event was answered with ‘yes’ (experienced or witnessed; scored as 1) or ‘no’ (not experienced or witnessed; scored as 0). The CTSQ contains 10 items to index post-traumatic stress symptoms of re-experiencing and hyperarousal, with a higher score indicating more severe posttraumatic stress symptoms. Questions can be answered with ‘no’ (the symptom was absent last week) or ‘yes’ (the symptom was present two or more times last week). The CTSQ demonstrated good convergent validity. Internal consistency was reported, with a Cronbach’s alpha of .69 (Kenardy et al., 2006). In the current study sample, we found a Cronbach’s alpha of .81. Based on the CTSQ, we categorized ACEs into three groups: 0 ACEs; 1–3 ACEs; and >4 ACEs. This categorization is in line with the approach used in other studies on ACEs (Riedl et al., 2020). Furthermore, scores range from 0–10, with symptom scores > 4 are considered a positive screen and indicative of posttraumatic stress symptomatology (Kenardy et al., 2006).

2.4.3. Mental health problems

To assess mental health problems, we used the Dutch translation of the Youth Self Report (YSR; Verhulst et al., 1997), a widely used instrument to assess self-reported mental health in adolescents (Deighton et al., 2014). The YSR is a 112 items scale that measures internalizing and externalizing mental health problems during the past six months on a 3-point likert scale (0 = ‘not true,’ 1 = ‘somewhat true,’ 2 = ‘very true’). The YSR was scored on eight syndrome scales anxious/depressed, somatic complaints, withdrawn/depressed (internalizing mental health problems), and aggressive and rule-breaking behaviours (externalizing mental health problems). Other scales include attention, social, and thought problems. The total problem score was the sum of all eight subscales. A higher score indicates more severe mental health problems, as reported by adolescents. The YSR has demonstrated good psychometric properties (Verhulst et al., 1997).

2.4.4. Psychiatric classification

The patients’ medical records were used to extract their diagnostic classification according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (American Psychiatric Association, 2013). These diagnoses were based on a child psychiatric examination, performed by a licensed clinical psychologist or psychiatrist, which is the most common procedure in The Netherlands. The diagnostic classification was divided into primary and secondary diagnoses if applicable.

2.5. Statistical analysis

Analyses were conducted (N = 1373) on age, sex, CTSQ, and YSR. Frequency analyses were performed to determine the prevalence of ACEs. ACEs were categorized as follows: 0 = 0 ACEs, 1 = 1–3 ACEs, and 2 = 4 or more ACEs. Group differences were analyzed using chi-square tests and analysis of variance (ANOVAs), with corresponding effect sizes reported. All statistical analyses were performed using IBM SPSS (Version 27.0).

3. Results

The sample comprised of adolescent girls (59.6%) and boys (40.4%). The majority of the participants were enrolled in pre-vocational secondary education (Low) (48.0%). Autism Spectrum Disorder was the most prevalent classification (41.5%), followed by ADHD (16.5%), anxiety disorders (9.9%), mood disorders (7.5%) or PTSD (7.0%). Yet with 87.7%, nearly all participants of the current sample exhibit two or more co-existing psychiatric diagnoses (comorbid psychiatric classification).

3.1. Prevalence of ACEs

Data analysis revealed that 30.9% (n = 425) of participants indicated that they had not experienced any ACE, whereas 69.1% (n = 948) reported having experienced one or more ACEs. Of all respondents, 52% (n = 713) reported experiencing between one and three ACEs, whereas 17.1% (n = 235) reported experiencing four or more ACEs (Table 1). The most frequently reported ACEs were bullying (49.2%), emotional abuse (17.8%), physical abuse (12.2%), and sexual abuse (10.1%) (Table 1).

Table 1. Characteristics of the sample (N = 1373).

	M	SD
Age	14.71	1.48
	n	%
Gender
Male	552	40.4%
Female	815	59.6%
Educational Level
Low (Pre-vocational secondary education)	665	48.0%
Intermediate (Senior general secondary education)	348	25.3%
High (Pre-university education)	292	21.3%
Other	68	5.0%
Classification (primary)
ADHD	227	16.5%
ASD	570	41.5%
Mood Disorders	103	7.5%
Anxiety/OCD Disorders	136	9.9%
Trauma and Stress related disorders	96	7.0%
Other	241	17.6%
Comorbid classification (secondary)
Yes	1204	87.7%
No	169	12.3%
Experienced ACEs (yes; n, %)
Sexual abuse	138	10.1%
Physical abuse	167	12.2%
Emotional abuse	244	17.8%
Neglect	91	6.6%
Accidents/disaster/war	112	8.2%
Parental loss	37	2.7%
Bullying	676	49.2%
Other*	359	26.1%
Witnessing ACEs (yes; n, %)
Sexual abuse	37	2.7%
Physical abuse	156	11.4%
Emotional abuse	163	11.9%
Neglect	96	7.0%
Accidents/disaster/war	111	8.1%
Other	126	9.2%
Number of ACEs
0	425	30.9%
1−3 ACEs	713	52.0%
4+ ACEs	235	17.1%

Note. M = Mean; SD = Standard Deviation; ACEs = Adverse Childhood Experiences.

Classification ‘Other’, including: personality disorders (n = 69) and eating disorders (n = 46).

*The departments where the research was conducted are outpatient facilities for general mental health, implying that referred children can have diagnoses from the full spectrum of DSM-5 classifications

3.2. ACEs and demographic variables

Table 2 presents the results for demographic variables per number of ACEs. A one-way ANOVA revealed a significant effect of ACEs on age, F(2, 1370) = 6.45, p = .002, with an associated effect size of R² = .009, suggesting a small effect size, meaning that ACEs explain only a small proportion of the variability in age. These results suggest that older youths report more ACEs. A Chi-square test of independence was performed to examine the relationship between ACEs and sex, ACEs and educational Level, and ACEs and psychiatric classifications. The results revealed a significant association (χ²(2) = 28.85, p < .001) between ACEs and sex. In our sample, female adolescents (72.7%) reported significantly more ACEs than male adolescents (27.0%). No significant association was found between ACEs and educational levels (χ²(6) = 8.81, p = .185). We found significant differences in the relationship between ACEs and psychiatric classification (χ²(10) = 93.73, p < .001). In our sample, we observed that more ACEs were associated with an increase in the prevalence of both mood disorders and post-traumatic stress disorder. In contrast, we observed a decrease in neurobiological developmental disorders, such as ASD and ADHD. Additionally, a significant association (χ²(2) = 14.65, p < .001) was found between the reported number of ACEs and comorbid psychiatric classification.

Table 2. Prevalence of demographic variables per number of ACEs.

	0 ACEs (n = 425)		1–3 ACEs (n = 713)		4+ ACEs (n = 235)		Test of differences F (2, 1370)	p-value	Effect size R²
	M	SD	M	SD	M	SD
Age	14.54	1.46	14.74	1.50	14.96	1.43	6.45	p = .002	.009
	0 ACEs (n = 425)		1–3 ACEs (n = 713)		4+ ACEs (n = 235)		Test of differences Χ²	p-value
	n	%	n	%	n	%
Gender							28.85	p < .001
Male	206	48.5%	283	39.7%	60	25.5%
Female	219	51.5%	426	59.7%	170	72.3%
Educational Level							8.81	p = .185
Low	194	45.6%	345	48.4%	126	53.6%
Intermediate	103	24.2%	187	26.2%	58	24.7%
High	108	25.4%	142	19.9%	42	17.9%
Other	20	4.7%	39	5.5%	9	3.8%
Classification (primary)							93.73	p < .001
ADHD	83	19.5%	112	15.7%	32	13.6%
ASD	186	43.8%	318	44.6%	66	28.1%
Mood Disorders	29	6.8%	49	6.9%	25	10.6%
Anxiety Disorders	45	10.6%	70	9.8%	21	8.9%
PTSD	6	1.4%	44	6.2%	46	19.6%
Other	76	17.9%	120	16.8%	45	19.1%
Comorbidity (secondary)							14.65	p < .001
Yes	355	83.5%	629	88.2%	220	93.6%
No	70	16.5%	84	11.8%	15	6.4%

Note. N = number; SD = Standard Deviation; R² =  coefficient of determination; p = p-value (level of significance); ACEs = Adverse Childhood Experiences; ADHD = Attention Deficit Hyperactivity Disorder; ASD = Autism Spectrum Disorder; PTSD = Post Traumatic Stress Disorder.

3.3. ACEs and their co-occurrence

Through frequency analyses, we examined the co-occurrence of ACEs categories (Table 3). The data revealed a substantial overlap among all ACEs categories, particularly in cases where bullying and emotional abuse were prevalent among all reported ACEs. For instance, 69% of participants who experienced sexual abuse also reported being bullied, and 70% of youths reporting neglect also indicated experiencing bullying. The only ACEs category with minimal overlap was for youths reporting the death of a parent.

Table 3. Co-occurrence of Adverse Childhood Experiences (ACEs) categories.

3.4. Correlations between age, mental health problems and post-traumatic stress symptoms

Pearson's correlation analysis was conducted to determine the relationship between adolescents’ age, mental health problems reported in the YSR, and post-traumatic stress symptoms reported using the CTSQ. Age exhibited a modest yet statistically significant positive correlation with internalizing mental health problems (r = 0.231, p < .001). Additionally, age was positively correlated with the total score on the YSR (r = 0.118, p < .001) and post-traumatic stress symptoms (r = 0.126, p < .001). Furthermore, internalizing problems demonstrated notable positive correlations with externalizing problems (r = 0.237, p < .001), total YSR score (r = 0.822, p < .001), and post-traumatic stress symptoms (r = .504, p < .001). In contrast, externalizing problems exhibited significant positive correlations with both the total YSR score (r = 0.679, p < .001) and post-traumatic stress symptoms (r = 0.245, p < .001). Notably, the strongest correlation was observed between internalizing mental health problems and the total YSR score (r = 0.822, p < .001) Table 4.

Table 4. Pearson’s Correlations for the Study Variables.

		Youth Self Report			CTSQ
	Age	Internalizing problems	Externalizing problems	Total problems	PTSD symptomatology
	r	r	r	r	r
Age	–
Youth Self Report
Internalizing problems	.231***	–
Externalizing problems	−.011	.237***	–
Total problems	.118***	.822***	.679***	–
CTSQ
PTSD symptomatology	.126***	.504***	.245***	.499***	–

Note. CTSQ = Child Trauma Screening Questionnaire; r = Pearson’s correlation coefficient.

*** p < .001.

3.5. Self-reported mental health problems and self-reported post-traumatic stress symptoms in relation to the number of ACEs

A series of analyses of variance (ANOVAs) was conducted to examine potential group differences, defined by the number of ACES, on various mental health problems and reported post-traumatic stress symptoms (Table 5). Post-hoc pairwise comparisons were conducted using Bonferroni correction and were found to be significant between all groups for all outcome measures. The results indicate that a higher number of ACEs was associated with more severe mental health problems on all internalizing and externalizing subscales. Furthermore, a higher number of ACEs was associated with higher self-reported PTSS (F(1, 759) = 131.73, p < .001, R² = .15).

Table 5. Means, Standard Deviations, and One-Way Analyses of Variance in Self-reported Mental Health Problems and Self-Reported Post-traumatic Stress Symptoms for the Number of Adverse Childhood Experiences (ACEs).

			1–3 ACEs (n = 713)		4+ ACEs (n = 235)		Test of Differences F (1,759)	Effect Size R²
			M	SD	M	SD
CTSQ
PTSD symptomatology			3.0	3.0	5.8	3.1	131.73***	.15
	0 ACEs (n = 425)		1–3 ACEs (n = 713)		4+ ACEs (n = 235)		Test of Differences F (2, 1370)	Effect Size R²
	M	SD	M	SD	M	SD
Youth Self Report
Anxious/ depressed	8.8	6.3	12.0	6.5	15.0	6.4	74.72***	.10
Withdrawn/ depressed	6.2	3.7	7.5	3.6	8.8	3.4	40.44***	.06
Somatic complaints	5.0	3.6	6.4	3.8	8.8	4.1	73.72***	.10
Social problems	4.6	2.7	6.8	3.4	8.3	3.6	111.88***	.14
Thought problems	6.3	4.1	8.5	4.6	11.5	4.9	100.61***	.13
Attention problems	8.2	3.4	9.1	3.5	10.8	3.3	44.66***	.06
Delinquent Behaviour	3.9	3.1	4.9	3.6	7.0	4.3	57.16***	.08
Aggressive Behaviour	6.8	4.7	8.6	5.2	10.6	5.7	42.17***	.06
Internalizing problems	20.1	11.4	25.9	11.8	32.6	11.8	88.72***	.12
Externalizing problems	10.7	7.0	13.5	7.8	17.6	8.9	59.31***	.08
Total problems	55.1	22.3	69.9	24.6	88.1	26.1	143.32***	.17

 Note. M = Mean; SD = Standard Deviation; R² =  coefficient of determination; CTSQ = Child Trauma Screening Questionnaire.

***p < .001.

4. Discussion

To the best of our knowledge, this is the first cross-sectional study of childhood adversity and its impact on youth mental health in a psychiatric population. This study showed that ACEs are highly prevalent among youth registered for mental health care. Furthermore, the results provided support for a graded and cumulative relationship between childhood adversity and mental health problems and revealed a substantial overlap among all ACEs categories, which implies that adolescents registered for mental health care commonly report experiencing multiple distinct types of ACEs.

The present study showed that 69.1% of participants reported experiencing one or more ACEs, with 17.1% indicating exposure to four or more ACEs. In general, prevalence rates exhibit substantial variability across studies. However, compared to other non-clinical samples (Bomysoad & Francis, 2020; Broekhof et al., 2022), the observed prevalence of 69.1% in our study falls towards the higher end of the range of ACEs prevalence. This can be attributed to the study population in this cross-sectional study, namely youth registered for mental health care. Regarding the types of ACE, bullying emerged as the most frequently reported ACE, with 49.2% of participants indicating some form of exposure to bullying. This finding is consistent with existing literature, which emphasizes the pervasive nature of bullying in adolescents’ lives (Hosozawa et al., 2021). Emotional (17.8%), physical (12.2%), and sexual abuse (10.1%) were also reported, albeit at lower frequencies. We also found that female adolescents reported significantly more ACEs, which is in line with the existing literature suggesting that females experience more complex and varied patterns of childhood adversity (Haahr-Pedersen et al., 2020). Furthermore, our results showed high co-occurrence rates among the ACEs categories. For instance, we found that youths who reported sexual abuse, physical abuse, or neglect frequently reported emotional abuse and bullying. These results suggest that youths reporting multiple ACEs not only report the same type of ACEs but also childhood adversity across various domains, indicating that ACEs should be assessed together as a whole rather than separately (Broekhof et al., 2022).

Importantly, our study elucidated the association between ACEs and self-reported mental health problems. The results showed a significant association between a higher number of ACEs and an increase in self-reported mental health problems across various domains, including all types and domains of internalizing and externalizing mental health problems. We also found an increased prevalence of mood disorders and PTSD. These results highlight the profound impact of ACEs on adolescents’ mental health and are consistent with other studies that have identified a graded relationship and the potential cumulative effect of ACEs (Petruccelli et al., 2019). The study highlights the potential role of exposure to multiple ACEs and its association with mental health problems and the results are in line with other studies that address adverse events as a risk factor in developing psychopathology during adolescence (Skandsen et al., 2023). Furthermore, our findings revealed a noteworthy relationship between ACEs and comorbid psychiatric classifications. Specifically, higher reported ACE counts were associated with a higher prevalence of comorbid psychiatric disorders. This emphasizes the complex interplay between ACE exposure and the development of multiple psychiatric conditions in adolescence (Bomysoad & Francis, 2020), warranting comprehensive assessment and treatment approaches.

5. Limitations of the study

This study has a few limitations. First, the findings relied mostly on self-reported measures. There is a risk of underreporting ACEs and their impact. For example, research indicates that a significant portion of victims struggle to disclose incidents of sexual violence. An important predictor of delayed disclosure is the age group of 12–17 years (Bicanic et al., 2015). Additionally, research reveals that 55%–65.6% of sexual violence victims experience unacknowledged rape (Wilson & Miller, 2016), meaning that survivors of sexual violence do not label their experiences as rape. Therefore, it would have been a valuable addition to also collect information about ACEs and their associated impact from significant others, such as parents and teachers, and compare it with the self-reports of youth. This is particularly true in cases of sexual abuse. However, it is worth noting that, in general, research has demonstrated the effectiveness of collecting data on child maltreatment and its direct impact on youth (Laurin et al., 2018). Furthermore, it is important to acknowledge that data on potential moderating and mediating variables that could elucidate the strength and direction of the observed associations between ACEs and mental health problems were not collected. Hence, it is important to be cautious when attempting to deduce causal relationships from cross-sectional data. Despite the aforementioned limitations, data from cross-sectional studies can still provide valuable insights into the association between ACEs and mental health problems. Cross-sectional studies allow for the examination of these relationships at a single point in time (Wang & Cheng, 2020). Therefore, they are particularly useful for generating hypotheses and identifying potential areas for further research. Additionally, cross-sectional data can offer important preliminary evidence regarding the prevalence and patterns of ACEs in specific populations. Finally, it is essential to recognize that not all available ACEs were included in this study. For example, issues related to parental substance abuse or parent incarceration were not included. Owing to logistical constraints, certain factors may not have been accounted for, potentially affecting the comprehensiveness of our findings. Nevertheless, the ACEs measured in the present study are highly relevant and globally recognized as severe childhood adversity with a profound impact.

6. Conclusion

In conclusion, this study contributes to our understanding of the prevalence and consequences of ACEs among youth registered for mental health care. Our findings underscore the high prevalence of ACEs in a youth psychiatric population and a graded relationship between childhood adversity and mental health problems in adolescence, thereby hampering the urgent need to address the impact of ACEs on mental health outcomes. Additionally, our results highlight the importance of incorporating self-report measures to explore ACEs in relation to mental health burdens. Future studies should continue to explore these associations, their strengths, and directions, and investigate effective strategies for prevention and intervention.

Author statement

RK, HK, WS, IB, and AdJ conceptualized and designed the study. RK, HK, and SP had full access to the raw data; RK and SP conducted the analysis, and HK and IH verified the analysis. RK, HK, SP, and IH wrote the first draft of the manuscript. All authors contributed to the interpretation of the data, reviewed and revised the manuscript, and approved the final manuscript as submitted.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Due to the nature of this research, participants of this study did not agree for their data to be shared publicly, so supporting data is not available.

Additional information

Funding

RK received a Fellowship from ZonMw (grant number 63632004). The funder had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results. All views expressed are those of the author(s) and not necessarily those of the funders.