RELATIONSHIP BETWEEN ADVERSE CHILDHOOD EXPERIENCE AND

DEPRESSION AND ANXIETY IN ADULTHOOD WITH RESPECT TO MARITAL

STATUS AND GENDER

NAME ……………………………………

ENROLLEMENT NUMBER …………………………………

STUDY CENTRE ……………………………………

REGIONAL CENTRE ……………………………………

YEAR …………………………………

NAME OF GUIDE …………………………………..

INTRODUCTION

It is well established fact that the period of childhood is very critical in development of
social, physical and psychological health of an individual. Various school of psychology like
cognitive psychology, psychoanalytical psychology, social psychology, Information
processing theories have emphasised that humans start learning right from the birth and form
schemas. These schemas are formed by experience and are resistant to change. And it is well
known that people rely on their experience (schema) for information processing from the
environment. We rely on the weight of experience to make judgments and decisions. We
interpret the past—what we’ve seen and what we’ve been told—to chart a course for the
future.

For example Sigmund Freud believed that the experience a child has during early childhood
and childhood will shape the personality during adulthood. The cause of any psychological
disorder a person is suffering from depends on his childhood experience.

John Bowlby (1907 - 1990) was a psychoanalyst (like Freud) and believed that mental health
and behavioural problems could be attributed to early childhood.

Bowlby also suggested that children have innate tendencies to form attachment with their
caregivers. And the type of attachment the child will form may predict what will be the
attachment style he/she will develop when he/she become an adult.

And there is significant relationship between the attachment pattern and depression and
anxiety. The findings of the study “The Relationship between Attachment Styles and Depression
Among Lebanese Young Adults” and the Previous literature confirm the relationship between
insecure attachment styles and major depression (AlAssadi, n.d.)

So it can be said that if early experience get scarred due to any reason then it will have a long
term effect on virtually all aspects of the child’s development including cognitive, social,
emotional and physical development, and lay the foundation for a wide range of outcomes in
later life, including social and emotional competence, mental health and achievement at
school or work (Center on the Developing Child at Harvard University, 2016; Price-
Robertson, Smart, & Bromfield, 2010). So it is very important that child gets a conducive
environment to lead a healthy life ahead.
Unfortunately so many children every year face the different types of adversity during
childhood which stains their experience for life. It has both short term and long term
consequences which often leads to different type of psychological disorders in such as
depression, anxiety, dissociation disorder, PTSD etc.

Children who experience toxic levels of stress, for example, through abuse or neglect or
extreme poverty, can experience physiological disruptions that can lead to poorer outcomes
in learning, behaviour, and physical and mental.(InBrief, n.d.)

Adverse childhood experiences (ACEs)

Adverse childhood experiences (ACEs) are events that are extreme stressors experienced by
an individual during development (ages 0-18 years old; Danese & McEwen, 2012) or ACEs
are defined as “stressful or traumatic experiences in childhood.

ACEs can be categorized into two broad groups: maltreatment, which refers to events that are
directly experienced by the individual (e.g., physical abuse, emotional neglect, sexual abuse
etc), or household adversity, which refers to circumstances in the individuals’ environment
that can cause high levels of stress (e.g., household dysfunction, due to substance misuse and
or mental illness amongst family members, violent treatment of mother, separation or divorce
of parents, imprisonment of family member” ; Hughes et al., 2017).

In India lots of children’s face different type of adversities, for example “According to the
National Study on Child Abuse report the prevalence of physical abuse was up to 69% in 13
states of India with higher prevalence among boys (54.68%), sexual abuse (53.22%) with
equal percentage among boys and girls and emotional abuse was 50% with equal prevalence
in both sexes.(ChildabuseIndia.Pdf, n.d.) Kacker, L., Varadan, S. and Kumar, P. (2007)
Study on child abuse: India 2007. Ministry of Women and Child Development,
Government of India.

Another study in 2019 in the state of Kerala indicated 91% prevalence amongst the youth
who had experienced ≥ 1 ACE, and about 50% of them had experienced ≥ 3 ACEs. Results
show that nine out of ten youth had been exposed to adverse experiences in childhood and
more than half of the sample had experienced three or more ACEs.(Damodaran & K, 2019)

According to standardized measures, an estimated 61.5% of adults and 48% of children in the

United States have been exposed to ACEs, with more than one-third of these having multiple
exposures.( Bethell C, Jones J, Gombojav N, Linkenbach J, Sege R. Positive Childhood
Experiences and Adult Mental and Relational Health in a Statewide Sample: Associations
Across Adverse Childhood Experiences Levels. JAMA Pediatr. 2019;173(11):e193007.
doi:10.1001/jamapediatrics.2019.3007) (Bethell et al., 2019b)

After seeing these ACE findings and studies mentioned above it is clear that ACEs are quite
common, even among a middle-class population: more than two-thirds of the population
report experiencing one ACE, and nearly a quarter have experienced three or more.

So it can be said that “positive experiences during childhood, including nurturing and
responsive caregiving environments, are associated with happy, productive, and healthy lives
throughout adulthood”(Bethell, Jones, Gombojav, Linkenbach, & Sege, 2019).

Conversely, negative or adverse experiences in childhood have been found to be associated

with detrimental health outcomes (Almuneef et al., 2016), increased risky behaviour (Afifi,
Cox, Martens, Sareen, & Enns, 2010), and generally poor outcomes later in life (Anda et al.,
2001, 2007; Baiden, Stewart, & Fallon, 2017).

So it is well-established that early life experiences set the foundation for health and
development and have a profound influence on life course trajectories.

Relationship between adverse childhood experience, Depression and Anxiety

Relationship between adverse childhood experience, Depression and anxiety are well
documented in western countries compared to India.

The original ACE study by the Centers for Disease Control and the Kaiser Permanente health
care organization in California on topic Relationship of Childhood Abuse and Household
Dysfunction to Many of the Leading Causes of Death in Adults and many more studies
continue to show the significant relationship between ACE, depression and anxiety in
adulthood.(Felitti et al., 1998)

For example,

According to the study done by Kshirod Kumar Mishra, Ramdas Ransing, Praveen Khairkar,
Sakekar Gajanan on “Association between childhood abuse and psychiatric morbidities
among hospitalized patients” the severity and complexity of child abuse are more in India as
compared to Western countries. Child abuse has distinct potential to increase vulnerability to
psychiatric co-morbidities, severity of illness, treatment failure, and outcome of illness. Thus,
child abuse can leave a lasting signature on the individual's mental health and functional
reorganization of a brain network. (Mishra et al., 2016)

Further, Adverse childhood experiences are common (Thompson & Cui, 2000) and have been
associated with many unfavourable psychological and physiological outcomes such as
depression (Bernet & Stein, 1999; Heim & Nemeroff, 2001; Hovens et al. 2010; Nelson et al.
2012; Colman et al. 2013), post-traumatic stress disorder (PTSD) (Widom, 1999; Heim &
Nemeroff, 2001; Moffitt et al. 2007; Hovens et al. 2010), cardiovascular disease (Dong et al.
2004) and chronic pain.(Thompson AH, Cui X (2000). Increasing childhood trauma in
Canada: findings from the National Population Health Survey, 1994/95. Canadian Journal of
Public Health 91, 197–200.)(Increasing Childhood Trauma in Canada: Findings From the
National Population Health Survey, 1994/95 - PMC, n.d., p. 95)

The effect of stress on child mind can be explained by following finding-

Early childhood is a particularly vulnerable time for the neurotoxic effect of prolonged,
unbuffered stress. During the first few years of life, the brain experiences rapid growth and
proliferations of neural connections. It is also the time during which the foundation and
laddering of executive function and self-regulation skills are laid. These cognitive skills,
including working memory, mental flexibility, and self-control, are important elements of
successful adult cognitive functioning. Disruption of neurodevelopment during this time can
lead to lasting effects. (Early childhood adversity, toxic stress, and the role of the
pediatrician: translating developmental science into lifelong health. Pediatrics.
2012;129(1):e224–e231. )((PDF) Early Childhood Adversity, Toxic Stress, and the Role of
the Pediatrician: Translating Developmental Science Into Lifelong Health, n.d.)

According to research published by the American Psychological Association “Exposure to

adversity in childhood is a powerful predictor of health outcomes later in life—not only
mental health outcomes like depression and anxiety, but also physical health outcomes like
cardiovascular disease, diabetes, and cancer,” said Katie McLaughlin, PhD, an associate
professor of psychology at Harvard University and senior author of the study published in the
journal Psychological Bulletin®.
In 2019 study in the state of Kerala similar to the global studies, this study also found
increased odds of having major depression in adulthood if they have experienced ACE in
childhood. (4 times higher). (Damodaran & K, 2019)

In addition, the study also found that those individuals with family dysfunction had higher
odds (2 times higher) of experiencing antipathy and sexual and psychological abuses
confirming that the impact of ACE goes beyond the present generation. (Damodaran & K,
2019)

Another studies suggests “Developmental, behavioural, educational, and family problems in

childhood can have both lifelong and intergenerational effects (Committee on Psychosocial
Aspects of Child and Family Health et al., 2012)

So studying ACE and its effect is very important because it has both lifelong and
intergenerational effects as shown by above studies.

In adverse childhood experience one type is emotional neglect, and it mainly comes in a form
of insecure attachment with the caregiver in childhood. And studies have found that the type
of attachment one has in childhood is likely to determine the type of attachment one forms
when become adult.

Current research on adult attachment divides the types of adult attachment into Secure,
Dismissing, Preoccupied, and Fearful based on different self-models and other models.

The concept of adult attachment was first proposed by Hazan & Shaver (1987).

Bowlby found that the loss of early security attachment was closely related to depression and
insecure attachment gradually led to a pessimistic disappointment and helpless self-intention.
When grown up, the complexity of interpersonal relationships will increase the tendency of
depression. Bifulco A. et al. studied the association between depression and attachment
styles, and the results showed that any type of insecure attachment was significantly
associated with depression. Main & Goldwyn's research confirms that individuals with
insecure attachment are more likely to suffer from depression and are more prone to
depressive symptoms.
A number of studies in human children suggest, for example, that disruptions in early
attachment relationships are associated with disturbances in stress–responsive biological
systems (~Hertsgaard, Gunnar, Erickson, & Nachmias, 1995;Meyer, Chrousos, & Gold,
2001; Nachmias,Gunnar, Mangelsdorf, Parritz, & Buss, 1996; Willemsen–Swinkels,
Bakermans–Kranenburg, Buitelaar, van, & van Engeland, 2000!.)

The Study on “ Childhood adversity in patients suffering from depression with a focus on
differences across gender” by Bhumika Shah, Jahnavi Kedare, Fiona Mehta evaluates the
occurrence of childhood adversity in male and female patients diagnosed with depression and
its relationship to the severity of depression. The majority of male (70%) and female (68%)
patients have experienced ACEs. Literature reports that 77.2%–84.61% of depressed patients
have experienced at least one category of childhood adversity. There have been reports of the
cumulative effect of the adverse experiences impacting future depression. Vitriol et al.
reported that 43% and Poole et al. reported 58% of the patients with MDD experience three
or more categories of childhood adversity which is higher compared to our results. Three or
more categories of childhood adversity were present in 24% of their patients.(Shah et al.,
2021)

Research reveals that more than two-thirds of depressed male and female patients have
experienced childhood adversities. In male patients, there was a correlation between the
severity of depression and having more than three adversities. (Shah et al., 2021)

Literature Review

The term “ACEs” is an acronym for Adverse Childhood Experiences. It originated in

research study conducted in 1995 by the Centres for Disease Control and the Kaiser
Permanente health care organization in California on topic “Relationship of Childhood Abuse
and Household Dysfunction to Many of the Leading Causes of Death in Adults”. Seven
categories of adverse childhood experiences were studied: psychological, physical, or sexual
abuse; violence against mother; or living with household members who were substance
abusers, mentally ill or suicidal, or ever imprisoned. A questionnaire about adverse childhood
experiences was mailed to 13,494 adults. More than half of respondents reported, at least one,
and one-fourth reported more than or equal to 2 categories of childhood exposure to
adversity. Persons who had experienced four or more categories of childhood exposure,
compared to those who had experienced none, had 4 to 12-fold increased health risks for
alcoholism, drug abuse, depression, and suicide attempt. The findings suggest that the impact
of these adverse childhood experiences on adult health status is strong and cumulative. High
levels of exposure to adverse childhood experiences would expectedly produce anxiety,
anger, and depression in children. And it may well continue into adulthood. (Felitti et al.,
1998)

Vincent Felitti, head of Kaiser Permanente's Department of Preventive Medicine in San

Diego, conducted interviews with people who had left the program, and discovered that a
majority of 286 people he interviewed had experienced childhood sexual abuse. The
interview findings suggested to Felitti that weight gain might be a coping mechanism
for depression, anxiety, and fear.

ACEs may include, but are not limited to, physical, sexual and emotional abuse, bullying,
parental death or loss, neglect and poverty (Felitti et al., 1998).

Overwhelming evidence for the impact of ACEs on outcomes in adulthood is also apparent
within mental health literature and it has been estimated that in the absence of childhood
adversity there would be a 22.9% reduction in mood difficulties, 31% reduction of anxiety,
41.6% reduction of behavioural difficulties, 27.5% reduction of substance-related difficulties
(Kessler et al., 2010) and a 33% reduction in psychosis (Varese et al., 2012).

ACEs have also been found, for example, to be associated with severity of hallucinations and
delusions in people experiencing psychosis (Bailey et al., 2018), suicide attempts (Xiang
et al., 2018), and risk of depression along with increased risk of relapse and poorer treatment
response (Nanni et al., 2018)

In a Study by (Brown & Harris, 1993)Brown GW, Harris TO (1993) on “A etiology of

anxiety and depressive disorders in an inner-city population: I. Early adversity” Psychol Med
23:143–154, Depression appears to be often linked to experiences of major loss in adulthood
as a whole and to be particularly susceptible to shortcomings in the quality of ongoing social
support. For anxiety only early adverse experiences appeared to be critical. (However, the
onset of both conditions is often provoked by a severely threatening event in the most recent
period--particularly 'loss' in depression, and 'danger' in anxiety.) Finally the critical role of
early experience for both anxiety and depression explains to a considerable extent why they
so often occur together.
Study conducted by Harkness KL, Wildes JE (2002), Childhood adversity and anxiety
versus dysthymia co-morbidity in major depression. Psychol Med 32:1–11  (Harkness &
Wildes, 2002)suggest that severe sexual abuse and psychological abuse were significantly
and preferentially associated with co-morbid anxiety, while severe physical abuse was
significantly and preferentially associated with co-morbid dysthymia. Indifference and
antipathy were significantly associated with both co-morbid anxiety and dysthymia.
Multivariate analyses revealed that severe sexual abuse was the adverse childhood experience
most strongly associated with co-morbid anxiety.

A strong association between early parental strain and major depression (independent of
anxiety) was also found. The overall pattern of results suggests that there may be unique
relationships linking particular adversities to particular manifestations of depression and
anxiety disorders later in life. A particularly strong association between early sexual abuse
and co-morbid depression/anxiety was found. (Levitan RD, Rector NA, Sheldon T, Goering P.
Childhood adversities associated with major depression and/or anxiety disorders in a
community sample of Ontario: issues of co-morbidity and specificity. Depress Anxiety.
2003;17(1):34-42. doi: 10.1002/da.10077. PMID: 12577276.)(Levitan et al., 2003)

Family dysfunction and abuse adversities were the strongest and most consistent predictors of
all four classes of psychopathologies examined (mood, anxiety, substance use and
externalizing), and for the most part, over all three life course stages (childhood, adolescence
and adulthood), consistent with evidence for the enduring effects of chronic stress on brain
structures involved in many psychiatric disorders and with stress-sensitization models of
psychopathology.( Benjet C, Borges G, Medina-Mora ME. Chronic childhood adversity and
onset of psychopathology during three life stages: childhood, adolescence and adulthood. J
Psychiatr Res. 2010 Aug;44(11):732-40. doi: 10.1016/j.jpsychires.2010.01.004. Epub 2010
Feb 9. PMID: 20144464.)(Benjet et al., 2010)

Some studies suggest that women are more impacted by sexual abuse and men by economic
hardship. The absence of childhood adversities was protective, it significantly decreased an
individual's risk for subsequent adult mental illness. The results support the clinical
impression that increased childhood adversity is associated with more complex adult
psychopathology. (Putnam KT, Harris WW, Putnam FW. Synergistic childhood adversities
and complex adult psychopathology. J Trauma Stress. 2013 Aug;26(4):435-42. doi:
10.1002/jts.21833. Epub 2013 Jul 25. PMID: 23893545.)(Putnam et al., 2013)
Study aimed to systematically review the evidence for an association between adversity
experienced in childhood (≤ 17 years old), and the diagnosis of psychiatric disorder in
adulthood ,there was strong evidence of an association between childhood adversity and later
mental illness, The finding suggests that childhood and adolescence is an important time for
risk for later mental illness, and an important period in which to focus intervention strategies
for those known to have been exposed to adversity, particularly multiple adversities.(Trivedi
GY, Pillai N, Trivedi RG. Adverse Childhood Experiences & mental health - the urgent need
for public health intervention in India. J Prev Med Hyg. 2021 Sep 15;62(3):E728-E735. doi:
10.15167/2421-4248/jpmh2021.62.3.1785. PMID: 34909501; PMCID: PMC8639107)
(TRIVEDI et al., 2021)

As discussed in the introduction there are many studies pointing out the relationship between
attachment, depression and anxiety. In a study of 438 people in a comprehensive university,
“the study of college students attachment relationship, social support, and depression” has
shown that there is a significant positive correlation between insecure attachment, anxiety
and depression. Secure individuals are less likely to be separated from intimate objects, and
can establish close relationships with partners and maintain individual independence. This
may be because secure attachment means that the individual does not worry about not being
able to attract the attention of the attachment object, and relies on the attachment object to
provide security and protection, and to have relatively non-defensive behaviour and
psychological integration of attachment experience, memory and emotion. This allows secure
attachment individuals to be flexible in dealing with complex interpersonal relationships in
adulthood, that is, to be able to integrate the needs, emotions, and different perspectives in a
relationship for the sake of their own safety and health. Insecure attachment means that the
individual is not confident that he or she can cause attention to the attachment object and can
rely on the attachment object to provide the necessary protection for physical and mental
safety. They intentionally or unconsciously cause advances to fall into pain and potential
disorders.(Chinvararak C, Kirdchok P, Lueboonthavatchai P (2021) The association between
attachment pattern and depression severity in Thai depressed patients. PLoS ONE 16(8):
e0255995. https://doi.org/10.1371/journal.pone.0255995)(Chinvararak et al., 2021)

Compared to those reporting no ACEs, respondents reporting four or more ACEs had over
four times the odds of Alcohol or Drug Use, Mental Illness, Depression, and/or Anxiety
outcomes and more than twice the odds of diabetes, hypertension, obesity, and/or smoking
outcomes.( Almuneef, M., Hollinshead, D., Saleheen, H., AlMadani, S., Derkash, B.,
AlBuhairan, F., … Fluke, J. (2016). Adverse childhood experiences and association
with health, mental health, and risky behavior in the kingdom of Saudi Arabia. Child
Abuse & Neglect, 60, 10–17. https://doi.org/10.1016/j.chiabu.2016.09.003) ((PDF)
Adverse Childhood Experiences and Association with Health, Mental Health, and Risky
Behavior in the Kingdom of Saudi Arabia, n.d.)

Other longitudinal studies (e.g., Lewis et al., 2011), systematic reviews and meta-analyses
(Agnew-Blais and Danese, 2016, Maniglio, 2010, Maniglio, 2012) have also found a strong
relationship between ACEs and mental health problems.

Furthermore, Maniglio, 2010, Maniglio, 2012 conducted systematic reviews and found that
having a history of childhood sexual abuse was a significant risk factor for developing both
depression and anxiety disorder, regardless of gender of the victim and severity of the abuse.

The wide-ranging negative associations between exposure to multiple ACEs and diminished
adult and child health are well documented. Most notable is the especially strong evidence
linking ACEs with adult mental health problems including depression. A robust literature
also exists regarding the effect of ACEs on adult relational health (often assessed by whether
adults report that they get the social and emotional support they need) and how diminished
adult social and emotional support contributes to poorer adult physical and mental health.
(Bethell, C., Jones, J., Gombojav, N., Linkenbach, J., & Sege, R. (2019). Positive
childhood experiences and adult mental and relational health in a statewide sample:
Associations across adverse childhood experiences levels. JAMA Pediatrics, 173(11).
https://doi.org/10.1001/jamapediatrics.2019.3007 ) (Bethell et al., 2019a)

Indeed, a recent paper has characterised early adversity as a violation of environmental

predictability, which has profound consequences for sensitive periods of development
(Nelson III & Gabard-Durnam, 2020). On this account, it is argued that experiences that the
child should expect, such as parental care, are either unreliable or atypical in adverse
households. As such individuals who have been exposed to ACEs may perceive the
environment as unstable (Danese & McEwen, 2012).And it has been suggested that adverse
experiences might lead to atypical learning strategies, which could explain why early
adversity is linked to the onset of emotional disorders such as anxiety and depression (Pulcu
& Browning, 2019).
In study cross-sectional study of adults in rural Uganda, the cumulative number of ACEs had
statistically significant associations with depression symptom severity, major depressive
disorder, and suicidal ideation. (Satinsky EN, Kakuhikire B, Baguma C, Rasmussen JD,
Ashaba S, Cooper-Vince CE, Perkins JM, Kiconco A, Namara EB, Bangsberg DR, Tsai AC.
Adverse childhood experiences, adult depression, and suicidal ideation in rural Uganda: A
cross-sectional, population-based study. PLoS Med. 2021 May 12;18(5):e1003642. doi:
10.1371/journal.pmed.1003642. PMID: 33979329; PMCID: PMC8153443.) (Satinsky et al.,
2021) Here ACEs were assessed using a modified version of the Adverse Childhood
Experiences-International Questionnaire, and depression symptom severity and suicidal
ideation were assessed using the Hopkins Symptom Checklist for Depression (HSCL-D). 

Conclusions: These results suggest that particular adverse experiences in childhood do set up

specific vulnerabilities to the expression of anxiety versus dysthymia co-morbidity in
adulthood major depression. 

RATIONALE OF STUDY

The first Adverse childhood Experience (ACEs) Study was published just over 20 years ago
(Felitti et al.1998). Since then there is growing number of research articles are being
published. Since 1998 till 2018 more than half (58.2 %) of all ACEs publications occurred in
the last three years of the study period (2016–2018). Substantial increases in the published
ACEs literature are indicative of a thriving multidisciplinary field of research. Now people
are recognizing the impact of ACEs and its economic burden on health system as well
(Adverse childhood experiences (ACEs) research: A bibliometric analysis of publication
trends over the first 20 years Shannon Struck a, Ashley Stewart-Tufescu a, Aleiia J.N.
Asmundson b, Gordon G. J. Asmundson c, Tracie O. Afifi d,).(Struck et al., 2021) Since
ACE is a relatively new term there is definitely so much scope for research on this topic as
we have seen it has so much prevalence and impact on people. Studies on the prevalence of
ACEs amongst individuals from diverse geographical, social, and economic circumstances
illustrates the global impact of this growing field of research (Burke,Hellman, Scott, Weems,
& Carrion, 2011; De Ravello, Abeita, & Brown, 2008; Ramiro, Madrid, & Brown, 2010;
Rossegger et al., 2009). While most of the Research studies on ACEs come from developed
countries, only a little is revealed about it from developing countries like India. Reliable
statistics on ACEs in the Indian context remain unavailable as there is lack of surveillance
data base and systematic investigations using the umbrella term “ACEs”. So there is clear
need to conduct more research in this area in India. Also as I myself have gone through one
of the ACEs that’s why I was compelled to do my project on ACEs. This is why I am trying
to do my project on this topic.

METHODOLOGY

RESEARCH PROBLEM

The present research aims to study the relationship between Adverse Childhood Experiences
(ACEs) and Depression & Anxiety in Young Adulthood.

OBJECTIVES

1. To find out the effect of ACEs on Young Adults

2. To find out the relationship between ACEs and depression and anxiety among young
adulthood.

3. Find impact of ACEs with respect to gender and marital status of Young Adults.

HYPOTHESIS

Adverse experiences in childhood will be associated with increased risk of both depression
and anxiety in adult life.

OPERATIONAL DEFINITION

ACEs were operationally defined as “stressful or traumatic experiences of childhood that

the youth might have experienced before their 17th birthday”. These included loss,
antipathy and neglect, and, abuse (physical, sexual and psychological).

Loss was defined as “death of any one parent or both before age 17 or continuous separation
of the youth from parents in childhood”.

Neglect was defined as “parent’s disinterest in material care, health, schoolwork, and
friendships” whereas antipathy included “the hostility, coldness, or rejection including ‘scape
goating’ behaviour shown to the child by parents or surrogate parents”.
Physical abuse was defined in terms of “hitting or punching or kicking or repeated attacks
where implements such as belts or sticks are used with the possibility of causing harm”.

Sexual abuse involved “physical contact or Electronic copy available at:

https://ssrn.com/abstract=3322512 7 approach of a sexual nature by any adult to the child.”

Psychological abuse comprised of “both isolated incidents, as well as a pattern of failure

over time (e.g., the restriction of movement; patterns of belittling, blaming, threatening,
frightening, discriminating against or ridiculing; and other non-physical forms of rejection or
hostile treatment) on the part of a parent or caregiver to provide a developmentally
appropriate and supportive environment.” The current study included all the subscales except
the subscale for “support”.

DEPRESSION- According to DSM-5, Major Depressive Disorder is likely if 5 or more of

the 9 symptoms are present for “most of the day, nearly every day" in the past 2 weeks and
one of the symptoms is depressed mood or little interest or pleasure in doing things
(questions 1 and 2 on the PHQ-9). Any degree of suicidal thoughts counts toward this
criteria. The symptoms must also cause significant distress and loss of function, and the
symptoms must not be better explained by substance use or another medical or psychiatric
condition. “Other” depression is diagnosed if there is significant impairment and/or distress
in major areas of functioning, but the full criteria for any specific depressive disorder are not
met. Here the PHQ-9 is used to diagnose Major Depressive Syndrome, but Major Depressive
Disorder must be diagnosed using additional clinical information (e.g. existence of past
manic/hypomanic episode, bereavement, other mental disorder, effects of a medication or
illness).

SAMPLE

The sample is selected to represent the population which we want to study. Since it is
difficult to study the entire population, a sample is selected following different procedure.
The sample selection process depends on the objectives and the nature of the sample.
Purposive sampling method will be used in the present study. Those individuals who are
between 20 to 45 years of age residing in the Mumbai will be taken. Early adulthood is the
stage of our life between the ages of about 20-40 years old. A total of 60 adults between age
20 years and 45years will be taken for the present study. Out of this, 30 will be male and 30
will be female.
RESEARCH DESIGN

Quantitative Descriptive Cross sectional study using survey method. Questionnaire is used to
obtain data on ACEs ,

TOOLS

Adverse childhood experience international questionnaire, ACE-IQ was designed to measure

adverse childhood experience. It is a 43- item scale. The scale was developed by according to
model of adverse childhood experience by World Health Organization (2009). The
questionnaire has seven sections; Section A (0) had demographic information such as sex,
age, education level, civic/marital status and work status in the last 12 months. Section B (1)
was 5-item eliciting information on marriage, which had yes or no response format. Section C
(2) had 5 items generating information on relationship with Parents/Guardians with 5 likert
response format for first two items ranging from never (1) to always (5) while the last three
items had 4 graduating response format ranging from never(1) to many times(4).Section D
consisted of 16- item eliciting information on family environment with yes or no response
format for the first five items and 4 likert format ranging from never(1) to many times(4) for
eleven. Section E(6) comprised of 3-item on peer violence with 4 graduating response format
for item 1 and 3 and second item on 7 likert response format. Section F (7) measured
witnessing community violence with 3-item and 4 likert response format ranging from never
(1) to many times (4). Section G(8) had 4 items eliciting information on exposure to
war/collective violence with 4 graduating response style from never (1) to many times (4).

Adverse Childhood Experiences – International Questionnaire (ACE-IQ; WHO,

2018).The ACE-IQ is a self-report measure, consisting of 45 items; 14 questions
are demographics, 30items explore adverse childhood experiences and one
item is used for clarification purposes regarding bullying. The items investigate
participants’ family environment, parental neglect, parental loss, verbal abuse,
physical abuse, sexual abuse and violence within a peer setting, community
setting or collective setting. They are rated on a 4-point Likert scale, except for
seven items (two rated on a 5-pointLikert scale and five require a “Yes” or “No”
answer). Higher scores indicate greater exposure to childhood adversities. The
psychometric properties of this questionnaire have been discussed in the
introduction
(PDF) Psychometric Assessment of Adverse Childhood Experiences International Questionnaire (ACE-
IQ) with Adults Engaging in Non-Suicidal Self-Injury. Available from:
https://www.researchgate.net/publication/350290298_Psychometric_Assessment_of_Adverse_Chil
dhood_Experiences_International_Questionnaire_ACE-IQ_with_Adults_Engaging_in_Non-
Suicidal_Self-Injury [accessed Dec 08 2022].

Patient Health Questionnaire-PHQ-9 for depression: The Patient Health Questionnaire

(PHQ) is a self-administered version of the PRIME-MD diagnostic instrument for common
mental disorders.  The PHQ-9 (Appendix) is the 9-item depression module from the full
PHQ. Major depression is diagnosed if 5 or more of the 9 depressive symptom criteria have
been present at least “more than half the days” in the past 2 weeks, and 1 of the symptoms is
depressed mood or anhedonia. Other depression is diagnosed if 2, 3, or 4 depressive
symptoms have been present at least “more than half the days” in the past 2 weeks, and 1 of
the symptoms is depressed mood or anhedonia. One of the 9 symptom criteria (“thoughts that
you would be better off dead or of hurting yourself in some way”) counts if present at all,
regardless of duration. As a severity measure, the PHQ-9 score can range from 0 to 27, since
each of the 9 items can be scored from 0 (not at all) to 3 (nearly every day). An item was also
added to the end of the diagnostic portion of the PHQ-9 asking patients who checked off any
problems on the questionnaire: “How difficult have these problems made it for you to do your
work, take care of things at home, or get along with other people?” Scores of 5, 10, 15, and
20 represent cutpoints for mild, moderate, moderately severe and severe depression,
respectively. (Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression
severity measure. J Gen Intern Med. 2001 Sep;16(9):606-13. doi: 10.1046/j.1525-
1497.2001.016009606.x. PMID: 11556941; PMCID: PMC1495268.) (Kroenke et al., 2001)

Generalized Anxiety Disorder-GAD-7 for anxiety –

The Generalized Anxiety Disorder Scale-7 (GAD-7) is a 7-item, self-rated scale developed
by Spitzer and colleagues (2006) as a screening tool and severity indicator for GAD. The
GAD-7 score is calculated by assigning scores of 0, 1, 2, and 3, to the response categories of
'not at all', 'several days', 'more than half the days', and 'nearly every day', respectively, and
adding together the scores for the seven questions.

Scores of 5, 10, and 15 are taken as the cut-off points for mild, moderate and severe anxiety,
respectively. When used as a screening tool, further evaluation is recommended when the
score is 10 or greater.

Using the threshold score of 10, the GAD-7 has a sensitivity of 89% and a specificity of 82%
for GAD. It is moderately good at screening three other common anxiety disorders - panic
disorder (sensitivity 74%, specificity 81%), social anxiety disorder (sensitivity 72%,
specificity 80%) and post-traumatic stress disorder (sensitivity 66%, specificity 81%). (Rutter
LA, Brown TA. Psychometric Properties of the Generalized Anxiety Disorder Scale-7 (GAD-
7) in Outpatients with Anxiety and Mood Disorders. J Psychopathol Behav Assess. 2017
Mar;39(1):140-146. doi: 10.1007/s10862-016-9571-9. Epub 2016 Sep 10. PMID: 28260835;
PMCID: PMC5333929.) ((PDF) Psychometric Properties of the Generalized Anxiety
Disorder Scale-7 (GAD-7) in Outpatients with Anxiety and Mood Disorders, n.d.)

https://www.hiv.uw.edu/page/mental-health-screening/phq-2

DATA ANALYSIS TECHNIQUES

REFERENCES

(Stewart-Tufescu et al., 2021)

(TRIVEDI et al., 2021)

AlAssadi, N. (n.d.). The Relationship Between Attachment Styles and Depression Among
Lebanese Young Adults. 104.

Benjet, C., Borges, G., & Medina-Mora, M. E. (2010). Chronic childhood adversity and onset
of psychopathology during three life stages: Childhood, adolescence and adulthood. Journal
of Psychiatric Research, 44(11), 732–740. https://doi.org/10.1016/j.jpsychires.2010.01.004
Bethell, C., Jones, J., Gombojav, N., Linkenbach, J., & Sege, R. (2019a). Positive Childhood
Experiences and Adult Mental and Relational Health in a Statewide Sample. JAMA
Pediatrics, 173(11), e193007. https://doi.org/10.1001/jamapediatrics.2019.3007

Bethell, C., Jones, J., Gombojav, N., Linkenbach, J., & Sege, R. (2019b). Positive Childhood
Experiences and Adult Mental and Relational Health in a Statewide Sample: Associations
Across Adverse Childhood Experiences Levels. JAMA Pediatrics, 173(11), e193007.
https://doi.org/10.1001/jamapediatrics.2019.3007

Bifulco, A., Bernazzani, O., Moran, P., & Jacobs, C. (2005). The childhood experience of
care and abuse questionnaire (CECA.Q): Validation in a community series. The British
Journal of Clinical Psychology / the British Psychological Society, 44, 563–581.
https://doi.org/10.1348/014466505X35344

ChildabuseIndia.pdf. (n.d.). Retrieved December 8, 2022, from

http://www.indianet.nl/pdf/childabuseIndia.pdf

Chinvararak, C., Kirdchok, P., & Lueboonthavatchai, P. (2021). The association between
attachment pattern and depression severity in Thai depressed patients. PLOS ONE, 16,
e0255995. https://doi.org/10.1371/journal.pone.0255995

Committee on Psychosocial Aspects of Child and Family Health, C. on E. C., Adoption, and
Dependent Care, and Section on Developmental and Behavioral Pediatrics, Garner, A. S.,
Shonkoff, J. P., Siegel, B. S., Dobbins, M. I., Earls, M. F., Garner, A. S., McGuinn, L.,
Pascoe, J., & Wood, D. L. (2012). Early Childhood Adversity, Toxic Stress, and the Role of
the Pediatrician: Translating Developmental Science Into Lifelong Health. Pediatrics, 129(1),
e224–e231. https://doi.org/10.1542/peds.2011-2662

Damodaran, D., & K, V. (2019). The Unveiled Indian Picture of Adverse Childhood
Experiences: Socio-Demographic Correlates Among Youth in Kerala. 6, 1248–1257.
https://doi.org/10.2139/ssrn.3322512

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V.,
Koss, M. P., & Marks, J. S. (1998). 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(4), 245–258.
https://doi.org/10.1016/s0749-3797(98)00017-8

Harkness, K., & Wildes, J. (2002). Childhood adversity and anxiety versus dysthymia co-
morbidity in major depression. Psychological Medicine, 32, 1239–1249.
https://doi.org/10.1017/S0033291702006177

Increasing Childhood Trauma in Canada: Findings From the National Population Health
Survey, 1994/95—PMC. (n.d.). Retrieved November 29, 2022, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6979586/
Kroenke, K., Spitzer, R. L., & Williams, J. (2001). The PHQ-9 Validity of a Brief Depression
Severity Measure. Journal of General Internal Medicine, 16. https://doi.org/10.1046/j1525-
14972001016009606x

Levitan, R. D., Rector, N. A., Sheldon, T., & Goering, P. (2003). Childhood adversities
associated with major depression and/or anxiety disorders in a community sample of Ontario:
Issues of co-morbidity and specificity. Depression and Anxiety, 17(1), 34–42.
https://doi.org/10.1002/da.10077

Mishra, K. K., Ransing, R., Khairkar, P., & Gajanan, S. (2016). Association between
childhood abuse and psychiatric morbidities among hospitalized patients. Indian Journal of
Social Psychiatry, 32(1), 50. https://doi.org/10.4103/0971-9962.176769

(PDF) Adverse childhood experiences and association with health, mental health, and risky
behavior in the kingdom of Saudi Arabia. (n.d.). Retrieved November 29, 2022, from
https://www.researchgate.net/publication/319617937_Adverse_childhood_experiences_and_
association_with_health_mental_health_and_risky_behavior_in_the_kingdom_of_Saudi_Ara
bia

(PDF) Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating
Developmental Science Into Lifelong Health. (n.d.). Retrieved November 29, 2022, from
https://www.researchgate.net/publication/276944888_Early_Childhood_Adversity_Toxic_Str
ess_and_the_Role_of_the_Pediatrician_Translating_Developmental_Science_Into_Lifelong_
Health

(PDF) Psychometric Properties of the Generalized Anxiety Disorder Scale-7 (GAD-7) in

Outpatients with Anxiety and Mood Disorders. (n.d.). Retrieved November 29, 2022, from
https://www.researchgate.net/publication/308005593_Psychometric_Properties_of_the_Gene
ralized_Anxiety_Disorder_Scale-7_GAD-
7_in_Outpatients_with_Anxiety_and_Mood_Disorders

Putnam, K. T., Harris, W. W., & Putnam, F. W. (2013). Synergistic childhood adversities and
complex adult psychopathology. Journal of Traumatic Stress, 26(4), 435–442.
https://doi.org/10.1002/jts.21833

Satinsky, E. N., Kakuhikire, B., Baguma, C., Rasmussen, J. D., Ashaba, S., Cooper-Vince, C.
E., Perkins, J. M., Kiconco, A., Namara, E. B., Bangsberg, D. R., & Tsai, A. C. (2021).
Adverse childhood experiences, adult depression, and suicidal ideation in rural Uganda: A
cross-sectional, population-based study. PLoS Medicine, 18(5), e1003642.
https://doi.org/10.1371/journal.pmed.1003642

Shah, B., Kedare, J., & Mehta, F. (2021). Childhood adversity in patients suffering from
depression with a focus on differences across gender. Annals of Indian Psychiatry, 5(2), 169.
https://doi.org/10.4103/aip.aip_28_21

Stewart-Tufescu, A., Asmundson, A. J. N., Asmundson, G. G. J., & Afifi, T. O. (2021).

Adverse childhood experiences (ACEs) research: A bibliometric analysis of publication
trends over the first 20 years. Child Abuse & Neglect, 112, 104895.
https://doi.org/10.1016/j.chiabu.2020.104895

Struck, S., Stewart-Tufescu, A., Asmundson, A. J. N., Asmundson, G. G. J., & Afifi, T. O.
(2021). Adverse childhood experiences (ACEs) research: A bibliometric analysis of
publication trends over the first 20 years. Child Abuse & Neglect, 112, 104895.
https://doi.org/10.1016/j.chiabu.2020.104895

TRIVEDI, G. Y., PILLAI, N., & TRIVEDI, R. G. (2021). Adverse Childhood Experiences &
mental health – the urgent need for public health intervention in India. Journal of Preventive
Medicine and Hygiene, 62(3), E728–E735.
https://doi.org/10.15167/2421-4248/jpmh2021.62.3.1785

The synopsis should be typed on A4 size paper in Times New Roman, font size 12 with 1.5
spacing. It can be of 15-20 pages. The information included in the synopsis should not be
plagiarized.