-
Participants were drawn from a project titled “Adolescent Health and Risky Behaviours in Anhui Province”. This project involved a cross-sectional survey conducted in Anhui, China in December 2013 intended to explore the relationship between ACEs and adolescent health; further details on the project are provided in our previous work [27-29]. The sample size was estimated based on an assumed 2.7% prevalence of suicide attempts [30]. The significance level and permissible error were set as 0.05 and 0.005, respectively. As the design effect of a 3-stage, random cluster sampling was ≥ 1, the estimated sample size was 4,037. A 3-stage, random cluster sampling method was used to select participants. The process is shown in Figure 1. We finally obtained an effective sample of 5,726 students aged 12–18 years (mean age of 14.81) for the analyses, including 2,848 males (49.7%) and 2,878 females (50.3%). The study protocol was reviewed and approved by the Biomedicine Ethics Committee of Anhui Medical University.
-
In this study, we simultaneously considered multiple indices of childhood adversity to determine which kinds of adversity matter most for risky adolescent health behaviors in the Chinese social context. Thus, we gathered data on exposure to adverse childhood events based on the living environments of the children in four domains (i.e., adverse family, peer, school, and personal events). Based on previous studies[10-15, 31] and our research on the Chinese cultural context, the following 27 categories were included (see Supplementary Method available in www.besjournal.com). Specifically, details about five types of childhood maltreatment (assessed by using the Chinese version of the Childhood Trauma Questionnaire-Short Form[27-29]), ten types of family adversity and three types of peer victimization[27], and one type of physical disability and chronic illness[28] have been provided in our previous studies. An additional eight items of school adversity were adopted from previous studies[14, 31-33]. Each type of childhood adversity was dichotomized (yes/no). Further details on the ACE measurements are provided in the Supplementary Method.
Types Items References Childhood maltreatment 25 items [1-2] Physical abuse (PA) The Childhood Trauma Questionnaire
Short Form (CTQ-SF)The CTQ-SF cut-off scores used in this study were as follows: PA ≥ 8; EA ≥ 9; SA ≥ 6; PN ≥ 8; and EN ≥ 10 Emotional abuse (EA) Sexual abuse(SA) Physical neglect (PN) Emotional neglect (EN) Childhood peer victimization Six items (details see our previous study[5]) [3-4] Physical peer victimization (1) hitting, kicking, pushing, shoving, or locking indoors
(2) blackmailing for money or damaging thingsThe response options: 1 = never; 2 = rarely; 3 = sometimes; 4 = often; and 5 = very often. We used the criterion that students were bullied sometimes to evaluate occurrences of physical, verbal and relational victimization. Verbal peer victimization (1) calling mean names or making fun or teasing in a hurtful way
(2) saying mean things about an accentRelational peer victimization (1) excluding others from their group of friends or leaving others out of things on purpose
(2) telling lies or spreading false rumours about others or sending mean notes and trying to make others unpopularChildhood family adversity Ten items (details see our previous study[5]) [5-6] Family financial difficulties Response option: 0 = no and 1 = yes. Parents often fight or quarrel Response option: 0 = no and 1 = yes. Family trauma (e.g., earthquake,
fire, and theft)Response option: 0 = no and 1 = yes. Parents overconsume alcohol or are addicted to gambling; Response option: 0 = no and 1 = yes. Disabled family member; Response option: 0 = no and 1 = yes. Parental absence; Response option: 0 = no and 1 = yes. Family member involved in a crime; Response option: 0 = no and 1 = yes. Parental divorce; Response option: 0 = no and 1 = yes. Death of family member; Response option: 0 = no and 1 = yes. Family member with a serious illness Response option: 0 = no and 1 = yes. Childhood school adversity Eight items [6-9] The teacher prejudiced against me Response option: 0 = no and 1 = yes. Being scolded or insulted by a teacher Response option: 0 = no and 1 = yes. Being physically punished by a teacher Response option: 0 = no and 1 = yes. Reluctance to go to school Response option: 0 = no and 1 = yes. Poor academic performance Response option: 0 = no and 1 = yes. Having difficulty getting along with classmates Response option: 0 = no and 1 = yes. Being laughed at by classmates Response option: 0 = no and 1 = yes. Being insulted by classmates Response option: 0 = no and 1 = yes. Physical disability and chronic illness Do you have any physical disabilities or long-term health problems in childhood?” (More details are provided in our previous study[10] ). The response options were as follows: yes, no, and not sure. the response option of “No” and “Not sure” was combined into the one group (i.e., No). Table . Details for ACEs items
-
We used the six types of risky health behaviors as outcomes, including smoking, drinking, sex-related behavior, self-harm, suicidal ideation and suicide attempts, based on the original study of ACEs and later ACE studies of adolescents [3-4, 34-35]. The following 6 questions were posed [36]: 1) smoking: “Have you ever tried smoking (including just a cigarette or two)?”; 2) drinking: “Have you ever had a habit of drinking alcohol (defined as drinking alcohol, including beer, liquor, wine, etc., at least once a month); 3) sexual intercourse: “Have you ever had sexual intercourse with someone?”; 4) self-harm: “In the last six months, how many times have you committed acts of self-harm that were not intended to end your life? (such as beating yourself, cutting yourself, pulling your own hair, etc. but not to end your life)”; 5) suicidal ideation: “Have you thought about ending your life in the past 6 months?”; and 6) suicide attempts: “Have you deliberately tried to end your life over the past 6 months?” These questions were coded with binary variables (yes/no).
-
Because demographic variables such as sex, grade level, self-perceived family socioeconomic status, self-perceived maternal and paternal relationships, friend quantity, only child status and character, and academic performance have previously been associated with risky health behaviors and ACEs [3-6, 18, 22, 35], the above sociodemographic information was collected through self-reports from the participants. Information on the sociodemographic covariates is shown in Supplementary Table S1 (available in www.besjournal.com).
Variables n High
adversity
n (%)Peer
victimization
n (%)School
adversity
n (%)Maltreatment
and peer
victimization
n (%)School adversity
and peer
victimization
n (%)Low
adversity
n (%)χ2
valueP
valueSex 28.421 < 0.001 Males 2,848 119 (58.6) 442 (50.6) 720 (45.5) 92 (62.6) 568 (19.9) 907 (50.1) Females 2,878 84 (41.4) 432 (49.4) 861 (54.5) 55 (37.4) 554 (18.9) 902 (49.9) Grade 74.350 < 0.001 Middle 2,958 99 (3.3) 517 (59.2) 722 (45.7) 86 (58.5) 515 (46.3) 1,019 (56.3) High 2,768 104 (3.8) 357 (40.8) 859 (54.3) 61 (41.5) 597 (53.7) 790 (43.7) Self-perceived family status 149.701 < 0.001 Poor 800 52 (25.6) 101 (11.6) 216 (19.4) 24 (16.3) 268 (17.0) 139 (7.7) Medium 4,377 136 (67.0) 678 (77.6) 833 (74.9) 112 (76.2) 1,167 (73.8) 1,451 (80.2) Good 549 15 (7.4) 95 (10.9) 63 (5.7) 11 (7.5) 146 (9.2) 219 (12.1) Only child 102.941 < 0.001 No 2,469 76 (37.4) 422 (48.3) 589 (37.3) 62 (42.2) 399 (35.9) 921 (50.9) Yes 3,257 127 (62.6) 452 (51.7) 992 (62.7) 85 (57.8) 713 (64.1) 888 (49.1) Family structure 42.718 < 0.001 Nuclear family 3,792 128 (63.1) 561 (64.2) 1,031 (65.2) 106 (72.1) 736 (66.2) 1,230 (68.0) Lager family 1,353 41 (20.2) 241 (27.6) 355 (22.5) 26 (17.7) 260 (23.4) 430 (23.8) Single-parent family 469 26 (12.8) 59 (6.8) 161 (10.2) 10 (6.8) 90 (8.1) 123 (6.8) Others 112 8 (3.9) 13 (1.5) 34 (2.2) 5 (3.4) 26 (2.3) 26 (1.4) Relationship with father 138.630 < 0.001 Poor 1,911 123 (60.6) 269 (30.8) 529 (33.5) 70 (47.6) 438 (39.4) 482 (26.6) Good 3,815 80 (39.4) 605 (69.2) 1,052 (66.5) 77 (52.4) 674 (60.6) 1,327 (73.4) Relationship with mother 125.274 < 0.001 Poor 1,353 94 (46.3) 175 (20.0) 370 (23.4) 64 (43.5) 304 (27.3) 346 (19.1) Good 4,373 109 (53.7) 699 (80.0) 1,211 (76.6) 83 (56.5) 808 (72.7) 1,463 (80.9) Character trait 40.795 < 0.001 Introvert 1,278 52 (25.6) 161 (18.4) 347 (21.9) 24 (16.3) 311 (28.0) 383 (21.2) Neutral 2,281 78 (38.4) 355 (40.6) 652 (41.2) 52 (35.4) 421 (37.9) 723 (40.0) Extrovert 2,167 73 (36.0) 358 (41.0) 582 (36.8) 71 (48.3) 380 (34.2) 703 (38.9) Academic performance 186.560 < 0.001 Low 1,380 80 (39.4) 143 (16.4) 452 (28.6) 52 (35.4) 347 (31.2) 306 (16.9) Medium 3,201 87 (42.9) 502 (57.4) 870 (55.0) 75 (51.0) 583 (52.4) 1,084 (59.9) High 1,145 36 (17.7) 229 (26.2) 259 (16.4) 20 (13.6) 182 (16.4) 419 (23.2) Number of friends 61.828 < 0.001 < 3 1,439 79 (38.9) 212 (24.3) 383 (24.2) 35 (23.8) 350 (31.5) 380 (21.0) ≥ 3 4,287 124 (61.1) 662 (75.7) 1,198 (75.8) 112 (76.2) 762 (68.5) 1,492 (79.0) Table S1. Descriptive statistics for the LCA classes by different sociodemographic characteristics
-
A series of LCA models were established to determine mutually exclusive ACE groups using Mplus 6.4. The optimal solution was selected based on the Akaike information criterion (AIC), Bayesian information criterion (BIC), adjusted BIC (aBIC), Lo-Mendell-Rubin (LMR) P value, and entropy value[37-39]. Lower AIC, BIC, and aBIC values and a significant p value from the LMR test show a better-fitting model, and entropy values closer to 1 show a clearer classification of groups[37-39].
A partial least square discriminant analysis (PLS-DA) was performed to determine which of the 27 ACE types best differentiated the ACE latent classes using R software version 3.5.1 (the R Foundation for Statistical Computing, Vienna, Austria) (mixOmcs packages)[40]. The optimal number of components was determined using a 5-fold cross-validation method[41]. We used the variable importance in the projection (VIP) index to determine the importance of the variables in the model, and variables with a VIP value higher than 1 were considered important variables from discriminating the different LCA classes. Univariate and multivariate logistic regression tests (adjusting for covariates) were used to explore the associations between LCA classes and risky health behaviors using SPSS version 21.0 (IBM, Armonk, NY, USA) as well as the relationships between the ACE types that most strongly discriminated LCA classes and risky health behaviors. The level of significance was set at < 0.05. Considering the low prevalence of some types of risky health behaviors, Poisson regression models were also conducted to explore the relationships, and the results remained robust. We include these results in the Supplementary Figures S1–S3 (available in www.besjournal.com).
Figure S1. Possion regression models for unadjusted and adjusted β (95% CI) for the association between ACE scores and risky health behaviors among adolescents (Reference group = None): (A) smoking, (B) drinking, (C) sexual intercourse, (D) self-harm, (E) suicidal ideation, and (F) suicidal attempts. In the adjusted models, we adjusted models, we adjusted the sociodemographic covariates, including sex, grade, self-perceived family socioeconomic status, self-perceived relation with mother and father, number of friends, only-child status and character trait, and academic performance.
Figure S3. Possion regression models for unadjusted and adjusted β (95% Cl) for the association between (A) being physically punished by a teacher (Reference group = No), (B) sexual abuse (Reference group = No) and (C) Family trauma (Reference group = No) and risky health behaviors among adolescents. In the adjusted models, we adjusted the sociodemographic covariates, including sex, grade, self-perceived family socioeconomic status, self-perceived relationship with mother and father, number of friends, only-child status and character trait, and academic performance.
-
As shown in Figure 2, two types of adversity have a prevalence rate of more than 40%, six types of adversity have a prevalence rate of more than 30%, and twelve types of adversity have a prevalence rate of 20%. Specifically, verbal peer victimization (41.9%), poor academic performance (40.2%), and being scolded or insulted by a teacher (36.7%) were the most common types of adversity. The prevalence rate of self-harm was 21.0% (1,203/5,726), followed by those of suicidal ideation (19.3%, 1,103/5,726), drinking (12.4%, 710/5,726), suicide attempts (1.8%, 105/5,726), sexual behavior (1.8%, 103/5,726) and smoking (0.8%, 44/5,726) .
-
In total, 85.3% of the individuals had experienced at least one type of ACE. Specifically, 19.6% of the participants had experienced one or two types of adversity, 27.4% had experienced 3-5 types ACEs, and 38.2% had experienced at least six types of ACEs. Descriptive statistics for ACEs scores and adolescent health risky behaviors are shown in Supplementary Table S2 (available in www.besjournal.com). Students with 3–5 ACEs and ≥ 6 ACEs were associated with an increased risk for drinking, sexual behavior, self-harm, suicidal ideation and suicide attempts in both univariate and multivariate regression models compared to those with no ACEs. However, only a positive association between ≥ 6 ACEs and smoking was observed (Figure 3).
Figure 3. Logistic regression models for unadjusted OR (95% CI) for the association between ACE scores and risky health behaviors among adolescents (Reference group = None): (A) smoking, (B) Drinking, (C) sexual intercourse, (D) self-harm, (E) suicidal ideation, and (F) suicidal attempts. In the adjusted models, we adjusted the sociodemographic covariates, including sex, grade, self-perceived family socioeconomic status, self-perceived relationship with mother and father, number of friends, only-child status and character trait, and academic performance.
Variables n (%) Smoking
n (%)Drinking
n (%)Sexual
intercourse
n (%)Self-harm
n (%)Suicidal
ideation
n (%)Suicidal
attempts
n (%)ACEs scores None 843 (14.7) 2 (0.0) 40 (0.7) 4 (0.1) 57 (1.0) 58 (1.0) 2 (0.0) 1−2 1,123 (19.6) 3 (0.1) 80 (1.4) 7 (0.1) 129 (2.3) 111 (1.9) 9 (0.2) 3−5 1,507 (27.4) 9 (0.2) 182 (3.2) 27 (0.5) 283 (4.9) 248 (4.3) 21 (0.4) ≥ 6 2,190 (38.2) 30 (0.5) 408 (7.1) 65 (1.1) 734 (12.8) 686 (12.0) 73 (1.3) LCA classes Low adversity 1,809 (31.6) 4 (0.2) 108 (6.0) 11 (0.6) 165 (9.1) 152 (8.4) 8 (0.4) School adversity and peer victimization 1,112 (19.4) 12 (1.1) 202 (18.2) 27 (2.4) 353 (31.7) 329 (29.6) 20 (1.8) Maltreatment and peer victimization 147 (2.6) 5 (3.4) 31 (21.1) 10 (6.8) 65 (44.2) 65 (44.2) 18 (12.2) School adversity 1,581 (27.6) 8 (0.5) 219 (13.9) 25 (1.6) 324 (20.5) 277 (17.5) 18 (1.1) Peer victimization 874 (15.3) 7 (0.8) 96 (11.0) 14 (1.6) 181 (20.7) 165 (18.9) 21 (2.4) High adversity 203 (3.5) 8 (3.9) 54 (26.6) 16 (7.9) 115 (56.7) 115 (56.7) 20 (9.9) Being corporally punished by the teacher No 4,053 (70.8) 20 (0.5) 377 (9.3) 55 (1.4) 24 (3.0) 668 (16.5) 60 (1.5) Yes 1,673 (29.2) 24 (1.4) 333 (19.9) 48 (2.9) 112 (26.0) 435 (26.0) 45 (2.7) Sexual abuse No 5,227 (91.3) 23 (0.4) 594 (11.4) 589 (23.9) 1,003 (19.2) 902 (17.3) 60 (1.1) Yes 499 (8.7) 21 (4.2) 116 (23.2) 992 (30.5) 200 (40.1) 201 (40.3) 45 (9.0) Family Trauma No 5,025 (87.8) 36 (0.7) 590 (11.7) 1,031 (27.2) 996 (19.8) 914 (18.2) 76 (1.5) Yes 701 (12.2) 8 (1.1) 120 (17.1) 34 (30.4) 207 (29.5) 189 (27.0) 29 (4.1) Table S2. Descriptive statistics for ACE scores, LCA classes, being corporally punished by the teacher, sexual abuse, and family trauma and adolescent risky health behaviors
-
We compared the fit statistics of the LCA models to two to seven classes (see Supplementary Table S3 available in www.besjournal.com). The 6-class model was chosen based on a lower BIC, the aBIC value and an entropy value of close to 0.8 (0.793): (1) low exposure to all ACEs, labeled low adversity (1,809, 31.6%); (2) a high probability of exposure to school adversity, labeled school adversity (1,581, 27.6%); (3) a high probability of exposure to both school adversity and peer victimization, labeled school adversity and peer victimization (1,112, 19.4%); (4) a high probability of exposure to peer bullying, labeled peer victimization (874, 15.3%); (5) a high probability of exposure to maltreatment and peer bullying, labeled maltreatment and peer victimization (203, 3.5%); and (6) a high probability of exposure to all types of ACEs, labeled high adversity (147, 2.6%) (Figure 4). Sex, grade level, self-perceived family status, only child status, family structure, paternal relationship quality, maternal relationship quality, character traits, academic performance, and friend quantity were significantly linked to the ACE groups (Supplementary Table S1).
No. of class AIC BIC aBIC LRT Entropy 1 132054.425 132234.050 132148.252 NA − 2 117971.518 118337.420 118162.647 P < 0.001 0.850 3 115306.634 115858.814 115595.065 P < 0.001 0.798 4 113794.595 114533.052 114180.327 P < 0.001 0.813 5 112946.301 113871.036 113429.335 P < 0.001 0.806 6 112278.353 113389.366 112858.689 0.0032 0.793 7 111737.474 113034.765 112415.113 0.1782 0.776 Note. AIC: Akaike Information Criterion; BIC: Bayesian Information Criterion; aBIC: the sample-size Adjusted BIC; LRT: Bootstrapped Likelihood Ratio Test. Table S3. Fit indices for LCA models with 1–7 classes
-
Descriptive statistics for the LCA groups and adolescent health risky behaviors are shown in Supplementary Table S2. As presented in Figure 5, compared to the low adversity subtype, participants in any other subtype of ACE exposure were associated with an increased risk for smoking, drinking, sexual behavior, self-harm, suicidal ideation and suicide attempts in both univariate and multivariate regression models, except for the nonsignificant association between school adversity and smoking. Notably, we found that “high adversity” and “maltreatment and peer victimization” had higher ORs for smoking, drinking, sexual behavior, self-harm, suicidal ideation and suicide attempts. Specifically, of the six types of risky adolescent health behaviors, high adversity presented the highest ORs, except for suicide attempts.
Figure 5. Logistic regression models for unadjusted and adjusted OR (95% CI) for the association between LCA classes and risky health behaviors among adolescents (Reference group = Low adversity): (A) smoking, (B) drinking, (C) sexual intercourse, (D) selfharm, (E) suicidal ideation, and (F) suicidal attempts. In the adjusted models, we adjusted the sociodemographic covariates, including sex, grade, self-perceived family socioeconomic status, self-perceived relationship with mother and father, number of friends, only-child status and character, and academic performance.
-
PLS-DA was performed to determine which of the 27 ACEs best differentiated the ACE groups. The model with 1 component was selected by 5-fold cross-validation. The ACEs with VIP scores of greater than 1 are deemed the most relevant for differentiating the 6 ACE groups. Figure 6 presents the VIP scores of the 27 ACEs sorted by VIP scores. Eleven ACEs were considered important (> 1), and being physically punished by a teacher, experiencing sexual abuse, and experiencing family trauma generated the 3 highest VIP scores (> 1.5). Other ACEs with VIP scores greater than 1 include having difficulty getting along with classmates, being scolded or insulted by a teacher, experiencing verbal peer victimization, being laughed at by classmates, experiencing one’s parents overconsume alcohol or being addicted to gambling, experiencing relational peer victimization, experiencing emotional abuse and having a family member with a serious illness.
Figure 6. Partial least squares discriminant analysis was used to evaluate the relative influence of the 27 adversity indicator variables in the creation of the latent profiles. Variable Importance in Projection (VIP) scores that extend to the right beyond vertical red line are > 1 and significantly differentiate the latent stress profiles. Eleven variables were considered were considered significant according to VIP scores > 1.
-
Descriptive statistics for being physically punished by a teacher, experiencing sexual abuse, experiencing family trauma and risky adolescent health behaviors are shown in Supplementary Table S2. As Figure 7 shows, being physically punished by a teacher, experiencing sexual abuse, and experiencing family trauma were significantly and positively correlated with six types of risky adolescent health behavior, except a nonsignificant association was found between experiencing family trauma and smoking. Interestingly, of the six types of risky adolescent health behaviors, “sexual abuse” generated the highest ORs.
Figure 7. Logistic regression models for unadjusted and adjusted OR (95% CI) for the association between (A) being physically punished by the teacher (Reference group = No), (B) sexual abuse (Reference group = No), and (C) family trauma (Reference group = No) and risky health behaviors among adolescents. In the adjusted models, we adjusted the sociodemographic covariates, including sex, grade, self-perceived family socioeconomic status, self-perceived relationship with mother and father, number of friends, only-child status and character trait, and academic performance.
HTML
Participants
Measures
Childhood Adversity
Adolescent Health Risky Behaviors
Sociodemographic Covariates
Statistical Analysis
Prevalence of Childhood Adversity and Risky Health Behaviors
ACEs Scores and Risky Adolescent Health Behaviors
Latent Class Analysis of Childhood Adversity
Associations between ACE Classes and Risky Adolescent Health Behaviors
ACEs That Most Strongly Discriminated ACE Groups
Relationships between being Physically Punished by a Teacher, Experiencing Sexual Abuse, and Experiencing Family Trauma and Risky Adolescent Health Behaviors
21372Supplementary Materials.pdf |