Adverse childhood experiences (ACEs) are psychosocial factors with a significant impact on all determinants of health. It is a worldwide issue that affects people of all ages, socioeconomic statuses, and cultures1. The term ACE is similar to and often used interchangeably with childhood trauma or childhood maltreatment2. Traumatic events during childhood include physical and emotional abuse, sexual abuse, mental illness, substance misuse at home, and household dysfunction, such as separation, divorce, domestic violence, or imprisonment 3.
Multiple studies have shown that there is an association between ACEs and health problems in adulthood, such as obesity, mental disorders, high blood pressure4, depression, diabetes, irregular sleep patterns5, lung cancer, metabolic issues, inflammation, liver diseases6, and mental health issues7. Children and adolescents who are exposed to multiple types of ACEs are more at risk of developing adult health risk behaviors and diseases since there is a graded link between the scores of ACEs and health outcomes. Maxia Dong, in one of her studies, found a dose-response relationship between the number of adversities experienced as a child and the risk of developing ischemic heart disease in the future8.
According to recent studies, college students experience high rates of maltreatment and lifelong rates of potentially traumatic incidents. Although the majority of all 18- to 19-year-olds are enrolled in college, there are very few studies on ACEs in college/university students. A study conducted in Ireland looked at childhood adversities in college students and discovered that 35% of them had at least two ACEs. However, in the United States, college students reported between 38% and 53% of lifetime unfavourable events9.
In terms of public health, ACEs have been connected to HIV risk exposure, lifetime alcoholism, opioid addiction, homelessness6 early smoking, depressive and anxious states, and early death. Julia Herzog in her study asserted that the effects of early exposure to unpleasant experiences (ACEs) may activate toxic stress during or after ACE exposure and affect children's normal brain development3,10.
ACEs are widely prevalent globally, and some researchers have found that low- and middle-income nations have higher rates of ACEs than high-income countries 4 owing to limited resources and less social health care 11 . Accumulating evidence shows that ACE is now considered a public health concern 5 . For instance, according to a population survey carried out in Mexico by UNICEF in 2016, 63% of children had suffered physical or psychological violence in the year prior. In the US and UK, however, the prevalence of having at least one ACE was 59% and 46%, respectively. In low middle-income countries, where the majority of children and teenagers live, many forms of challenges, or polyvictimization, are more common than in high-income countries, which increases the burden of health issues 4 . The results of the survey indicated that ACEs may have a greater healthcare cost compared to other causes of healthcare utilization. Evidence generally suggests that people with ACEs may need healthcare services more frequently, especially specialized emergency services. Estimates place the lifetime cost per victim at $400,533. Half of the ACEs that are checked for are related to child abuse and neglect. A total of 124 billion USD, or 210,012 USD per victim in 2010 currencies, was projected to represent the economic burden associated with these illnesses in 2008 12.
Although there is a dearth of reliable prevalence data for Pakistan, it is estimated that the country's prevalence may be approximately 50% 13,14. It should be noted that Pakistan has a high proportion of the youthful population, with 70 million children under the age of 18. Many of these children are living in poverty and have high rates of malnutrition, issues such as child labor, and homelessness. It is difficult to discuss this sensitive subject, and it has become socially taboo due to conservative cultural ideas and corporal punishment. This is made worse by a lack of institutional and national financing for child protection, as well as a lack of knowledge in this area, all of which contribute to an atmosphere where children are exposed to abuse1. There is no previous study performed in Pakistan that focused on the co-occurrence of multiple childhood adversities or their correlation. This study aims to determine the prevalence of ACEs in university students in Lahore, Pakistan, and their correlations with each other along with a Latent Class Analysis. In the cultural prospect of this region, the co-occurrence of multiple ACEs is very common as some of them have become a part of the societal norms and family system. This study will provide a better understanding of patterns of Adverse Childhood Experiences and help policymakers in planning prevention campaigns in the future.