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Adverse Childhood Experiences as a significant predictor of worsened well-being among Polish medical and dental students

Introduction and purpose. Adverse Childhood Experiences (ACEs) are a major public health problem. The aim of the study was to investigate the prevalence of Adverse Childhood Experiences among medical and dental students in Poland and to examine a relationship between ACEs and chosen factors associated with well-being of the students. Material and method. The research tool consisted of the Adverse Childhood Experiences standardized questionnaire and authors’ questions. 934 medical students and 228 dental students took part in the study (a total of 1162 participants). The respondents came from 18 Polish universities. Results. 57.40% of the students experienced at least 1 childhood adversity, 8.43% of them were affected by 4 or more ACEs. The most common adverse childhood experiences were: emotional neglect (23.06%), emotional abuse (22.98%) and mental illness or a suicide attempt in a household member (21.86%). On average, women experienced more childhood adversities than men. An overall graded relationship was found between ACEs and: frequent feelings of loneliness, low self-assessment of academic performance, problems with maintaining stable body weight, reaching for alcohol in order to de-stress and being non-religious. Conclusions. Adverse Childhood Experiences are common among Polish medical and dental students and are linked with multiple aspects of worsened well-being of the students. The study emphasizes a need to create strategies that aim to educate on Adverse Childhood Experiences in order to prevent them and help those who are affected by them.


Introduction
Adverse Childhood Experiences (ACEs) are a major public health problem. They are the 10 types of the most common potentially traumatic events that can happen to a child under 18 years of age. ACEs are grouped into 3 domains that contain a total of 10 categories: abuse (emotional, physical and sexual), neglect (emotional and physical) and household dysfunctions (mental illness in a household member, physical violence towards mother, substance abuse in a household member, parental separation or divorce and imprisonment of a household member) [1].
Exposure of a child to stressors, such as ACEs, can lead to toxic stress response which results from dysregulation of neuroendocrine and immune systems which affects many systems of the body leading to long-term disturbances of their functioning [2]. Many studies have shown a dose-response relationship between ACEs and multiple physical and mental health problems in adult life, such as: cardiovascular diseases, chronic lung diseases, headaches, autoimmune diseases, obesity, sleeping problems, depression, PTSD, anxiety and early death. Moreover, a relationship was found between ACEs and many aspects of worsened socioeconomic status and negative behaviors in later life, such as: smoking, substance abuse, unemployment, risky sexual behaviors and criminal behaviors [3,4,5,6]. It was established that 4 or more ACEs are a strong predictor of poor health [7].
Adverse Childhood Experiences are common among Polish students. A research carried out in 2016 among 1760 Polish students showed that 76.6% of them experienced at least 1 ACE and 19.22% of them were affected by 4 or more ACEs. This study included students of 5 universities among which there were no medical universities [8]. To our best knowledge, no study has been conducted on the prevalence of ACEs among Polish medical and dental students.

Aim
The aim of the study was to analyze the prevalence of Adverse Childhood Experiences among medical and dental students in Poland and to investigate a relationship between ACEs and chosen factors associated with well-being of the students.

Material and method
The research tool included the Adverse Childhood Experiences standardized questionnaire and author's questions which concerned sociodemographic characteristics of an investigated group and investigated factors. All questions were closed and single-choice. The author's questions were measured with Likert scale. Answers were collected in the April of 2020. The research tool was placed on official groups dedicated to medical and dental students on Facebook social networking site. The questionnaire was anonymous and participation in the research was voluntary. Collected data was analyzed statistically. To assess a relationship between the two variables, the Chi-square test of independence was used. The level of significance was set at p < 0.05.

Demographic characteristics
The research was carried out among 1162 participants: 80.38% of them were medical students (n = 934) and 19.62% of them were dental students (n = 228). Among respondents there were students of all of the 18 Polish universities that offer medical education and all of the 10 Polish universities that offer dental education. Women constituted of 76.33% of the participants (n = 887) and men -23.67% (n = 275). Among respondents there were students of each year of both medical and dental studies. The age of the respondents ranged from 18 to 34 years, the mean age was 21.71 ± 1.97 years, whereas the median age 21 years. 43.20% (n = 502) of the students stated that they often feel lonely. 47.07% (n = 547) of the students rated their academic performance positively. 60.07% (n = 698) of the respondents didn't have problems with maintaining stable body weight. 48.62% (n = 565) of the participants stated that they don't reach for alcohol in order to de-stress or discharge negative emotions. 44.66% (n = 519) of the students described themselves as religious. (Table 1).
Overall, more than a half (n = 667, 57.40%, 95% CI = 54.95 -59.85) of the participants of the study experienced at least 1 childhood adversity. (Chart 1.) The most common adverse childhood experiences were: emotional neglect (23.06%, n = 268), emotional abuse (22.98%, n = 267) and mental illness or a suicide attempt in a household member (21.86%, n = 254). 20.40% (n = 237) of the participants had a household member who abused substances. 16.35% (n = 190) of the students were affected by parental separation or divorce. 7.66% (n = 89) of the respondents experienced physical abuse. 3.7% (n = 43) of the participants of the study were affected by sexual abuse. 3.53% (n = 41) of the participants witnessed violence towards their mother or step-mother. 1.72% (n = 20) of the students reported being physically neglected. 1.55% (n = 18) of the respondents had a household member who became imprisoned.
Chart 1. Prevalence of the number of Adverse Childhood Experiences among Polish medical and dental students.

Factors associated with Adverse Childhood Experiences
An overall graded relationship was found between Adverse Childhood Experiences and: frequent feelings of loneliness, negative self-assessment of academic performance, having problems with maintaining stable body weight, reaching for alcohol in order to de-stress or discharge negative emotions and being non-religious. (Table 4).

Discussion
In our study results of the Adverse Childhood Experiences questionnaire had a mean score of 1.23 and a median of 1. Similar results were obtained in a study carried out among 239 students from a public university in the Midwest with a mean score of 1.1 and a median score of 1.0 [9]. In our analysis 57.4% of respondents reported at least one ACE exposure and 8.43% of students reported ≥ 4 exposures. A. F. Sciolla et. al. in a research on the population of 86 third-year medical students of one medical school on the West Coast of the USA obtained similar results: 51% of them reported at least one ACE exposure. Moreover, all of the students who reported at least four ACEs were women [10]. Whereas a research by Kennedy Amone-P'Olak and Nkalosang K. Letswai on 392 students of the university in Botswana showed that about 73% of respondents reported one or more ACEs, about 15% reported 5 or more Adverse Childhood Experiences [11]. According to a research conducted among 48 526 adult Americans from 5 states of America, 55.4% of the respondents reported at least one ACE, whereas 13.7% of them reported at least 4 ACEs [12].
According to our study the most often reported Adverse Childhood Experience was physical abuse (23.06% of respondents) and the least often reported ACE was mental illness in a household member (1.55% of respondents). In the study by A. F. Sciolla the most often reported ACE was mental illness in household member (29% of respondents), whereas physical neglect was reported the least often (6% of respondents) [10]. The most often reported ACE in already mentioned research from Botswana was parental separation or divorce which effected 36.3% of the students [11]. In a study conducted among 1346 students from Hong Kong, China, Taiwan, and Japan the most often reported ACE was physical abuse -experienced by 28.08% of students. Respondents also often experienced domestic violence and parental separation, reported respectively by 23.33% and 19.24% of the students [13].
Our study enabled to assess a relationship between adverse childhood experiences and gender. The mean ACE score for women was 1.30, whereas the mean ACE score for men was 1.0. A relationship between female gender and increased exposure to adverse childhood experiences was a subject of numerous studies. Similar conclusions were obtained by Andrés F. Sciolla et al. whose research concerned 86 medical students of one medical school on the West Coast of the USA and Beáta Kovács-Tóth et al. studying a population of 516 Hungarian teenagers aged 12-17 [10,14].
Our study showed that women had a statistically significant higher chance than men of experiencing psychological abuse, sexual abuse and emotional neglect. The available literature provides similar conclusions [10,14,15]. Moreover, the research conducted by Andrés F. Sciolla et al. showed a correlation between female gender and higher exposure to physical abuse [10]. In our study also more women than men experienced physical abuse, but this difference is not statistically significant.
Not every research leads to similar conclusions. In an analysis carried out on 737 students from one middle school and one high school located in Seoul in South Korea by E-Jin Park et al., the mean ACE score was higher among men than among women. Furthermore, the mean scores in the physical abuse, sexual abuse and general trauma domains were significantly higher in men than in women [16].
The obtained results indicate a relationship between experiencing ACEs and having problems with maintaining stable body weight. A research conducted in the USA by Lorraine M. McKelvey et al. among 1335 demographically diverse families with low income allowed a conclusion that there is a correlation between ACEs and excess weight defined as having a BMI greater than the 95 th percentile [17].
ACE exposure is significantly associated with psychological distress [18]. It is not surprising that the authors' study showed a significant relationship between ACEs and drinking alcohol in order to de-stress or discharge negative emotions. The analysis carried out among 1466 German students by Jascha Wiehn et al. showed a similar relationship. It was found that physical neglect has a significant effect on risky drinking, whereas experiencing emotional abuse and peer violence significantly correlate with drug abuse. Moreover, it was proved that experiencing four or more ACEs is associated with smoking, drug abuse, early sexual initiation and having multiple sexual partners [15].
Furthermore, based on a research conducted by Zhihui Jia et al. on a population of 884 senior high school students from Nanchang in China, it can be concluded that ACEs increase the probability of depressive symptoms, suicidal thoughts and suicidal plans [19].

Conclusions
Adverse Childhood Experiences are common among Polish medical and dental students. 57.40% of them experienced at least 1 ACE, whereas 8.43% of them were affected by 4 or more ACEs. The most commonly reported childhood adversities were emotional neglect (23.06%), emotional abuse (22.98%) and mental illness or a suicide attempt in a household member (21.86%). On average, women were affected by more ACEs than men. An overall graded relationship was found between Adverse Childhood Experiences and many aspects of worsened well-being in adult life of the students, such as: frequent feelings of loneliness, negative selfassessment of academic performance, having problems with maintaining stable body weight, reaching for alcohol in order to de-stress or discharge negative emotions and being nonreligious. Our study emphasizes the importance of implementing strategies that aim to educate on Adverse Childhood Experiences in order to prevent them and help those who are affected by them.