Association of adverse childhood experiences with functional identity and impulsivity among adults: a cross-sectional study

Introduction

The Centers for Disease Control and Prevention (CDC) report a high prevalence of physical (28%) and sexual abuse (21%) associated with an unstable living environment among the American youth¹. Previous studies demonstrate a significant relationship between experience of abuse and physical, behavioral and social problems among the youth¹. Although there is abundant data exploring the prevalence of adverse childhood experiences in higher income countries, in low and middle income countries (LAMI) data is more scarce² Moreover, a paucity of data has been identified in the LAMI, necessitating the need to transculturally translate the impact of adverse childhood events (ACEs) on social, cognitive and emotional impairment and adoption of high risk behaviors³.

Childhood emotional mistreatment; particularly emotionally abusive acts, has been found to be associated with increased odds of lifetime diagnoses of several mental disorders⁴. The early, prolonged, and severe trauma can also increase impulsivity, diminishing the capacity of the brain to regulate emotions. Neurobiological studies show that childhood mistreatment leads to failure of inhibitory processes ruled by the frontal cortex over a fear-motivated hyper-responsive limbic system⁵. Therefore, impulsivity is a double edged sword, presenting itself as sequela of trauma as well as a risk factor for the development of a pathological response to trauma⁶. Many psychiatric disorders feature impulsivity, including substance-abuse disorders, attention deficit hyperactivity disorder, borderline personality disorder, conduct disorder and mood disorders. Impulsivity has also been associated with suicidal behaviors within various psychiatric populations exhibiting low serotonergic activity⁷. In mental health disorders especially substance use disorders, superimposition of the behavioral aftermaths of ACEs on impulsivity potentiate the risk of alcohol abuse by many folds⁸.

Similarly, previous studies have also established an association between ACEs and development of identity in adolescence. Development of a stable identity is a major developmental task, with its changing facets responsible for shaping the attachment styles and self-esteem in adolescence^9,10. Serafini and Adams describe the importance of identity in providing structure for higher self-esteem and positive self-image; providing the goals necessary for self-direction¹¹. This provides a sense of free will; harmony for social and academic adjustment; and future orientation that manifests as achievements in academia, aspirations and determination¹¹. To address the gaps in scientific literature, the present study explores the association of adverse childhood experiences with demographics, subsequent impulsivity and functional identity among Pakistani adults.

Methods

This study was designed as a cross-sectional study, where 260 medical students aged 18 and above and currently enrolled in King Edward Medical University and CMH Lahore Medical College & Institute of Dentistry, both in Lahore, were conveniently interviewed from April to May, 2017. Institutional review board approval was sought and obtained from the Ethical Review Board of CMH Lahore Medical College, Pakistan (approval number: 21/ERC/CMHLMC). A consent form, an anonymous questionnaire on sociodemographic characteristics, and English versions of the Adverse Childhood Experiences (ACE) scale, Functions of Identity scale (FIS) and Barratt’s Impulsiveness Scale (BIS-11) were employed in this study. Participation in this study was voluntary and written informed consent was obtained from all participants. The participants were ensured anonymity and that only group findings would be reported.

The Adverse Childhood Experiences (ACE) questionnaire is an important assessment tool that measures multiple types of abuse and adverse experiences that one may have encountered as a child¹. It assesses adverse childhood experiences related to abuse (physical, psychological and sexual); neglect (emotional and physical) and household dysfunction (alcoholism or drug use at home, loss of biological parent, mental illness in home, violent treatment by mother and imprisoned household member). Responses to the ACE are recorded on a dichotomous scale (yes/no) and then scores are summed with higher scores corresponding to a higher number of ACEs. It has exhibited adequate reliability (Cronbach’s alpha 0.6 to 0.8) and validity in previous study¹.

The Functions of Identity Scale (FIS) is a valid and reliable 5-point Likert scale, comprising 15 questions that assess five domains of psychological functions that identity serves for an individual: structure, goals, personal control, harmony and future¹¹. Higher scores on these subscales correspond to a stronger sense of identity.

Barratt’s Impulsiveness Scale (BIS-11) is a 30-item self-report Likert scale, with seven subscales; attention, motor, self-control, cognitive complexity, perseverance, and cognitive instability¹². Higher scores on the scale or its subscales correspond to worsening impulsivity. All of these scales were found to be reliable in the present sample with following Cronbach’s α; ACE (0.71), FIS (0.86) and BIS-11 (0.78).

All data were analyzed in SPSS v. 21. Descriptive statistics were computed for the whole data. Frequencies were calculated and reported for ten domains of ACE, impulsivity and functions of identity. Partial correlations were run to assess the association of impulsivity and functions of identity with ACEs, adjusting for gender, age and socioeconomic status.

Results

A total of 232 medical students (232/260= 89.2%) responded to the surveys. The majority of them were females (n=188, 81%), with a mean age of 21.22 ± 1.31 years, mean number of siblings 3 ± 1.46, mean order of birth 1.94 ± 0.78 and a mean income greater than 30,000 PKR (n=208, 89.7%). Mean scores on subscales of Functional Identity Scale and Barratt’s Impulsiveness Scale are given in Table 1.

Mean score (SD) on the ACE scale was 1.37 (1.75). A total of 122 (52.6%) respondents had experienced at least one ACE. Verbal, physical, sexual adverse events and poor support and affection from family were the most reported adverse events. A significant proportion of respondents cited verbal (34.5%), physical (22.0%) and sexual abuse (15.5%), poor family support (19.0%), neglect (9.9%), separation/divorce of parents (4.7%), and witnessed domestic abuse (11.2%), substance abuse (3.9%), mentally or suicidal patient in the family (11.2%) and criminal background (4.7%). Detailed statistics are presented in Table 2.

ACE scores yielded a significantly positive association with cognitive stability, perseverance and motor impulsivity on the Barrat’s impulsivity scale. Whereas, it yielded negative association with structure and harmony subscales of the functional identity as well as cognitive complexity subscale of the impulsivity scale. Detailed statistics are presented in Table 3. Moreover, no significant correlation was found with gender (P= 0.07), number of siblings (P= 0.95) and order in birth (P=0.08) and hoursehold income (P= 0.21). Age of participants was positively associated with ACE scores (r= 0.15, P= 0.02).

Conclusion

In our study, adverse childhood experiences were significantly negatively associated with structure and harmony subscales of the functional identity scale. Providing structure is a major function of one’s identity, deprivation of this results in poor self-esteem and negative self-image¹¹. These adverse experiences may provide a better orientation in adulthood to fulfill one’s potential in academics and career in adulthood¹¹.

Individuals reporting higher episodes of ACEs reported higher impulsivity, translating to a greater motor impulsiveness and a disrupted executive functioning among these individuals¹².

The results of this study should be generalized with caution. The cross-sectional nature of this study does not establish causality and temporality, therefore, future studies should employ a longitudinal study design.

Data availability

Dataset 1: Impulsivity and adverse childhood events. The dataset contains all variables pertaining to demographics, responses to Functional Identity Scale and Barrat’s Impulsiveness Scale. DOI, 10.5256/f1000research.13007.d182670¹³.

Consent

Participation in this study was voluntary and written informed consent was obtained from all participants. The participants were ensured anonymity and that only group findings would be reported.