Adverse childhood experiences and depressive symptoms among young adult Hispanic immigrants: Moderating and mediating effects of distinct facets of acculturation stress

Abstract

Hispanic immigrants experience more adverse childhood experiences (ACEs) and depressive symptom chronicity/severity than non-Hispanic peers. Acculturation stress relates to both depressive symptoms and ACEs, but the mechanism is not well-understood. We conducted a secondary data analysis of baseline data, from an ongoing longitudinal study to test theoretically-based mediating and moderating effects of acculturation stress on the relationship between ACEs and depression in a sample of young adult Hispanic immigrants (N = 391). Results indicated ACEs predicted depressive symptoms. Mediation and moderation effects were significant for cumulative and distinct facets of acculturation stress. Implications for mental health nurses are discussed.

Introduction

Depressive disorders¹ (described henceforth as depression) are a widespread public health problem with consequences that disproportionately impact Hispanics in the US. For example, in a representative sample of US adults, the lifetime prevalence of major depressive disorder was 20.6% and 12-month prevalence of major depressive disorder was 10.4% (Hasin et al., 2018). Recent trends demonstrate an increase in mental health concerns, such as depressive symptoms, especially among young adult groups (herein defined 18–44; Twenge et al., 2019). Hispanic adults in general report lower rates of depressive disorders compared to non-Hispanic adults (Alegría et al., 2008; Hasin et al., 2018), yet they are overburdened by higher depressive symptom severity² and chronicity³ (González et al., 2010). Interestingly, foreign-born Hispanic adults (i.e., immigrants) evidence lower rates of depression compared to US-born Hispanic adults (Alegría et al., 2008; Rodriguez et al., 2020), despite significant stressors Hispanic immigrants experience in the US, such as lack of access to physical and mental health care (Cabassa et al., 2006; De Jesus & Xiao 2014; Ortega et al., 2018), acculturation stress (Berry, 2006), and adverse childhood experiences (Llabre et al., 2017). This phenomenon is often referred to as the Hispanic Immigrant Health Paradox; despite poor social determinants of health, Hispanic immigrants experience a health advantage which erodes with greater time living in the US, increased acculturation, and across subsequent generations (Alcántara et al., 2017). In the present study, we aim to understand the Hispanic Immigrant Health Paradox as it relates to depression, by addressing how ACEs and acculturation stress contribute to the development of depressive symptoms among young adult Hispanic immigrants.

Both adverse childhood experiences (ACEs) and acculturation stress may contribute to the emergence of depression among Hispanic immigrants. ACEs are exposure to traumatic events and/or repeated exposure to distressing situations before the age of 18 such as experiencing or witnessing emotional or physical abuse, neglect, and household dysfunction (CDC, 2019). ACEs increase the likelihood of developing depressive symptoms in adulthood (Chapman et al., 2004; Kremer et al., 2019), and Hispanic immigrants report a higher prevalence of ACEs than the general US population (Llabre et al., 2017), despite lower rates of depression. Acculturation stress may serve as an additional contributor to depressive symptoms in Hispanic immigrants. Acculturation stress can be broadly defined as stress associated with the pressures of the immigration process, adopting beliefs of the dominant culture, and living in the US (Berry, 2006). Interpersonally-based acculturation stress can be defined as the challenges pertaining to the immigration process and adjusting to life in the US that arise in relationships with romantic partners, with children (pertaining to parenting specifically), and within one’s family (Cervantes, et al., 2016). Examples include intergenerational gaps in levels of acculturation⁴, the strain on the family when adopting to a new culture, and conflicts that may result in parenting, which appear to be particularly salient in this population (Cervantes et al., 2016). Disparate studies indicate these stressful and/or traumatic experiences in early life can deplete “reserve capacity,” or an individual’s available resources to cope with adversity (Gallo et al., 2009), and may have implications for the development of depressive symptoms. However, to our knowledge, no studies have examined the relationships among depressive symptoms, ACEs, and acculturation stress (and interpersonal acculturation stress in particular), among young adult Hispanic immigrants.

Background

Reserve Capacity Model

We utilize the Reserve Capacity Model (Gallo et al., 2009) to guide the hypotheses explaining how the presence of stressors, such as ACEs and acculturation stress, may increase the risk for development of depressive symptoms in Hispanic immigrants. The Reserve Capacity Model proposes individuals develop health risks and adverse health outcomes in the presence of depleted reserve capacity - the interpersonal, intrapersonal, tangible, and culture-specific resources an individual possesses needed to manage negative experiences. Further, an individual’s sociocultural context, encompassing socioeconomic and cultural characteristics in an individual’s environment, gives rise to psychosocial risk and resilience factors such as stressful events, positive life events, and positive/negative emotions. As a person utilizes resources in their reserve capacity, the less ability they have to replenish these resources, which in turn can give rise to negative health outcomes (e.g., morbidity, mortality, disability). This model has previously been utilized to undersand the role of resilience, intrapersonal, and interpersonal resources in protecting against adverse health outcomes, such as depressive symptoms (Cano et al., 2020), in a sample of Hispanic emerging adults. However, this study did not account for culturally-relevant stressors in the development of depressive symptoms, such as acculturation stress and ACEs. Herein, we build on this previous work by focusing on psychosocial risk factors (i.e., ACEs, acculturation stress) to examine how acculturation stress could theoretically result and interact with ACEs to contribute to the development of adverse mental health outcomes (i.e., depressive symptoms) in a sample of Hispanic immigrants.

Psychosocial Risk Factors

Adverse childhood experiences (ACEs)

ACEs are highly prevalent, with several state and national surveys reporting over 50% of the US population experiencing at least one ACE and 12.5%−14.3% reporting four or more ACEs, the threshold that has been deemed to be associated with a higher likelihood of negative mental health outcomes (Felitti et al., 1998; Green et al., 2010; Rose et al., 2014). Hispanic immigrants in the US may experience an even higher prevalence of ACEs than the general US population. Data derived from the Study of Latinos (an epidemiological study with a representative US Hispanic sample) found 74.9% of Hispanic immigrants experience at least one ACE, and 26.3% reported four or more ACEs (Llabre et al., 2017). It is important to note that these may be conservative estimates of the prevalence of ACEs, obscured by inaccurate measurement tools for immigrants (i.e., current tools may not capture ACEs specific to country or origin or the immigration process; Caballero et al., 2017). ACEs are associated with an increased prevalence of mental health concerns. Though the more commonly discussed sequelae of ACEs include post-traumatic stress disorder (Vranceanu et al., 2007), anxiety (Reiser et al., 2014), and substance use (Allem et al., 2015), the development of depressive symptoms (Chapman et al., 2004) is a most important one. Depressive symptoms predispose individuals to other mental and physical health problems (Richards & O’Hara, 2014) and result in absenteeism (being absent from work) and presenteeism (inability to be “present”) in the workplace (Evans-Lacko & Knapp, 2016), and can lead to suicide (Kleiman et al., 2014). Once an individual experiences depression, the more likely they are to experience depression in the future. For example, a recent meta-analysis describing the relationship between ACEs and adult depression, found those who report ACEs are 2.66 (95% CI: 2.38–2.98) to 3.73 (95% CI: 2.88–4.83) times more likely to have depression as an adult (Nelson et al., 2017).

Acculturation stress

Hispanic immigrants may experience acculturation stress connected to immigration-related obstacles faced in the US, such as learning a new language and adapting the majority culture’s norms (Berry, 2006). Acculturation stress domains span stressors such as occupational, language-related, and interpersonally-based acculturation stressors (Cervantes et al., 2016). Acculturation stress affects mental wellbeing, leading to adverse outcomes such as depressive symptoms (Arbona et al., 2010; Torres 2010). For example, previous studies support the relationship between family cultural conflict and poorer health outcomes, such as depressive symptoms in representative samples of US Hispanic populations (Rivera et al., 2008) and in Mexican-origin mothers (Marsiglia et al., 2011). Marital acculturation stress (Helms et al., 2014) and marital stress in general (Hollist et al., 2007) are also associated with depressive symptoms in Hispanic adults.

The Interplay among ACEs, (interpersonally-based) acculturation stressors, and depressive symptoms

ACEs occur during key developmental phases in which relationship building and coping skills form, subsequently influencing relationships in adulthood (Pearlman, 1997). Thus, ACE exposure is associated with a lower likelihood of forming meaningful relationships later in life, a lower sense of social well-being (Mosley-Johnson et al., 2018), and interpersonal stress (Baker et al., 2019). Specifically ACEs have been linked to parenting stress (Nam et al., 2015; Steele et al. 2016), family stress (Narayan et al. 2017), and marital stress (Umberson et al., 2005). It stands to reason that immigrants may have increased stressors in the aforementioned areas in light of intergenerational gaps (Lui 2015), decreased contact with their social support networks in their country of origin and family separations (Hurtado-de-Mendoza et al., 2014), and noted difficulties forming social ties in a new environment (Hurtado-de-Mendoza et al., 2014).

While the relationship between ACEs and depression is well-documented in the general US population (Chapman et al., 2004; Gilbert et al., 2015; Merrick et al., 2017) and in Hispanic individuals (Benjet et al., 2010; Kremer et al., 2019; Rojas-Flores et al.,2017), there is a dearth of research to help explain the relationship between ACEs and depressive symptoms for Hispanic immigrants specifically. We propose the relationship between ACEs and depressive symptoms in Hispanic immigrants is important to understand in context of the stressors related to acculturation and pressures of living in the US, which may compound on a high degree of ACEs experienced by large segment of the US population (Radford & Noe-Bustamante, 2019).

It has been extensively noted that immigrants are affected by high rates of stressors such as acculturation stressors (inclusive of interpersonally-based ones; Cervantes, et al., 2013; Cervantes et al., 2014; Cervantes et al., 2016) and ACEs (Llabre et al., 2017), both of which are recognized risk factors for the development of depression (Bekteshi & Kang, 2018; Benjet et al., 2010; Kremer et al., 2019; Rojas-Flores et al., 2017). Further, some researchers have begun acknowledging the interpay among these distinct psychosocial phenomena, as described above. Nonetheless, to our knowledge, there is no definitive research that elucidates what mechanisms explain the relationship (mediators) and under what conditions the relationship exists (moderators) for Hispanic immigrants, which could represent malleable targets for intervention.

Study Aims and Hypotheses

In the present study, we tested these relationships concurrently in young adult Hispanic immigrants. We utilized the Reserve Capacity Model to inform our study aims and analyses. This study is guided by the following study aims (a) to examine the relationship between depressive symptoms and ACEs, (b) to determine whether cumulative and interpersonally-based acculturation stress explains the relationship between ACEs and depressive symptoms, (c) to determine whether cumulative and interpersonally-based acculturation stress alters the relationship between ACEs and depressive symptoms. To this end, we hypothesized (a) ACEs would be positively associated with development of depressive symptoms, (b) acculturation stress would explain the relationship between ACEs and depressive symptoms, (c) interpersonally-based acculturation stress would explain the relationship between ACEs and depressive symptoms, (d) acculturation stress would alter the relationship between ACEs and depressive symptoms, such that a higher level of acculturation stress would strengthen the relationship between ACEs and depressive symptoms, and (e) interpersonally-based acculturation stressors would alter the relationship between ACEs and depressive symptoms.

Methods

Design

This study is a secondary analysis of baseline data from an ongoing, longitudinal study on the health of young adult (ages 18–44) Hispanic immigrants in the southeastern region of the US (N=391), known as the SER Hispano project. A community-engaged research approach was used in which community stakeholders were engaged as collaborators across the design and implementation of the study. As such, community stakeholders served as co-investigators and members of the research team and were actively involved in recruiting, screening, and collecting data for the study. Institutional Review Board approval was obtained prior to initiating study related activities.

Sample and setting

Community-based recruitment strategies (e.g. Hispanic community organization partnerships, attendance at cultural events, recruitment ads in culturally relevant media) were used to reach the target population. Eligibility for participants to be enrolled in the study required individuals to (a) self-identify as Latino/a or Hispanic (b) migrated from Latin America/Caribbean to the US, (c) live in the US for at least one year, and (d) be within 18–44 years old at the time of enrollment. Individuals who reported plans to move to another geographic area, impeding follow-up data collection, were excluded.

Procedures

Interested individuals who met the aforementioned criteria were scheduled for a baseline visit at their home or a community partner’s organization, per participant preference. These visits were conducted by a trained, bilingual data collector also according the participant’s language preference. Research Electronic Data Capture (REDCap), a secure online application that helps collect and manage research data (Harris et al. 2009), was used to help manage the visit from consent to compensation. First, informed consent was obtained. Once this was reviewed with participants, participants provided a digital signature and were emailed or mailed a copy. Then a series of standardized measures were administrated. Participants had a choice to self-administer the survey or have staff administer this using a structured interview style. Once data collection was completed, participants were provided compensation ($50).

Measures

All measures used were linguistically and culturally adapted and validated for use in English and Spanish, as described by Nagy et al. (2021).

Demographic questionnaire.

A comprehensive demographic questionnaire was created by the research team. Age, age at migration, gender, race, country of origin, marital status, monthly household income, and number of children were collected from participants.

Adverse Childhood Experiences.

The Adverse Childhood Experience International Questionnaire (ACE-IQ; WHO, 2018) measure was used to assess exposure to adversity and trauma. The measure was created for use of assessing ACEs for those over the age of 18 and for use across countries, enhancing cultural applicability. The ACE-IQ assesses for 13 categories of exposure (31 items total), including physical neglect, emotional neglect, emotional abuse, physical abuse, sexual abuse, living with someone who used alcohol/drugs, a member of the household who is mentally ill/suicidal, a member of the household who was incarcerated, parental death/separation/or divorce, domestic violence, peer violence/bullying, witnessing community violence, and exposure to war/collective violence (WHO, 2018). Items were rated on the following scales: (yes/no), a 5-point Likert scale which ranged from 0 (never) to 5 (always), and a 4-point Likert scale which ranged from 0 (never) to 4 (many times) depending on the category of ACE assessed (WHO, 2018). A positive response for an ACE type was recorded if an individual responded any level of exposure for the item. The ACE-IQ score used in this study reflects the number of total ACEs each individual reported but did not account for level of exposure. The possible range of ACEs was 0 to 31. This is commonly used as a proxy for total exposure in other studies reporting ACEs exposure (Felitti et al., 1998). Internal consistency reliability was good (α =.87) in the current sample.

Acculturation Stress.

The Hispanic Stress Inventory 2 (HSI-2) - Immigrant Version was utilized to comprehensively measure acculturation stress (Cervantes et al., 2016). The HSI-2 assesses facets of acculturation stress in 10 distinct subscales: Parental Stress (13 items), Occupation and Economic Stress (12 items), Marital Stress (12 items), Discrimination Stress (11 items), Immigration-Related Stress (9 items), Marital Acculturation Gap Stress (9 items), Health Stress (8 items), Language-Related Stress (6 items), Pre-Migration Stress (6 items), and Family-Related Stress (5 items). If the participant reported they experienced the stressor in the past six months (yes/no), they were asked to rate how the stressor affected them using a 5-point Likert scale. The scale ranged from 1 (not at all worried/ tense) to 5 (extremely worried/tense) for each stressor (Cervantes et al., 2016). We utilized the total HSI-2 standardized t-score, and then used the interpersonally-based acculturation stress subscale standardized t-scores in our follow-up analyses (parental, marital, marital-acculturation gap, family-related stress). A standardized t-score of >60 indicated elevated acculturation stress. Previous reliability tests (Cronbach’s α =.97) demonstrate it is appropriate to use in Hispanic immigrants (Cervantes et al., 2016). In our sample, reliability was excellent (α =.96).

Depressive Symptoms.

The Patient Health Questionnaire (PHQ-9) was used to measure depressive symptoms within the prior 2 weeks through a nine-item scale (Kroenke et al., 2002). Items were rated using a 4-point Likert-scale ranging from 0 (not at all) to 3 (nearly every day). The PHQ-9 is acceptable to use among diverse populations, including Hispanic populations, in measuring depressive symptoms (Huang et al., 2006). The measure has good internal consistency in our sample (α = .86). A higher PHQ-9 score indicates greater depressive symptom severity. A score of 0 indicates no depressive symptoms and a score of 27 indicates high depressive symptoms. In this sample, depressive symptoms were positively skewed. We treated depressive symptoms as a count variable with negative binomial parameters to account for this skew.

Analysis Plan

To characterize the sample, we used Statistical Package for the Social Sciences (SPSS) Version 24 (IBM, 2016) to derive descriptives such as means and standard deviations for the demographics and key variables (Table 1 and 2). We also used SPSS to determine zero-order correlations among ACES, depression symptoms, and acculturation stress variables (Table 3). For mediation and moderation analyses detailed below, we utilized Mplus 8.4 (Muthen & Muthen, 2018).

Table 1.

Demographic Information of Study Sample

Variable	n	%	M	SD
Age	391		33.86	6.94
Sex: Female	269	68.80%	-	-
Male	122	31.20%
Marital Status	391		-	-
Single	90	23.00%
In a relationship, not legally married	108	27.60%
Married	172	44.00%
Divorced	8	2.00%
Separated	10	2.60%
Widowed	1	0.30%
Prefer not to answer	2	0.50%
Number of Children			-	-
No Children	115	29.40%
1	54	13.80%
2	101	25.80%
3	73	18.70%
4	31	7.90%
5 or more	17	4.30%
Country of origin			-	-
Mexico	211	54.0%
Honduras	42	10.70%
El Salvador	30	7.70%
Colombia	21	5.40%
Guatemala	18	4.60%
Peru	17	4.30%	-	-
Venezuela	15	3.80%
Puerto Rico	8	2.00%
Dominican Republic	8	2.00%
Costa Rica	4	1.00%
United States*	4	1.00%
Ecuador	4	1.00%	-	-
Cuba	3	0.80%
Argentina	3	0.80%
Nicaragua	2	0.50%
Uruguay	1	0.30%

^*Hispanic-identifying participants who were born in the United States were included if they had moved back to their country of heritage and re-migrated to the United States later.

Table 2.

Descriptive Statistics for Study Variables

Variable	n	%	M	SD	Min.	Max.
Depressive Symptoms (PHQ-9)
Minimal	214	54.7	6.06	4.59	0.00	20.00
Mild	111	28.4	18.74	4.44	5.00	27.00
Moderate	39	10.0	12.56	5.53	0.00	26.00
Moderately Severe	16	4.1	11.13	5.04	0.00	23.00
Severe	10	2.6	48.49	14.21	12.00	90.00
Total Score	390	--	5.25	4.84	0.00	25.00
Adverse Childhood Experiences (ACEs)
1 or more ACEs	386	98.7
4 or more ACEs	340	87.0
8 or more ACEs	247	63.2
12 or more ACEs	141	36.1
Number of ACEs Reported	391		10.07	5.92	0.00	30.00
Acculturation Stress (HSI-2)
Total Scale Score	383		55.44	11.55	42.29	98.66
Marital Stress	381		58.53	15.27	49.05	133.87
Marital Acculturation Gap	380		52.43	11.46	46.00	110.86
Parental Stress	378		50.10	8.46	45.51	106.70
Family Stress	391		56.18	12.73	43.33	97.01

Note. ACEs=Adverse Childhood Experiences; PHQ-9: Patient Health Questionnaire; Hispanic Stress Inventory (HSI)- Immigrant Version 2 t- scores

^*p < .05,

^**p < .01

Table 3.

Pearson correlations among demographics, acculturation stress, ACEs, and depressive symptoms

Variable	2	3	4	5	6	7	8	9
1. Age	−.003	−.094	−.183**	.066	.109*	.062	−.072	.276**
2. Sex	--	−.079	.077	.110*	.061	.041	.052	.172**
3. ACEs	--	--	.308**	.413**	.254**	.229**	.361**	.174**
4. PHQ-9	--	--	--	.489**	.367**	.277**	.530**	.107*
5. HSI total T-score	--	--	--	--	.603**	.606**	.772**	.446**
6.HSI marital stress T-score	--	--	--	--	--	.675**	.527**	.310**
7. HSI marital acculturation gap stress T-score score	--	--	--	--	--	--	.472**	.236**
8. HSI family stress T- score	--	--	--	--	--	--	--	.230**
9. HSI parental stress T-score	--	--	--	--	--	--	--	--

Note. N = 391; ACEs=Adverse Childhood Experiences; PHQ-9: Patient Health Questionnaire; HSI-Hispanic Stress Inventory-Immigrant Version 2 t-scores

^*p < .05,

^**p < .01

We took a two-phase approach to understanding direct and indirect relationships among ACES, depression symptoms, and acculturation stress variables. Age and gender were controlled for to account for recall bias as age increases, and gender, as previous studies suggest ACE exposure may vary with gender differences (Hunt et al., 2017; Strine et al., 2012).

For phase one, we tested for mediation using indirect effects (MacKinnon & Fairchild, 2009). Specifically, controlling for age and sex, we tested the indirect relationship from ACEs to the potential mediator, total acculturation stress (path a), and from total acculturation stress to the outcome depressive symptoms (path b). The indirect effect was defined by the product a×b, and a bootstrapped confidence interval that did not contain zero around this product indicated mediation (path c’). We repeated this process with each of the interpersonally-based subscales. Although testing mediation with cross-sectional data may be biased (e.g., Maxwell & Cole, 2007), we believe that the measures have an implied time frame with ACES during childhood, acculturation stress in the past six months, and depressive symptoms over the last two weeks, that mitigated, but did not eliminate the potential for bias.

In phase two, we created interaction terms between the independent variable (ACEs) and the moderator variables (acculturation stress scales) and tested for significant interaction effects on the outcome (depressive symptoms), while controlling for age and sex. We tested the total scale and subscale effects separately. Significance was set to p < .05. Standardized results are shown for the confidence intervals.

Results

Participant characteristics

The sample (N=391) had a mean age of 33.86 (SD=6.94; range 18–45) years. Female participants comprised the majority of our sample (68.60%; n=269). Individuals from Mexico were most commonly represented in our sample (54.0%, n=211), followed by Honduras (10.70%, n=42), El Salvador (7.70%, n=30), and Colombia (5.40%, n=21). A large percentage of our sample reported either being in a relationship (27.60%, n=108) or being married (44.00%, n=172). Most participants had at least one child (70.59%; n=276). ACEs were prevalent, with 98.70% (n=386) of individuals reporting at least one ACE category. The mean number of ACEs was 10.07 (SD =5.92). Depressive symptoms mean score was 5.23 (SD=4.83). Accordingly, most of the sample was categorized as having minimal to mild depressive symptoms (83.12%; n=325). Acculturation stress total mean t-score was 55.44 (SD = 11.55) indicating “non-elevated” scores for the entire sample. Interpersonally-based acculturation stress t-scores were highest in marital stress (M = 58.53; SD = 15.27) and family-related stress (M = 56.18; SD = 12.73) subscales, yet neither mean score was in the “elevated” range. Marital acculturation gap (M = 52.43 SD = 11.46) and parental stress (M = 50.10; SD = 8.46) subscales were the lowest, in the “non-elevated” range. Additional characteristics of the study sample are in Table 1 and 2.

Phase 1: Mediation

Total Acculturation Stress

ACEs were related to acculturation stress (b = .81, SE = 0.10, β = .41, p< .001, 95% CI [0.32, 0.50]) and depressive symptoms (b = 0.19, SE = 0.08, β = .23, p =.02, 95% CI [.05, 0.42]). Acculturation stress was also related to depressive symptoms, b = 0.33, SE = 0.04, β = .78, p< .001, 95% CI [0.64, 0.90]. There was a small, but significant indirect effect from ACES to acculturation stress to depressive symptoms, b = 0.26, SE = 0.04, p < .001, β = .19, 95%CI [0.14, 0.26], indicating partial mediation. Refer to Figure 1 for a graphic representation of these results.

Figure 1.

Statistical mediation models for phase 1: Total acculturation stress

Note. Age and sex not displayed; Standardized coefficients are displayed

* p<0.05; ** p<0.01

Acculturation Stress Subscale Mediation

ACEs were related to parenting stress, b = 0.25, SE = 0.07, β = .17, p = .001, 95%CI [0.07, 0.26], family stress, b = 0.78, SE = 0.11, β = .36, p < .001, 95%CI [0.27, 0.45], marital stress, b = 0.65, SE = 0.13, β = .25, p < .001, 95%CI [0.16, 0.33], and marital gap stress, b = 0.44, SE = 0.11, β = .23, p < .001, 95%CI [0.13, 0.32]. Depressive symptoms were related to family stress, b = 0.27, SE = 0.04, β = .72, p < .001, 95%CI [0.55, 0.85] and marital stress, b = 0.08, SE = 0.03, β = .26, p = .01, 95%CI [0.04, 0.44], but not parenting stress, b = 0.01, SE = 0.05, β = .02, p = .84, 95%CI [−0.14, 0.19] nor marital gap stress, b = −0.04, SE = 0.03, β = −.09, p = .26, 95%CI [−0.24, 0.06]. There were small, but significant indirect effects from ACEs to family stress to depressive symptoms, b = 0.21, SE = 0.04, β = .16, p < .001, 95%CI [0.11, 0.22] and from ACEs to marital stress to depressive symptoms, b = 0.05, SE = 0.02, β = .04, p = .01, 95%CI [0.01, 0.07], indicating partial mediation. No indirect effects were noted for parental stress to depressive symptoms, b = 0.003, SE = 0.01, β = .002, p =.83, 95%CI [−0.02, 0.02], and from ACEs to marital gap stress, b = −0.02, SE = 0.02, β = −.01, p = .27, 95%CI [−0.04, 0.01]. Refer to Figure 2 for a graphic representation of these results.

Figure 2.

Statistical mediation models for phase 1: Interpersonally-based acculturation stress

Note. Age and sex not displayed; Standardized coefficients are displayed

* p<0.05; ** p<0.01

Phase 2: Moderation

Total Acculturation Stress Moderation

When controlling for age and gender, ACEs (b = .23, SE = .08, β = .27, p =.002, 95%CI [.10, .44]) and total acculturation stress (b = .38, SE = 0.04, β = .88, p < .001, 95%CI [0.74, 1.01]) shared significant relationships to depressive symptoms. The interaction effect of ACEs and total acculturation stress was significant (b = −.18, SE = 0.05, β = −.31, p < .001, 95%CI [−0.47, −0.14]). Refer to Figure 3 for a graphic representation of these results.

Figure 3.

Statistical moderation models for phase 2: : Total acculturation stress

Note. Age and sex not displayed; Standardized coefficients are displayed; AS=Acculturation stress

* p<0.05; ** p<0.01

Acculturation Stress Subscale Moderation

Marital stress (b = 0.10, SE = 0.04, β = .29, p = .008, 95%CI [.08, .50]), familial stress (b = .26, SE = .04, β = .64, p < .001, 95%CI [0.48, 0.81] was significantly related to depressive symptoms when accounting for ACEs. Parental stress (b = 0.02, SE = 0.05, β = .03, p =.70, 95%CI [−0.14, 0.21]) and marital acculturation gap stress (b = −0.03, SE = 0.05, β = −.07, p =.52, 95%CI [−0.28, 0.14]) did not relate to depressive symptoms when accounting for ACEs. No significant interaction effects were noted for any interpersonally-based acculturation stressor: marital (b = −0.11, SE = 0.06, β = −.18, p =.08, 95%CI [−0.37, 0.02]), parental (b = −.13, SE = 0.08, β = −.13, p =.11, 95%CI [−0.30, 0.03]), familial (b = −0.03, SE = 0.06, β = −0.05, p =.56, 95%CI [−0.23, 0.13], or marital acculturation gap stress (b = 0.05, SE = 0.07, β = 0.07, p =.49, 95%CI [−0.13, 0.28]. Refer to Figure 4 for a graphic representation of these results.

Figure 4.

Statistical moderation models for phase 2: Interpersonally-based acculturation stress

Note. Age and sex not displayed; Results for individual subscales effect on depressive symptoms can be found in text; Standardized coefficients are displayed

** p<0.01

Discussion

This study explores the mediating and moderating effects of acculturation stress, specifically interpersonally-based acculturation stress, on the relationship between ACEs and depressive symptoms in a community-dwelling sample of young adult, Hispanic immigrants. No previous studies focus on understanding how acculturation stress, particularly interpersonal acculturation stress, helps explain why and under what conditions the relationship between ACEs and depressive symptoms exists in Hispanic immigrants residing in the southeast region of the US. We present four key findings from our study (a) ACEs are highly prevalent in young adult Hispanic immigrants, (b) ACEs, acculturation stress, interpersonally-based acculturation stress, and depressive symptoms are related to each other, (c) total acculturation stress, marital stress, and family stress help explain the pathway to depressive symptom development (d) acculturation stress moderates the relationship between ACES and depressive symptoms. We contextualize these findings with regard to exisiting literature and the Reserve Capacity Model below.

Dovetailing with the published literature on ACEs, our study found that ACEs are highly prevalent in young adult Hispanic immigrants – in the current sample 98.7% of participants reported at least one ACE and the mean number of ACES was approximately 10. The rates of childhood victimization identified within this sample are higher than those reported in US-representative samples (i.e., 74.9% of Hispanic immigrants in the SOL study; Llabre et al., 2017). We hypothesize, these trends are driven by a mostly female sample (68.80% in the current sample vs. 62.0% in the SOL study) as women have been noted to report higher rates of ACEs (e.g., sexual abuse, intimate partner violence) compared to men (Schilling et al., 2007). Second, our sample had a younger mean age than the SOL study (33.86 in the current sample vs. 40.0 in the SOL study), which may be less sensitive to recall bias and could result in a more accurate representation of ACEs for this group. Third, we utilized the ACE-IQ measure, which is a more comprehensive indicator of ACEs compared to the Adverse Childhood Experiences (ACE) scale (Felitti et al., 1998) utilized in the SOL study. The ACE-IQ measure is inclusive of political, war, and gang-related violence to capture trauma experiences that may occur more frequently in other countries, which can lead to a more accurate reporting of ACEs prevalence and a potentially larger number of ACEs reported. Thus, future studies may choose to use a more comprehensive measure, such as ACE-IQ, when accounting for ACEs in Hispanic immigrants.

Our study found significant relationships among ACEs, acculturation stress, interpersonally-based acculturation stress, and depressive symptoms. First, our findings coincide with the existing literature, which demonstrate associations among ACEs (Llabre et al., 2017), acculturation stress (Cervantes et al., 2016), and facets of interpersonally-based acculturation stress (Cervantes et al., 2016; Rivera et al., 2008) with depressive symptoms. Our results also indicated that as an individual’s exposure to ACEs increases, so do their chances of developing depressive symptoms – consistent with prior literature with non-immigrants (Nelson et al., 2017) and Hispanic immigrant groups (Kremer at al., 2019). Second, ACEs and interpersonally-based acculturation stress were significantly associated. These results are also consistent with previous research that found experiencing childhood trauma was associated with experiencing parenting stress (Steele et al., 2016), marital stress (Umberson et al., 2005), and family-related stress (Narayan et al., 2017) in adulthood. Our study extends these findings to the unique acculturation stress Hispanic immigrants experience in relation to parenting, marital, and family-related stress. Lastly, the findings from the present study support previously documented relationships between interpersonally-based aspects of acculturation stress, such as family-related stress (Rivera et al., 2008) and marital acculturation stress (Helms et al., 2014), and depressive symptoms among Hispanic immigrants. Our study extends these findings to Hispanic immigrants in the southeast and the unique interpersonally-based acculturation stress related to parenting and family stressors, that they encounter in the US.

Total acculturation stress, marital stress, and family stress help explain the pathway to depressive symptom development among Hispanic immigrants who report ACEs. First, these results are partially-supported by a previous study, where a higher number of ACEs was found to affect psychological health in relationship to increased adulthood general life stress among a representative US sample (Nurius et al., 2015). Our findings differ, as we utilized acculturation stress to capture the unique stress experienced by Hispanic immigrants. This distinction is an important one to consider, as a targeted account of stress experiences of Hispanic immigrants in the US, may provide a more accurate account of the pathways to depressive symptom development than those studies that utilize measures of general life stress. Thus, researchers and clinicians alike can provide a targeted assessment of stress and intervention to Hispanic immigrants who are at risk for depressive symptoms.

Total acculturation stress served as a moderator of the relationship between ACES and depressive symptoms, but specific interpersonal aspects of acculturation stress did not moderate this relationship. Our findings suggest total acculturation stress and ACEs independently increase depressive symptoms. However, the combined effect of acculturation stress and ACEs decrease depressive symptoms. There may be underlying protective features from acculturation stress that ultimately may have a more beneficial impact on depressive symptoms than the consequence of experiencing acculturation stress. These findings require further research to investigate underlying protective factors related to acculturation stress. For example, aspects of being a parent or having a partner may be protective for depressive symptoms but are not captured in our current study.

The moderating and mediating effects of interpersonal acculturation stress on the relationship of ACEs and depressive symptoms can also be interpreted in context of the Reserve Capacity Model (Gallo et al., 2009). As an individual is faced with increased stress (e.g. ACEs, acculturation), their “reserve capacity” may deplete and lead to adverse health outcomes like depressive symptoms (i.e. the Reserve Capacity Model; Gallo et al., 2009). Thus, our findings demonstrate the importance of considering multiple sources of culturally-relevant stress, such as interpersonal acculturation stress and ACEs, in the development of depressive symptoms among Hispanic immigrants.

Strengths and limitations

There are several limitations from the present study. First, our data rely on self-report measures which have an inherent risk of recall bias, thereby making accurate recall of past events difficult due to the retrospective nature of the data and time between the occurrence of ACEs and reporting of ACEs. Second, our measurement of ACEs also has limitations. For example, we report on prevalence of each ACE category occurrence, not for level of exposure. The ACE-IQ does not account for specific trauma related to the migration process, which may be particularly salient for immigrant populations resulting in increased reporting of ACEs. Furthermore, participants may have reservations sharing information regarding ACEs due to the stigma or sensitive nature of the questions. To reduce this risk, we offered participants the opportunity to answer questions on their own for this part of the questionnaire. Lastly, limitations exist when conducting moderation and mediation analyses with cross-sectional data.

Despite the aforementioned limitations, this study includes several strengths, such as community-based participatory research methods, sample of an understudied subset of Hispanic individuals in the US (i.e., southeastern US), and use of culturally-adapted measures. We also provide a contextually-rich examination of acculturation stress through the comprehensive measurement tool, the HSI-2, allowing for the specific examination of interpersonally-based acculturation stress.

Clinical and research implications

Findings from this study suggest ACEs may be higher in Hispanic immigrants than previously reported. Nurses providing care for Hispanic immigrants should consider ACEs and other trauma exposures during assessment and strategies for providing trauma-informed care to improve engagement in their mental wellbeing. As observed with the high number of ACEs reported in this study that may have resulted from using a more inclusive ACEs measure that captures experiences in other countries, it is important to use culturally and contextually appropriate measures to assess for ACEs. Nurses are uniquely suited to conduct these assessments, as the largest healthcare workforce in the US and are often the healthcare workers patients interact with and trust the most (Aiken, 2007; Riffkin, 2014). Equipping nurses with the knowledge to provide trauma-informed care to Hispanic immigrants is a practical consideration in working towards improving mental health treatment for Hispanic immigrants.

Furthermore, ACEs and acculturation stress have independent relationships with depressive symptoms. Therefore, positive screenings for depressive symptoms may be further informed by the assessment of ACEs and acculturation stress the individual has, so as to accurately target the roots of the present depressive symptoms. Clinicians working with Hispanic immigrants are encouraged to consider addressing acculturation stress in a comprehensive manner, including both interpersonally-based and other forms of acculturation stress, when working towards targeting depressive symptom development.

The recent Future of Nursing 2020–2030: Charting the Path to Achieve Health Equity report also calls on nurses to take an upstream approach to close the health disparities gap for underserved communities, such as Hispanic immigrants (Wakefield, Williams, Le Menestrel, Flaubert, 2021). The findings from our study inform how nurses and researchers can address socially and contextually-relevant stress and trauma before it results in the development of adverse mental health outcomes, such as depression. For example, those who are working with Hispanic immigrants may consider adding an assessment for acculturation stress, such as administering the Hispanic Stress Inventory- Immigrant Version 2 (Cervantes et al., 2016), to detect specific acculturation stressors and discussing culturally-relevant strategies to mitigate particular stressors with patients.

Future research will benefit from prospective longitudinal investigation of the effects of ACEs and acculturation stress on depressive examination of subsequent mental health outcomes (Schalinski et al., 2016; von Cheong et al., 2017). Since the marital and family stress subscales displayed significant mediation effects between ACEs and depressive symptoms, future research may seek to determine the specific aspects of marital and family stress contributing to depressive symptom development among Hispanic immigrants. Assessing ACEs should also move beyond prevalence of ACEs to a more detailed approach, accounting for ACE type, frequency of exposure, and age at which exposure occurred. Additionally, future investigations would benefit from assessing resilience processes (Cano et al., 2020), such as instrumental resources and social support networks, in conjunction with the relationships among ACEs, acculturation stress, and depressive symptoms.

Conclusion

The current study sheds light on the relationships between ACEs, acculturation stress, interpersonally-based acculturation stress, and depressive symptoms in Hispanic immigrants in the US. Our findings suggest ACEs are highly prevalent in Hispanic immigrants in the US and share a significant relationship with depressive symptoms. Acculturation stress and specifically marital and family acculturation stress are significant mediators in the relationship between ACEs and depressive symptoms, while total acculturation stress served as a moderator. Thus, prevention and treatment for depressive symptoms in Hispanic immigrants requires accounting for culturally-relevant stressors and provision of trauma-informed care.