The relationship between adverse childhood experiences and resilience among college students in Saudi arabia: a cross-sectional study

Abstract

Adverse childhood experiences (ACEs) are prevalent worldwide and affect health and the quality of life. The quality of resilience is known to help individuals cope with stress and adversities such as ACEs. ACEs and resilience have a negative correlation, but their relationship among college students remains unclear. This study aimed to examine the relationship between ACEs and resilience, with a specific focus on the impact of ACEs on resilience levels among individuals in Saudi Arabia. The study utilized a cross-sectional design and was conducted with 327 college students (51.4% male, 48.6% female; age range = 18–25) from two governmental universities in Riyadh Province. A convenience sampling method was used to collect information on the site using two main tools: the ACE Questionnaire and CD-RISC10. A t-test, ANOVA, and multiple linear regression were performed to examine the main aims of the study. The results showed a negative association between ACEs and resilience among college students. In other words, the resilience levels were lower among students with a higher prevalence of ACEs. The results also revealed that approximately 65% of the participating students reported at least one ACE, and approximately 32% reported four ACEs or more; emotional abuse was the most reported ACEs type. Additionally, the resilience scores in this study were relatively moderate, with a mean score of approximately 24 and a median of 25. College students are at risk of experiencing traumatic events. Examining college students’ health, specifically the consequences of past adversities on their mental health, is needed. This is because college students endeavor to identify their life roles and make important decisions regarding their future.

Introduction

Adverse childhood experiences (ACEs) are events that occur before the age of 18, which include a variety of adversities that cause stress during childhood^1–3. ACEs include, but not limited to, different types of abuse, household dysfunction, neglect, and violence^4–6. They are related to physiological, psychological, and behavioral consequences⁷. ACEs hinder emotional development and heighten susceptibility to mental health disorders throughout life that can modify stress management systems and affecting emotional processing. They cause stress and trauma during childhood, and contribute to an elevated risk of negative health outcomes throughout the course of life^8–11. ACEs also have long-term consequences, including depression, anxiety, and emotional dysregulation, underscoring their lasting influence on psychological well-being¹². Whereas positive childhood experiences have a protective role in fostering psychological resilience and mitigating the risk of mental health issues. For instance, protective contextual elements such as supportive familial relationships and pleasant peer interactions, augment self-esteem and cultivate resilience in university students¹³. In addition, positive childhood experiences have a substantial inverse relationship with symptoms of depression and anxiety in adulthood¹⁴. Indeed, it is significant to evaluate both negative and good early life events in the investigation of psychological outcomes, as they jointly influence emotional development and mental health across the lifespan¹⁵.

Globally, approximately 40% of the population are exposed to ACEs, which are associated with nearly 30% of mental health disorders^9,16. The prevalence of ACEs varies widely and may be influenced by diverse cultural, social, environmental, and economic factors that impact individuals’ health globally. Notably, developing countries report significantly higher rates of ACEs compared to developed countries¹⁷. For example, a study conducted among Palestinian pregnant women revealed that approximately 88% experienced at least one form of ACE and 4 or more ACEs¹⁸, and another study among medical students in Iraq reported that approximately 72% experienced at least one form of ACEs^19,20.a developing country with cultural and traditional norms reflective of countries in the middle east, women reported lower prevalence of ACEs compared to men²⁰.

The cumulative effect of ACEs can significantly increase the risk of chronic medical disorders including obesity, diabetes, and heart disease. Psychologically, those who have had ACEs could be more likely to have depression, anxiety, PTSD, or another mental illness⁷. ACEs are linked, behaviorally, to dangerous health practices like poor eating, smoking, drug misuse, and unsafe sexual activity²¹. Moreover, ACEs affect social contacts, employment stability, and school performance, so transcending health. With consequences for public health, social services, educational systems, and the economy, ACEs have a significant long-term social burden²². Although excessive exposure to ACEs is clearly associated with negative health consequences, many individuals do not experience long-term negative health issues but demonstrate resilience instead. They are able to recover from adverse and stressful events^23–25.

Resilience is broadly characterized as the ability to adapt positively and maintain mental health in the face of adversities. It is a dynamic process involving the use of psychological, social, cultural, and physical resources to manage stress and maintain well-being^26–28. Operationally, resilience reflects individuals’ perceptions of their ability to cope with and recover from challenges. Connor and Davidson (2003) emphasized the role of internal resources such as self-esteem, problem-solving, and stress management in overcoming adverse events. This multifaceted concept encapsulates the capacity to navigate and adapt to life’s challenges effectively^29,30.

Resilience affects not only how people react to transient pressures but also supports long-term psychological development and life satisfaction. Particularly in populations under great stress, such as those with negative childhood events, it acts as a protective element that can help to prevent mental health problems³¹. Resilience also depends critically on social support systems, cultural values, and mental health resource access. Additionally, resilience is not a fixed quality but rather one that one may develop over time by means of deliberate activities including mindfulness, cognitive-behavioral techniques, and encouraging surroundings³². Therefore, Designing appropriate treatments, particularly in educational and therapeutic environments, depends on an awareness of the processes and elements that support resilience thereby enabling people to flourish despite hardship.

Correlations between ACEs and resilience have been discovered; however, they have been investigated differently across studies. For example, resilience has been examined as an influencer on ACEs, as an outcome in relation to ACEs, and as a moderator between ACEs and health-related outcomes. In line with the purpose of this study, most studies have reported negative or inverse correlation between ACEs and resilience^33–35. For example, an inverse correlation in a dose-dependent manner was reported among adult women in Iceland³³. Similar results were reported in a study conducted among college students in China³⁶.

College students undergo a pivotal phase of life characterized by significant psychological, academic, and social transitions, making them particularly susceptible to traumatic and adverse experiences. This stage is marked by efforts to achieve independence, develop individuality, and define future life roles and interests³⁷. For many, these challenges are further compounded by ACEs, which are associated with long-term negative outcomes, including mental health issues, impaired coping mechanisms, and difficulties in adapting to stressors⁷.

While the literature highlights a negative and inverse relationship between ACEs and resilience³⁴, research exploring this relationship in Saudi Arabia is limited, and no studies have specifically focused on college students. Moreover, the interaction between ACEs and the unique stressors faced by college students—such as academic pressures, financial burdens, and social isolation—warrants further investigation. Understanding this relationship is crucial, as college students represent a distinct and significant cohort within the public health domain. Addressing their needs requires a nuanced understanding of how ACEs can undermine resilience and exacerbate vulnerabilities during this critical developmental stage. Therefore, this study aimed to examine the relationship between ACEs and resilience, with a specific focus on the impact of ACEs on resilience levels among college students in Saudi Arabia. Other objectives include examining the prevalence of ACEs and resilience, as well as their variations in response to demographic factors.

Methods

Study design

The study utilized a cross-sectional design.

Setting and participants

This study was conducted at two government universities in the Riyadh Province, Saudi Arabia. The two universities have different structures: one is among the first universities in Saudi Arabia, while the other is a young university. In addition, the two universities differ in their geographical locations: one is located in an urban area, whereas the other is rurally located. The participants consisted of 327 college students from two universities, exceeding the calculated desired sample size. This study utilized various statistical tests to examine its aims, and the most stringent test was selected to determine the estimated sample size using G*Power 3.1. Accordingly, the following parameters were applied: an alpha (α) level of 0.05, a power of 0.95, and a medium effect size (Cohen’s f²) of 0.25. Based on these parameters, the desired sample size for this study was calculated to be 305.

While participating students enrolled in traditional undergraduate programs pursuing different majors, most were enrolled in nursing programs. The participating students were present on-site during the data collection period. This study targeted students currently enrolled in traditional undergraduate programs, particularly those aged between 18 and 25 years. Consequently, students older than 25, those holding associate or diploma degrees and bridging to a baccalaureate degree, and students who did not wish to participate were excluded from the study. The STrengthening of the Reporting of OBservational studies in Epidemiology (STROBE) checklist was used to report the study.

Measurements

Demographic questions

The demographic questions in this study included four questions on age, sex (male or female), area of residence during childhood (rural, suburban, or urban), and university major (nursing, other health, science, or humanities majors).

Adverse childhood experience (ACE) questionnaire

The ACE Questionnaire used in this study comprises 19 items and is self-reported to measure exposure to ACEs before the age of 18 years^38,39. The original version of this questionnaire was developed by Dube et al. (2004)⁴⁰ and comprised 10 items. Later, Kalmakis et al. (2018)³⁸ adapted this questionnaire to include 19 items without major changes to the original version, except for splitting some of the original items and itemizing them separately. The adapted questionnaire includes six items on physical, emotional, and sexual abuse; four items on neglect; and nine items on household dysfunction. All items have dichotomous (yes or no) outcomes. The scores are summed to obtain a total score ranging from 0 to 19. This is an example of an ACE Questionnaire item: “prior to your 18th birthday, did a parent or other adult in the household swear at you, insult you, put you down, or humiliate you”.

The Arabic version of the 19-item ACE Questionnaire was used in this study. The Arabic version of the ACE Questionnaire was translated by Alhowaymel and Alenezi (2022)³⁹. The original ACE Questionnaire had adequate test–retest reliability (r =.64, p <.001)⁴⁰ and (r =.71, p <.001)⁴¹. The internal consistency reliability of the adapted 19-item ACE Questionnaire was acceptable (α = 0.835)³⁸. The Arabic version of the 19-item ACE Questionnaire has acceptable internal consistency and reliability (α = 0.864)³⁹. In this study, the 19-item ACE Questionnaire-Arabic version demonstrated acceptable internal consistency and reliability (α = 0.864).

Connor-davidson resilience scale 10 (CD-RISC 10)

The CD-RISC 10 is self-reported, comprises 10 items, and is designed to measure the ability to tolerate and bounce back from negative experiences over the last month. The CD-RISC-10 is a shorter version adapted by Campbell-Sills and Stein (2007)²⁹ from the original 25-item version of CD-RISC that was developed by Connor and Davidson (2003)³⁰. The CD-RISC 10 is a 5-point Likert-type scale (0 = ‘not true at all’ to 4 = ‘true nearly all the time’), where high scores indicate an individual’s ability to bounce back from negative experiences. The following is an example of an item from the CD-RISC 10: “I try to see the humorous side of things when I am faced with problems.”

The Arabic version of the CD-RISC-10 was used in this study. The translation and psychometric analysis of the Arabic version of the CD-RISC 10 were conducted by Toma et al. (2017)⁴². The internal consistency reliability of the original CD-RISC 25 and shorter version CD-RISC-10 was acceptable (α = 0.89 and α = 0.85, respectively)^29,30. In this study, the CD-RISC 10-Arabic showed acceptable internal consistency reliability (α = 0.864).

Data collection

A non-probability convenience sampling technique was used to recruit participants. Data collectors, including faculty members and graduate students who voluntarily participated in the data collection process, attended the university sites for two days at each location. Students were invited to participate through flyers that included the study description, locations, and timing of data collection. Once they agreed to participate, eligible students scanned a quick response (QR) code using their cellphones and began answering the questionnaire online. The participating students filled out demographic information and then proceeded to answer the main questions. The data collection phase was conducted during February 2022.

Ethical consideration

The design and data collection for this study were approved by the Standing Research Ethics Committee of Shaqra University (ERC# ERC_SU_20210051). Informed consent was obtained from the participants. This study was conducted in accordance with the guidelines of the Declaration of Helsinki. For transparency, the participating students were made aware of the aims of the study. They were also made aware of their right to withdraw from the study at any time without any consequences. To maintain full privacy and confidentiality, data collectors did not obtain identifiers or personal information for personal privacy or to protect participants’ information. The study data were stored on the investigator’s personal computer.

Data analysis

The Statistical Package for Social Sciences (SPSS) version 28 was used for the analysis. Descriptive statistics for demographic information, ACEs, and resilience were calculated to determine means, standard deviations, frequencies, and percentages. An independent sample t-test and one-way analysis of variance (ANOVA) were performed to compare and determine differences in ACEs and resilience based on the participants’ demographic characteristics. Additionally, multiple linear regression analysis was performed to examine the relationship between ACEs and resilience in two steps. In the first step, only ACEs and resilience were entered. In the second step, possible confounding variables were entered to assess their impact on resilience and whether they influenced the relationship in the first step. For this analysis, dummy variables were created for the confounding variables to meaningfully perform the analysis. The alpha level of ≤ 0.05 was used to determine statistical significance.

Results

Demographic characteristics of participants

Table 1 presents the sample characteristics. The average age of the participants was 20.7 (SD = 2.3), range from to 18–25 years. The participating students were relatively equal in terms of sex (51.4% male, 48.6% female). Most participating students resided in suburban areas during their childhood (41.6%), and the majority were enrolled in nursing programs (53.2%).

Table 1.

Descriptive characteristics of participants (N = 327).

Variables	N	%
Age (Range = 18–25; Mean = 20.7; Std. Dev. = 1.47)	260
Sex	327
Male		51.4
Female		48.6
Area of residence during childhood	327
Rural		21.4
Suburban		41.6
Urban		37.0
University major	327
Nursing		53.2
Other health majors		5.2
Other scientific majors		11.9
Humanities		29.7

Prevalence of aces and resilience among college students

Table 2 shows the prevalence of ACEs and resilience among the participating students. The mean ACEs score was 2.93. Additionally, the results show that 65.1% of the participating students reported at least one ACE, and 31.8% reported four or more ACEs. The highest reported form of ACEs was emotional abuse (43.43%) and the lowest was sexual abuse (15.29%). The mean resilience score was 24.32, (median score was 25), the lowest quartile (i.e., 1–25% of students) scored between 0 and 20, and the top quartile (i.e., 76–100%) scored between 30 and 40.

Table 2.

Prevalence of aces and resilience (N = 327).

Variables	%	Mean	SD
ACEs score (Range 0–19)		2.93	3.54
0 ACEs	34.9
1 ACE	14.1
2 ACEs	10.4
3 ACEs	8.9
4 + ACEs	31.8
Emotional abuse	43.43
Physical abuse	40.37
Sexual abuse	15.29
Neglect	36.70
Family dysfunction	34.86
Variables	Score range	Mean	SD	Median
Resilience score	0–40	24.32	7.07	25
Q1 – (1–25%)	0–20
Q2 – (26–50%)	21–24
Q3 – (51–75%)	25–29
Q4 – (76–100%)	30–40

The associations between aces, resilience, and participants’ demographic characteristics

Independent sample t-tests and ANOVA were performed to determine the mean differences in ACEs and resilience in relation to participants’ demographic characteristics. In addition, the mean difference in resilience in relation to ACEs was determined by comparing those who experienced ACEs to those who did not. The results showed no statistically significant differences in ACEs scores in relation to any of the demographic characteristics. However, there was a statistically significant difference in resilience scores in relation to students’ sex (t (325) = 1.73, p <.05). Male students had higher positive resilience scores (M = 24.98, SD = 7.22) than female students (M = 23.63, SD = 6.85) did. Additionally, when comparing students who reported ACEs to those who did not, in terms of resilience, the results showed that their resilience scores were significantly different (t (325) = 2.47, p <.01). Those who had not experienced ACEs had higher positive resilience scores (M = 25.63, SD = 7.58) than those who had experienced ACEs (M = 23.62, SD = 6.69) (Table 3).

Table 3.

Associations between aces, resilience, and participants’ demographic characteristics (N = 327).

Demographics	ACEs				Resilience
	N	M (SD)	t/F	p	N	M (SD)	t/F	p
Sex			0.82	0.206			1.73	0.042*
Male	168	3.09 (3.77)			168	24.98 (7.22)
Female	159	2.77 (3.29)			159	23.63 (6.85)
Area of residence during Childhood			0.69	0.502			2.47	0.086
Rural	70	2.58 (3.73)			70	22.73 (8.17)
Suburban	136	2.87 (3.44)			136	24.50 (6.79)
Urban	121	3.20 (3.56)			121	25.04 (6.59)
University major			1.09	0.354			0.941	0.421
Nursing	174	2.97 (3.48)			174	24.67 (6.62)
Other health majors	17	1.47 (2.50)			17	26.18 (6.92)
Other scientific majors	39	3.26 (4.09)			39	23.69 (9.05)
Humanities	97	2.99 (3.58)			97	23.63 (6.99)
ACEs							2.47	0.007**
No ACEs					114	25.63 (7.58)
Had ACEs					213	23.62 (6.69)

* = p <.05; ** p <.01.

Hierarchical linear regression analysis was conducted to predict resilience. In the first step, ACEs were entered as the predictor variable. In the second step, ACEs, sex, area of residence during childhood, and university major were included. In the third step, the interaction variables of ACEs with the demographic variables were added.

The results of the first model revealed that ACEs significantly and negatively predicted resilience (F¹ = 9.15, R² = 0.027, p <.01]). This result indicates that for each one-unit increase in ACEs, there was a decrease in the resilience score of 0.330. Although the R² value indicates a small effect size, it suggests that ACEs account for a meaningful portion of the variance in resilience scores. When the possible confounding variables were entered in the second model, ACEs remained statistically significant and negatively predicted resilience (F⁴ = 3.49, R² = 0.042, p <.01]), with a slightly greater contribution. Specifically, for each one-unit increase in ACEs, there was a decrease in the resilience score of 0.343. The R² value in this model also reflects a small but notable practical effect, supporting the importance of ACEs in influencing resilience even after controlling for demographic factors (Table 4).

Table 4.

Hierarchical linear regression analysis predicting resilience from aces, demographic variables, and interaction effects (N = 327).

Variable	CDRISC
	Step 1			Step 2			Step 3
	Ba	b	p	Ba	b	p	Ba	b	p
ACEs	-.330	-.165	.003**	-.343	-.172	.002**	-.396	-.199	.040*
Sex (female/male)	-	-	-	1.117	.079	.220	.971	.069	.287
Area of residence during Childhood (non-urban/urban)	-	-	-	.595	.041	.530	.608	.042	.522
University Major (other majors/nursing)	-	-	-	.633	.045	.416	.681	.048	.383
ACEs*sex	-	-	-	-	-	-	-.322	-.123	.214
ACEs*residence	-	-	-	-	-	-	.220	.068	.409
ACEs*major	-	-	-	-	-	-	.311	.111	.161
Model Summary	F (1) = 9.15 R2 = .027; p = .003*			F (4) = 3.49 R2 = .042; p = .008*			F (7) = 2.58 R2 = .053; p = .014*

^a = Unstandardized coefficients; ^b = Standardized coefficients; * = p <.05; ** = p <.01.

In the third model, which included the interaction variables of ACEs with the demographic variables, ACEs continued to significantly and negatively predict resilience (F⁴ = 2.58, R² = 0.053, p <.05]). However, neither the confounding variables nor the interaction terms significantly predicted resilience, indicating that no demographic variables moderated the relationship between ACEs and resilience. While the increase in R² was modest, it still indicates a consistent and practically relevant negative association between ACEs and resilience (Table 4). Additionally, a visual inspection of the regression line (Fig. 1) illustrates the direction of the relationship between ACEs and resilience. The line clearly shows a decrease in resilience scores with increased exposure to ACEs.

Fig. 1.

ACEs and resilience.

Discussion

This study examined the prevalence of ACEs, resilience, and the relationship between them among college students in Riyadh, Saudi Arabia. Our results revealed a negative association between ACEs and resilience among college students. In other words, the resilience levels were lower among students with a higher prevalence of ACEs. This result is consistent with a recent systematic review and meta-analysis that synthesized the current knowledge on the relationship between ACEs and resilience in youth³⁴. All nine studies included in this review reported a negative association, except for one. Similar to our study, two studies conducted among over 500 college students in Eretria⁴³, and among over 1,800 college students in China³⁶ found a negative relationship between ACEs and resilience. This result supports the evidence of the life-course effect of ACEs on health and that ACEs are risk factors to well-being. When interpreting these results, it is important to note that ACEs consistently and significantly negatively predicted resilience across all three models, though with modest coefficients. The influence was greater when demographic variables were added and smaller when interaction variables were introduced. The low R² values suggest that other important predictors of resilience may not have been included and should be explored in future research.

Another result from our study showed that approximately 65% of the participating students reported at least one ACE, and approximately 32% reported four ACEs or more; emotional abuse was the most reported form of ACEs. This result is similar to those of most studies conducted in Saudi Arabia. For example, a study conducted in the rural areas of the Riyadh Province in Saudi Arabia showed that approximately 68% of participants reported at least one ACE, and 34% reported four or more ACEs³⁹. Another study conducted among patients with irritable bowel syndrome in Saudi Arabia found that approximately 63% of patients had at least one ACE⁴⁴. However, this result is lower than that of a national study conducted in Saudi Arabia, which reported that approximately 81% of participants reported at least one ACE, and 29% reported four or more ACEs⁴⁵. Generally, developing countries have higher rates of ACEs than developed countries¹⁷. For instance, a study conducted among Palestinian pregnant women revealed that 88% experienced at least one form of ACE¹⁸, and another study among medical students in Iraq reported that approximately 72% experienced at least one form of ACEs¹⁹. It is important to note that no significant differences were found in ACE scores across demographic variables such as sex, area of residence during childhood, or university major. This suggests that ACEs are relatively evenly distributed in this sample, which enhances the generalizability of ACEs as a measure across various groups.

In this study, the resilience score was relatively moderate, with a mean of approximately 24 and median of 25. This result is similar to those of other studies on Saudi Arabia conducted among critical care nurses during COVID-19⁴⁶, and healthcare professionals⁴⁷. College students may be able to bounce back and recover from difficulties. Similar to ACEs scores, no significant differences were found in resilience scores except for sex, with male students reporting higher resilience scores than females. This finding could reflect gender-related differences in coping strategies, societal expectations, or emotional expression, which should be explored further in future research.

College students face unique transitional challenges, such as identity development, academic pressures, and shifting life roles, which may interact with ACEs and resilience. Understanding how these stressors influence resilience could provide valuable insights into the relationship between past adversities and current well-being. This study provides evidence for healthcare practitioners, including nurses, regarding the importance of early screening and identifying adversities in enhancing the future health of individuals. Practitioners, especially in Saudi Arabia, can utilize these findings to advocate for increased engagement in screening for ACEs by implementing a care approach such as trauma-informed care. Additionally, they can actively inquire about significant life events experienced by their patients, particularly during their younger years. By doing so, practitioners can assist in detecting life-threatening events and taking appropriate action accordingly. It is essential to evaluate both negative and positive early life events when analyzing childhood experiences in relation to psychological and health outcomes, as both collectively influence emotional development and mental health throughout the lifespan.

Limitations of the study

This study has some limitations. The study was conducted in a particular region of Saudi Arabia and included college students from two universities in the Riyadh Province. This limits the generalizability of our results. In Addition, this study used self-report measures that could introduce intentional or unintentional reporting errors. Cultural factors may also influence the reporting of ACEs, along with the possibility of social desirability bias, wherein participants may underreport ACEs to present themselves in a more favorable light. These elements should be considered when discussing the implications and limitations of the research, as they could affect the accuracy and completeness of self-reported data. Moreover, this is a cross-sectional study and could only examine associative relationships, not a temporal sequence between variables of interest. Having a more representative sample, incorporating additional direct measures, and utilizing a longitudinal design that accounts for potential influencing factors on reporting would help overcome these limitations. Despite these limitations, this study was the first to examine the relationship between ACEs and resilience among college students in Saudi Arabia. This study establishes a basis for future studies in the country to enabling researchers to further examine these two variables among this population.

Conclusion

This study examined the relationship between ACEs and resilience among college students in Saudi Arabia. The results support existing evidence on the negative relationship between ACEs and resilience, where students with a greater prevalence of ACEs reported lower levels of resilience. Educators, researchers, and other relevant legislators should further investigate issues related to college students such as experiences of ACEs to improve their health and future. Greater effort should be undertaken to identify ACEs at an early age and offer solutions. For example, trauma-informed care can provide helpful resources to traumatized individuals, including college students. This approach should be implemented effectively, particularly in developing countries.

Author contributions

F.A conceptualized the study, collected, organized, and analyzed the data, and wrote the manuscript.

Funding

This research has received no specific funding.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The design and data collection for this study were approved by the Standing Research Ethics Committee of Shaqra University (ERC# ERC_SU_20210051). All participants signed an online consent form once they agree to participate in the study and before proceeding to complete the survey. For transparency, the participating students were made aware of the aims of the study. They were also made aware of their right to withdraw from the study at any time without any consequences. To maintain full privacy and confidentiality, data collectors did not obtain identifiers or personal information for personal privacy or to protect participants’ information. The study data were stored on the investigator’s personal computer.

Competing interests

The authors declare no competing interests.