Abstract
Background
Adverse childhood experiences (ACEs) are associated with adverse physical and mental health outcomes and may influence the development of empathy. Although previous studies have reported inconsistent relationships between ACEs and empathy, this association has not been examined among university students in Saudi Arabia.
Objective
To examine the association between adverse childhood experiences (ACEs) and the development and expression of empathy among students at King Abdulaziz University, Jeddah.
Methods
A cross-sectional study was conducted among 1,693 students aged 18–30 years at King Abdulaziz University using an Arabic questionnaire that included socio-demographic characteristics, the Adverse Childhood Experiences questionnaire, and the Interpersonal Reactivity Index (IRI). Data were analyzed using Pearson’s correlation, analysis of variance (ANOVA) with post hoc tests, and a General Linear Model. Internal consistency was evaluated using Cronbach’s alpha.
Results
The mean ACE score was 3.23 ± 2.5. Students in the high-risk ACE group demonstrated significantly higher scores in Perspective-Taking (16.49 ± 4.8), Fantasy (17.49 ± 5.7), Empathic Concern (19.21 ± 4.5), and Personal Distress (15.27 ± 4.8) compared with low-risk participants (all p < 0.001). ACE scores showed weak to moderate positive correlations with all IRI domains (r = 0.111–0.252, p < 0.001). Variables significantly associated with higher ACE risk included income level, Perspective‑Taking, Fantasy, and Personal Distress.
Conclusion
Higher ACE exposure was associated with increased empathy, particularly in Perspective-Taking and Personal Distress, indicating both adaptive empathic abilities and heightened emotional burden. The present study underscores the importance of addressing ACEs within public health and educational strategies.
Keywords: Adverse Childhood Experiences, Empathy, Interpersonal Reactivity Index, University Students, Saudi Arabia
Introduction
Empathy is a multidimensional construct relevant across psychology, psychiatry, neuroscience, and other scientific disciplines. Empathy is essential for social activity as it allows us to feel and react to the feelings of others in a socially appropriate manner. Empathy is a social and interpersonal capacity that should be understood independently from its therapeutic applications. It reflects a temporary ability to understand and share another person’s experience, while effective engagement in therapy is also about responding to the person’s experience, emotion regulation, empathetic responding with responsiveness and awareness that takes place at various work areas. Empathy is not the feeling of someone else’s emotions without reason, but engagement with one’s self emotionally and cognitively. Generally, empathy has been defined into emotional, cognitive, and motivational dimensions in the management of sophisticated social processes [9].
Adverse childhood experiences (ACEs) are long-recognized as significant risk factors for adverse physical and mental health outcomes in adulthood [10]. Survivors of abuse, neglect or household dysfunction may be disrupted emotionally from early on, and may also develop empathy deficits. Low levels of empathy have been associated with childhood neglect and inadequate caregiving, both of which are factors that are also related to depressive symptoms in adolescence [5, 6]. Empirical evidence also indicates that individuals with experiences of childhood abuse may have lower empathic capacity on the one hand and greater maladaptive or antisocial tendencies on the other [17]. However, it is important to note that although family environments strongly influence empathic development, there are also genetic and temperamental approaches that could influence empathic concern and prosocial behavior [3].
Per the World Health Organization (WHO), childhood maltreatment includes all types of physical and emotional abuse, emotional neglect, and exploitation and neglect of persons younger than 18 years. These experiences may have a damaging impact upon a child’s health, development, dignity and overall well-being, especially when they take place in relationships based on trust, control or responsibility [15].
Multiple studies have shown a negative correlation between ACEs and empathy. In one Ugandan research, higher ACE exposure and depressive symptoms and suicidal ideation were related [16], and lower levels of empathy were noted between people with higher ACE scores [22]. It was found that in Korea childhood maltreatment was negatively associated with emotional empathy, according to a study by Lee et al., [13]. In this study, we found significant long-lasting effects of early adversity on emotional regulation and social cognition. A report conducted at Gannan Medical University found that medical students exposed to childhood trauma showed lower degrees of empathy among university populations, and that belief in a just world could mediate the effect. Empathy can benefit from targeted educational approaches, focusing on communication skills, trust-building and ethical values, especially amongst trauma backgrounds [21]. However, this research was conducted among premedical students and so generalization of the findings was limited.
Studies with people working in adulthood have also attached childhood adversity to difficulty in emotional processing. A Portuguese research among social workers identified that victims of violence exposure were exposed to such forms of violence more frequently including emotional abuse. Emotional neglect, along with family instability in the form of violence and divorce, emerged as robust predictors of alexithymia, a condition characterised by impaired capacity to name and articulate emotions [4]. Nonetheless, the small sample, including predominantly female participants, precludes generalization.
In contrast to these findings, some multi-sample studies suggest that individuals with extensive childhood trauma may exhibit heightened empathy in certain contexts. It may be reflected in the observed paradox that people are more in tune with others’ emotions following personal suffering. But the results are mostly based on self-report measures and need to be cross-validated by employing objective and longitudinal research modalities in heterogeneous groups of participants [11].
Saudi Arabia has a well-known and alarming prevalence of ACEs, as reported in some researches. More than half of adult participants exposed themselves to one or more forms of ACE, with emotional abuse most reported as ACE [1]. Their findings emphasize the need to investigate the psychological and social consequences of childhood adversity for individuals in this subcontinent’s young adults. No systematic study has studied the link between ACEs and forming and expressing empathy in Saudi Arabia to date. Thus, this cross-sectional research aims to investigate the influence of adverse childhood experiences on empathy among university students in Saudi Arabia.
Methods
Study design and participants
This cross-sectional questionnaire-based study employed a convenience sampling technique and included students from King Abdulaziz University, Jeddah, Saudi Arabia. Data were collected during the month of December 2024 using a self-administered electronic questionnaire distributed through official university email platforms. The survey was distributed to all university students, totaling 86,883 recipients. A total of 2,033 submissions were received. 1,693 students completed the questionnaire, yielding a response rate of 83.2% and considered for final data analaysis after applying inclusion and data-quality criteria. The remaining questionnaires were excluded due to incomplete responses or non-submission.
Participants were recruited from multiple academic faculties, including health sciences, engineering, science, humanities, business, and other university colleges, to ensure broad academic representation. Participation was voluntary, and confidentiality and anonymity were assured. An electronic informed consent form was provided at the beginning of the questionnaire.
Individuals younger than 18 years were excluded. Questionnaires with missing or incomplete responses were excluded using listwise deletion, resulting in a final analytic sample of 1,693 participants.
Questionnaire
Participants completed a questionnaire comprising three parts:
Socio-demographic data
Data related to age, gender, marital status, nationality, monthly income, academic performance, and college were collected.
Adverse childhood experiences (ACEs) questionnaire
The ACE questionnaire for adults was originally developed through the collaborative efforts of Kaiser Permanente and the Centers for Disease Control and Prevention (CDC) and is publicly available. The adult screening tool used in this study was adapted by the Office of the California Surgeon General and the California Department of Health Care Services, in collaboration with the California Surgeon General’s Clinical Advisory Subcommittee. The questionnaire is in the public domain and does not require permission for research use. An Arabic version of the ACE questionnaire was obtained from the ACEs Aware initiative [2].
The ACE questionnaire is a 10-item instrument that assesses exposure to adverse or traumatic experiences occurring before the age of 18 years, including physical, sexual, and psychological abuse, as well as household dysfunction such as substance use, incarceration, and domestic violence. Each item is scored as 1 (yes) or 0 (no), yielding a total score ranging from 0 to 10, with higher scores indicating greater exposure to adverse childhood experiences.
Interpersonal reactivity index (IRI)
The Interpersonal Reactivity Index, developed by Davis, is a 28-item self-report measure of empathy rated on a 5-point Likert scale ranging from “Does not describe me well” to “Describes me very well.” The theoretical framework underlying the IRI was first described by Davis [7], while the finalized scale and its psychometric properties were reported in Davis [8]. The IRI is publicly available and may be used for academic research without requiring formal permission from the author.
An Arabic version of the IRI was prepared using a forward–backward translation technique. It comprises four subscales consisting of seven items:
Perspective Taking
Fantasy
Empathic Concern
Personal Distress
Each item is scored from 0 to 4, with subscale scores ranging from 0 to 28.
Statistical analysis
Data were analyzed using IBM SPSS version 27 (IBM Corp., Armonk, NY, USA). Descriptive statistics summarized participant demographics and study variables. Categorical variables were reported as frequencies and percentages, while continuous variables were reported as means and standard deviations.
Reliability analysis: Cronbach’s alpha was calculated to assess internal consistency.
Inferential statistics:
Pearson’s correlation coefficient was used to examine relationships between ACE scores and the four IRI subscales.
One-way ANOVA was used to examine differences in IRI scores across ACE risk categories, with the Least Significant Difference (LSD) post-hoc test applied when homogeneity was met. When heterogeneity was present, the Games-Howell test was used.
A General Linear Model (GLM) was used to examine factors associated with ACE risk, incorporating gender, monthly income, GPA, and IRI domains as independent variables. Statistical significance was set at p < 0.05. Assumptions of normality and homoscedasticity were verified prior to conducting parametric tests. Ethical approval was obtained from the appropriate Research Ethics Committee (Institutional Review Board (IRB) of King Abdulaziz University, Jeddah, Saudi Arabia - Reference No: 173 − 24).
Results
The study included 1,693 participants aged 18 to 30 years (mean age 22.03 ± 3.4). Most were women (71.2%), single (89.1%), and Saudi nationals (93.7%). Monthly income varied, with 39.8% earning less than 10,000 SAR. Academic performance was evenly distributed, with 47.3% of students reporting a GPA of 4.5–5.0 on a five-point grading scale used at King Abdulaziz University, where 5.0 indicates excellent academic performance. The participant demographics are shown in Table 1.
Table 1.
Sociodemographic characteristics of the included students (N = 1693)
| Demographics | N | Min | Max | Mean | SD |
|---|---|---|---|---|---|
| Age (years) | 1693 | 18 | 30 | 22.03 | 3.4 |
| Count | % | ||||
| Total | 1693 | 100.0 | |||
| Sex | Male | 488 | 28.8 | ||
| Female | 1205 | 71.2 | |||
| Marital status | Single | 1509 | 89.1 | ||
| Married | 160 | 9.5 | |||
| Divorced | 24 | 1.4 | |||
| Nationality | Saudi | 1586 | 93.7 | ||
| Non-Saudi | 107 | 6.3 | |||
| Monthly income | Less than 10,000 | 674 | 39.8 | ||
| 10,000–20,000 | 654 | 38.6 | |||
| More than 20,000 | 365 | 21.6 | |||
| GPA | 4.5–5 | 801 | 47.3 | ||
| 4–4.5 | 397 | 23.5 | |||
| 3–4 | 395 | 23.3 | |||
| < 3 | 100 | 5.9 | |||
Abbreviations: SD standard deviation, GPA grade point average
Table 2 shows the Perspective-Taking scale scores, with higher scores reflecting an ability to adopt others’ viewpoints. The mean score was 15.94 ± 4.9. The mean score for the Fantasy scale was 16.21 ± 6.0, suggesting that the participants often imagine themselves in fictional scenarios. The Empathic Concern scale demonstrated the highest mean score (18.84 ± 4.5), indicating strong feelings of sympathy and concern for others. A mean score of 14.28 ± 4.9 on the Personal Distress scale suggests moderate self-focused feelings of discomfort in stressful situations.
Table 2.
Interpersonal reactivity index (IRI) (N = 1693)
| Interpersonal Reactivity Index (IRI) n = 1693 | A | B | C | D | E |
|---|---|---|---|---|---|
| Perspective-taking scale | |||||
| I sometimes find it difficult to see things from the “other guy’s” point of view (-). | 61 (3.6) | 116 (6.9) | 318 (18.8) | 439 (25.9) | 759 (44.8) |
| I try to look at everybody’s side of a disagreement before I make a decision. | 154 (9.1) | 262 (15.5) | 448 (26.5) | 445 (26.3) | 384 (22.7) |
| I sometimes try to understand my friends better by imagining how things look from their perspective. | 193 (11.4) | 216 (12.8) | 422 (24.9) | 467 (27.6) | 395 (23.3) |
| If I’m sure I’m right about something, I don’t waste much time listening to other people’s arguments (-). | 342 (20.2) | 303 (17.9) | 386 (22.8) | 347 (20.5) | 315 (18.6) |
| I believe that there are two sides to every question and try to look at them both. | 160 (9.5) | 198 (11.7) | 448 (26.5) | 457 (27.0) | 430 (25.4) |
| When I’m upset with someone, I usually try to “put myself in his/her shoes” for a while. | 524 (31.0) | 456 (26.9) | 361 (21.3) | 214 (12.6) | 138 (8.2) |
| Before criticizing somebody, I try to imagine how I would feel if I were in their place. | 254 (15.0) | 264 (15.6) | 356 (21.0) | 374 (22.1) | 445 (26.3) |
| Fantasy scale | |||||
| I daydream and fantasize, with some regularity, about things that might happen to me. | 268 (15.8) | 253 (14.9) | 312 (18.4) | 379 (22.4) | 481 (28.4) |
| I really get involved with the feelings of the characters in a novel. | 326 (19.3) | 287 (17.0) | 365 (21.6) | 357 (21.1) | 358 (21.1) |
| I am usually objective when I watch a movie or play, and I don’t often get completely caught up in it (-). | 91 (5.4) | 144 (8.5) | 365 (21.6) | 398 (23.5) | 695 (41.1) |
|
Becoming extremely involved in a good book or movie is somewhat rare for me (-). |
96 (5.7) | 167 (9.9) | 274 (16.2) | 361 (21.3) | 795 (47.0) |
| After seeing a play or movie, I have felt as though I were one of the characters. | 532 (31.4) | 315 (18.6) | 269 (15.9) | 274 (16.2) | 303 (17.9) |
| When I watch a good movie, I can very easily put myself in the place of a leading character. | 400 (23.6) | 255 (15.1) | 322 (19.0) | 322 (19.0) | 394 (23.3) |
| When I am reading an interesting story or novel, I imagine how I would feel if the events in the story were happening to me. | 316 (18.7) | 234 (13.8) | 309 (18.3) | 358 (21.1) | 476 (28.1) |
| Empathic concern scale | |||||
| I often have tender, concerned feelings for people less fortunate than me. | 483 (28.5) | 364 (21.5) | 423 (25.0) | 268 (15.8) | 155 (9.2) |
| Sometimes I don’t feel very sorry for other people when they are having problems (-). | 67 (4.0) | 126 (7.4) | 221 (13.1) | 313 (18.5) | 966 (57.1) |
| When I see someone being taken advantage of, I feel kind of protective towards them. | 168 (9.9) | 177 (10.5) | 329 (19.4) | 530 (31.3) | 489 (28.9) |
| Other people’s misfortunes do not usually disturb me a great deal (-). | 74 (4.4) | 120 (7.1) | 287 (17.0) | 380 (22.4) | 832 (49.1) |
| When I see someone being treated unfairly, I sometimes don’t feel too much pity for them (-). | 58 (3.4) | 62 (3.7) | 125 (7.4) | 212 (12.5) | 1236 (73.0) |
| I am often quite touched by things that I see happening. | 208 (12.3) | 280 (16.5) | 469 (27.7) | 410 (24.2) | 326 (19.3) |
| I would describe myself as a pretty soft-hearted person. | 148 (8.7) | 127 (7.5) | 336 (19.8) | 415 (24.5) | 667 (39.4) |
| Personal distress scale | |||||
| In emergency situations, I feel apprehensive and ill-at-ease. | 175 (10.3) | 246 (14.5) | 324 (19.1) | 414 (24.5) | 534 (31.5) |
| I sometimes feel helpless when am in the middle of a very emotional situation. | 227 (13.4) | 241 (14.2) | 386 (22.8) | 422 (24.9) | 417 (24.6) |
| When I see someone get hurt, I tend to remain calm (-). | 347 (20.5) | 352 (20.8) | 352 (20.8) | 277 (16.4) | 365 (21.6) |
| Being in a tense emotional situation scares me. | 344 (20.3) | 302 (17.8) | 325 (19.2) | 341 (20.1) | 381 (22.5) |
| I am usually pretty effective in dealing with emergencies (-). | 275 (16.2) | 390 (23.0) | 469 (27.7) | 318 (18.8) | 241 (14.2) |
| I tend to lose control during emergencies. | 609 (36.0) | 466 (27.5) | 338 (20.0) | 146 (8.6) | 134 (7.9) |
| When I see someone who badly needs help in an emergency, I go to pieces. | 252 (14.9) | 268 (15.8) | 409 (24.2) | 397 (23.4) | 367 (21.7) |
A=Does not describe me well – E=Describes me very well
(-)=Reverse-scored question
Values are presented as number of participants (percentage). Responses were rated on a 5-point Likert scale ranging from Does not describe me well to Describes me very well. Subscale scores are reported as mean ± standard deviation. Items marked with (–) were reverse scored
The mean ACE score was 3.23 ± 2.5. The distribution of specific ACEs is detailed in Table 3. Participants were categorized as low-risk (31.7%), intermediate-risk (23.9%), and high-risk (44.4%) based on their ACE scores as shown in Table 4.
Table 3.
Adverse childhood experiences (N = 1693)
| Adverse Childhood Experience | No n (%) | Yes n (%) |
|---|---|---|
| Did you feel that you didn’t have enough to eat, had to wear dirty clothes, or had no one to protect or take care of you? | 1223 (72.2) | 470 (27.8) |
| Did you lose a parent through divorce, abandonment, death, or other reason? | 1261 (74.5) | 432 (25.5) |
| Did you live with anyone who was depressed, mentally ill, or attempted suicide? | 1106 (65.3) | 587 (34.7) |
| Did you live with anyone who had a problem with drinking or using drugs, including prescription drugs? | 1482 (87.5) | 211 (12.5) |
| Did your parents or adults in your home ever hit, punch, beat, or threaten to harm each other? | 1003 (59.2) | 690 (40.8) |
| Did you live with anyone who went to jail or prison? | 1525 (90.1) | 168 (9.9) |
| Did a parent or adult in your home ever swear at you, insult you, or put you down? | 625 (36.9) | 1068 (63.1) |
| Did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? | 1001 (59.1) | 692 (40.9) |
| Did you feel that no one in your family loved you or thought you were special? | 943 (55.7) | 750 (44.3) |
| Did you experience unwanted sexual contact (such as fondling or oral/anal/vaginal intercourse/penetration)? | 1292 (76.3) | 401 (23.7) |
| Perceived impact of ACE’s on health | Count | % |
|---|---|---|
| Not Much | 535 | 31.6 |
| Somewhat | 553 | 32.7 |
| A Lot | 605 | 35.7 |
Table 4.
Descriptive statistics of interpersonal reactivity index (IRI) subscales and adverse childhood experiences (ACEs) scores (N = 1,693)
| Domains | N | Min | Max | Mean | SD |
|---|---|---|---|---|---|
| Perspective-taking scale | 1693 | 1.00 | 28.00 | 15.94 | 4.9 |
| Fantasy scale | 1693 | 1.00 | 28.00 | 16.21 | 6.0 |
| Empathic concern scale | 1693 | 1.00 | 28.00 | 18.84 | 4.5 |
| Personal distress scale | 1693 | 1.00 | 28.00 | 14.28 | 4.9 |
| Adverse Childhood Experience | 1693 | 0.00 | 10.00 | 3.23 | 2.5 |
| Count | % | ||||
| Total | 1693 | 100.0 | |||
| Adverse Childhood Experience | Low Risk | 536 | 31.7 | ||
| Intermediate Risk | 405 | 23.9 | |||
| High Risk | 752 | 44.4 | |||
Min and Max values represent the observed range in the study sample. The theoretical (possible) range of the IRI subscales is 0–28, and that of the ACE score is 0–10
Abbreviations: IRI Interpersonal Reactivity Index, ACEs Adverse Childhood Experiences
Regarding reliability, the Cronbach’s alpha for the Perspective-Taking scale was 0.617 (Table 5), indicating moderate internal consistency. The Fantasy scale had an alpha of 0.726, suggesting good reliability. The Empathic Concern scale had an alpha of 0.570, indicating limited reliability, and the Personal Distress scale had an alpha of 0.541, indicating relatively low internal consistency.
Table 5.
Reliability statistics
| Reliability Statistics | Cronbach’s Alpha | N of Items |
|---|---|---|
| Inter Personal Reactivity Index | 0.78 | 28 |
| Perspective-taking scale | 0.617 | 7 |
| Fantasy scale | 0.726 | 7 |
| Empathic concern scale | 0.570 | 7 |
| Personal distress scale | 0.541 | 7 |
| Adverse Childhood Experience | 0.759 | 10 |
The ACE scale demonstrated good internal consistency (α = 0.759), indicating reliable measurement of childhood adversity.
As shown in Table 6, Pearson’s correlations revealed:
Table 6.
Correlation analysis
| Correlations | Fantasy scale | Empathic concern scale | Personal distress scale | Adverse Childhood Experience | |
|---|---|---|---|---|---|
| Perspective-taking scale | r | 0.291** | 0.447** | 0.124** | 0.135** |
| p-value | < 0.001 | < 0.001 | < 0.001 | < 0.001 | |
| N | 1693 | 1693 | 1693 | 1693 | |
| Fantasy scale | r | 0.325** | 0.363** | 0.252** | |
| p-value | < 0.001 | < 0.001 | < 0.001 | ||
| N | 1693 | 1693 | 1693 | ||
| Empathic concern scale | r | 0.365** | 0.111** | ||
| p-value | < 0.001 | < 0.001 | |||
| N | 1693 | 1693 | |||
| Personal distress scale | r | 0.228** | |||
| p-value | < 0.001 | ||||
| N | 1693 | ||||
** Correlation is significant at the 0.01 level (2-tailed)
A weakly positive correlation between Perspective-Taking and ACE scores (r = 0.135, p < 0.001).
A moderately positive correlation between Fantasy and ACE scores (r = 0.252, p < 0.001).
A weakly positive correlation between Empathic Concern and ACE scores (r = 0.111, p < 0.001).
A moderately positive correlation between Personal Distress and ACE scores (r = 0.228, p < 0.001).
Table 7 summarizes the associations between ACE risk categories and sociodemographic characteristics. Gender showed a significant association with ACE risk (p = 0.002), with a higher proportion of females classified as high risk compared to males (46.1% vs. 40.2%). Monthly income was inversely associated with ACE risk (p = 0.012), as participants earning less than 10,000 SAR had the highest prevalence of high-risk ACE scores (49.7%). Academic performance was also significantly related to ACE risk (p = 0.017), with higher proportions of high-risk ACE scores observed among participants with lower GPA levels. No significant associations were observed for age, marital status, or nationality. Gender, monthly income, and GPA were treated as potential confounders and were included in subsequent analyses. The high-risk ACE group exhibited elevated scores across all domains compared to the low-risk group, particularly in the Fantasy scale (17.49 ± 5.7 vs. 14.10 ± 5.9, p < 0.001) and Personal Distress scale (15.27 ± 4.8 vs. 12.34 ± 4.6, p < 0.001) as shown in Table 8.
Table 7.
Association between adverse childhood experiences (ACEs) and sociodemographic characteristics of the study participants (N = 1693)
| Demographics | Total | Adverse Childhood Experience | p-value | |||
|---|---|---|---|---|---|---|
| Low Risk | Intermediate Risk | High Risk | ||||
| Total | 1693 | 536(31.7%) | 405(23.9%) | 752(44.4%) | - | |
| Age | 1693 | 22.13 ± 3.7 | 21.87 ± 3.4 | 22.05 ± 3.3 | 0.499 | |
| Gender | Male | 488 | 185(37.9%) | 107(21.9%) | 196(40.2%) | 0.002a |
| Female | 1205 | 351(29.1%) | 298(24.7%) | 556(46.1%) | ||
| Marital status | Single | 1509 | 470(31.1%) | 361(23.9%) | 678(44.9%) | 0.192 |
| Married | 160 | 61(38.1%) | 39(24.4%) | 60(37.5%) | ||
| Divorced | 24 | 5(20.8%) | 5(20.8%) | 14(58.3%) | ||
| Nationality | Saudi | 1586 | 505(31.8%) | 380(24.0%) | 701(44.2%) | 0.761 |
| Non-Saudi | 107 | 31(29.0%) | 25(23.4%) | 51(47.7%) | ||
| Monthly income | Less than 10,000 | 674 | 191(28.3%) | 148(22.0%) | 335(49.7%) | 0.012a |
| 10,000–20,000 | 654 | 221(33.8%) | 163(24.9%) | 270(41.3%) | ||
| More than 20,000 | 365 | 124(34.0%) | 94(25.8%) | 147(40.3%) | ||
| GPA | 4.5–5 | 801 | 253(31.6%) | 213(26.6%) | 335(41.8%) | 0.017a |
| 4–4.5 | 397 | 142(35.8%) | 90(22.7%) | 165(41.6%) | ||
| 3–4 | 395 | 111(28.1%) | 82(20.8%) | 202(51.1%) | ||
| < 3 | 100 | 30(30.0%) | 20(20.0%) | 50(50.0%) | ||
a significant using the Chi-Square Test at < 0.05 level
Abbreviation: GPA grade point average
Table 8.
Interpersonal reactivity index (IRI) by ACE risk categories
| Interpersonal Reactivity Index (IRI) | Total | Adverse Childhood Experience | p-value | ||
|---|---|---|---|---|---|
| Low Risk | Intermediate Risk | High Risk | |||
| Perspective-taking scale | 1693 | 15.03 ± 5.0A | 16.12 ± 4.9B | 16.49 ± 4.8B | < 0.001a, b |
| Fantasy scale | 1693 | 14.10 ± 5.9A | 16.61 ± 5.9B | 17.49 ± 5.7C | < 0.001a, b |
| Empathic concern scale | 1693 | 17.99 ± 4.5A | 19.29 ± 4.3B | 19.21 ± 4.5B | < 0.001a, c |
| Personal distress scale | 1693 | 12.34 ± 4.6A | 14.99 ± 4.6B | 15.27 ± 4.8B | < 0.001a, b |
a significant using One-Way ANOVA Test at < 0.05 level
b Post-Hoc Test = LSD
c Post-Hoc Test = Games-Howell
Capital letters represent the Post-Hoc multiple pairing summary indicator. When two measures share the same letter, they are statistically similar
Table 9 shows that male participants were less likely to fall into the high‑risk ACE category compared with female participants (p = 0.002). Income level was inversely associated with ACE risk, with lower-income participants showing a higher prevalence of high-risk ACE scores (p = 0.012).
Table 9.
Variables associated with ACE risk in the general linear model
| Dependent Variable: Adverse Childhood Experience | |||||
|---|---|---|---|---|---|
| Parameter | B | S.E. | 95% Confidence Interval | p-value | |
| Lower Bound | Upper Bound | ||||
| Intercept | 1.187 | 0.135 | 0.922 | 1.452 | < 0.001a |
| Gender | |||||
| Male | -0.069 | 0.045 | -0.158 | 0.020 | 0.130 |
| Monthly income | |||||
| Less than 10,000 | 0.168 | 0.054 | 0.063 | 0.274 | 0.002a |
| 10,000–20,000 | 0.037 | 0.054 | -0.068 | 0.143 | 0.486 |
| GPA | |||||
| 4.5– 5 | -0.072 | 0.088 | -0.243 | 0.100 | 0.413 |
| 4–4.5 | -0.108 | 0.092 | -0.288 | 0.073 | 0.242 |
| 3–4 | 0.054 | 0.092 | -0.126 | 0.234 | 0.558 |
| Perspective-taking scale | 0.014 | 0.005 | 0.005 | 0.023 | 0.002a |
| Fantasy scale | 0.022 | 0.004 | 0.015 | 0.030 | < 0.001a |
| Empathic concern scale | -0.008 | 0.005 | -0.019 | 0.002 | 0.113 |
| Personal distress scale | 0.034 | 0.005 | 0.025 | 0.044 | < 0.001a |
a significant using General Linear Model at < 0.05 level
Abbreviation: GPA grade point average
Discussion
The current findings have important practical implications for student mental health promotion and prevention strategies at the university level. The observed increased risk of adverse childhood experiences among women and students from lower-income backgrounds is consistent with prior evidence indicating that ACE exposure is strongly shaped by structural, socioeconomic, and gender-related vulnerabilities during childhood [12, 14, 20]. These results underscore the importance of early identification of at-risk subgroups within university populations—particularly female students and those from socioeconomically disadvantaged contexts—through systematic screening approaches aimed at detecting cumulative adversity.
The positive associations observed between ACE exposure and empathy-related domains, including Perspective-Taking, Fantasy, and Personal Distress, require careful interpretation. While higher Perspective-Taking and Empathic Concern scores may reflect adaptive social attunement or heightened awareness of others’ emotional states developed in response to adversity [18, 19], these increases, however, should not be interpreted as uniformly beneficial. Emerging evidence suggests that individuals exposed to early-life adversity may develop heightened emotional sensitivity or hypervigilance as coping mechanisms, which can inflate certain empathy scores without necessarily translating into positive psychosocial functioning [6, 11].
Notably, elevated Fantasy and Personal Distress scores among students with higher ACE exposure may indicate maladaptive or emotionally burdensome forms of empathy. Elevated Fantasy scores may reflect reliance on imaginative or avoidant coping strategies, while higher Personal Distress suggests difficulties with emotional regulation and increased vulnerability to emotional overload when confronted with others’ distress. These patterns are consistent with literature linking ACEs to emotion dysregulation, heightened stress reactivity, and alexithymia in adulthood [4]. The relatively lower internal consistency of the Empathic Concern and Personal Distress subscales may have attenuated the strength of associations observed, and conclusions involving these domains should therefore be interpreted with caution. Thus, empathy following childhood adversity may reflect a complex combination of adaptive awareness and maladaptive emotional responses rather than purely prosocial functioning.
From a practical standpoint, these findings highlight the need for trauma-informed, campus-based mental health interventions that address both the potentially adaptive and maladaptive emotional sequelae of ACE exposure. University mental health services should prioritize interventions that enhance emotional regulation, reduce distress, and strengthen adaptive coping and resilience, particularly among high-risk groups identified through ACE screening. Stress-management programs and psychological support strategies that are sensitive to gender and socioeconomic context may help mitigate disparities in mental health outcomes associated with early adversity, as documented in cohort studies [14].
Overall, the present results reinforce the importance of integrating ACE-informed frameworks into student support services and mental health policy within higher education institutions. By identifying high-risk subgroups and tailoring interventions accordingly, universities may play a crucial role in reducing the long-term psychological and emotional burden associated with adverse childhood experiences among students.
Limitations
This study is subject to several limitations. To begin with, response bias may be introduced by the use of self-reported questionnaires. Second, the study was conducted at a single university using convenience sampling, limiting the generalizability of the results. Third, the reliability of some of the Interpersonal Reactivity Index subscales was limited, such as Empathic Concern and Personal Distress; although these subscales had significant associations with ACE outcomes, their lower internal consistency should be considered in interpreting the findings. At last, the cross-sectional design of this study limits the potential inference of causality. Longitudinal or experimental studies are needed to clarify the temporal and causal relationships between ACEs and empathy and the possible differences between different populations and settings.
Conclusions
This research supports the hypothesis that adverse childhood experiences shape the emotional and empathic development of individuals. While high ACE scores were associated with enhanced Perspective-Taking and Empathic Concern, they were also correlated with higher Personal Distress, which may negatively impact well-being. These findings underscore the importance of addressing childhood adversity within public health and educational systems to mitigate its long‑term impact and promote resilience.
Acknowledgements
We thank the participating students and the assistance of research coordinators during data collection.
Clinical trial number
Not applicable.
Authors’ contributions
All authors contributed substantially to this work. Sulhi Alfakeh (Corresponding Author) conceptualized and designed the study, supervised data collection and analysis, interpreted findings, drafted the initial manuscript, and coordinated revisions. Wid Kattan contributed to study design, assisted in data interpretation, and critically revised the manuscript for important intellectual content. Aseel Ba Durayq participated in data collection, contributed to the literature review, and assisted in drafting the introduction and discussion sections. Sohaib Althagfi supported statistical analysis, contributed to interpretation of results, and reviewed the manuscript for accuracy. Halah AlGhamdi assisted in data acquisition, contributed to methodological refinement, and reviewed the manuscript for clarity and coherence. Abdulaziz Adnan contributed to participant recruitment and data management, assisted in writing the methods section, and reviewed the final draft. Razan Alsubaie assisted with data entry and preliminary analysis, prepared tables and figures, and reviewed the manuscript draft. All authors read and approved the final manuscript.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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
Ethical approval was obtained from the Institutional Review Board (IRB) of King Abdulaziz University, Jeddah, Saudi Arabia (Reference No: 173 − 24). Informed consent was obtained from all participants prior to data collection. This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki.
Consent for publication
Not applicable. The manuscript does not contain identifiable individual data, images, or videos.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Almuneef M, Qayad M, Aleissa M, Albuhairan F. Adverse childhood experiences, chronic diseases, and risky health behaviors among Saudi Arabian adults: A pilot study. Child Abuse Negl. 2014;38(11):1787–93. 10.1016/j.chiabu.2014.06.003. [DOI] [PubMed] [Google Scholar]
- 2.Aware A. ACEs Aware master FAQ. (2021). https://www.acesaware.org/wp-content/uploads/2019/11/ACEs-Aware-FAQ-updated-2.25.20-WEB-VERSION.pdf
- 3.Berzenski SR, Yates TM. The development of empathy in child maltreatment contexts. Child Abuse Negl. 2022;133:105827. 10.1016/j.chiabu.2022.105827. [DOI] [PubMed] [Google Scholar]
- 4.Cerqueira A, Almeida TC. Adverse childhood experiences: relationship with empathy and alexithymia. J Child Adolesc Trauma. 2023;16(3):559–68. 10.1007/s40653-023-00520-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Chen H, Meza JI, Yan Y, Wu Q, Lin X. Parental attachment and depression in adolescents: A moderation-mediation model of empathy and gender. Curr Psychol. 2023;42(7):5898–909. 10.1007/s12144-021-01698-4. [Google Scholar]
- 6.Crouch E, Jones J, Strompolis M, Merrick M. Examining the association among ACEs, childhood poverty and neglect, and physical and mental health: data from two state samples. Child Youth Serv Rev. 2020;116:105155. 10.1016/j.childyouth.2020.105155. [Google Scholar]
- 7.Davis MH. A multidimensional approach to individual differences in empathy. JSAS Catalog of Selected Documents in Psychology. 1980;10:85.
- 8.Davis MH. Measuring individual differences in empathy: evidence for a multidimensional approach. J Personal Soc Psychol. 1983;44(1):113–26. 10.1037/0022-3514.44.1.113. [Google Scholar]
- 9.Esagian G, Esagian-Pouftsis S, Kaprinis SG. Empathy in psychiatry and psychotherapy. Psychiatrike. 2019;30(2):156–64. 10.22365/jpsych.2019.302.156. [DOI] [PubMed] [Google Scholar]
- 10.Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The adverse childhood experiences (ACE) study. Am J Prev Med. 1998;14(4):245–58. 10.1016/s0749-3797(98)00017-8. [DOI] [PubMed] [Google Scholar]
- 11.Greenberg DM, Baron-Cohen S, Rosenberg N, Fonagy P, Rentfrow PJ. Elevated empathy in adults following childhood trauma. PLoS ONE. 2018;13(10):e0203886. 10.1371/journal.pone.0203886. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Kocatürk M, Türk-Kurtça T. Moral disengagement, attitudes towards violence and irrational beliefs as predictors of bullying cognition in adolescence. Int Educ Stud. 2020;13(10):47–59. 10.5539/ies.v13n10p47. [Google Scholar]
- 13.Lee J, Kim H, Chang SM, Hong JP, Lee D-W, Hahm B-J, Kim B-S. The association of childhood maltreatment with adulthood mental disorders and suicidality in korea: A nationwide community study. J Korean Med Sci. 2021;36(37):e240. 10.3346/jkms.2021.36.e240. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Merrick MT, Ford DC, Ports KA, Guinn AS. Prevalence of adverse childhood experiences from the 2011–2014 behavioral risk factor surveillance system in 23 States. JAMA Pediatr. 2018;172(11):1038–44. 10.1001/jamapediatrics.2018.2537. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Mikton C, Butchart A. Child maltreatment prevention: A systematic review of reviews. Bull World Health Organ. 2009;87(5):353–61. 10.2471/blt.08.057075. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Muwanguzi M, Ssewanyana D, Ndugga P, Nsubuga H. Adverse childhood experiences, empathy, depressive symptoms, and suicidal ideation among university students in Uganda. BMC Psychology. 2023;11(1):1–12. 10.1186/s40359-023-01107-5. [DOI] [PMC free article] [PubMed]
- 17.Najjuka SM, Mamun MA, Arinaitwe I, Ashaba S. Exploring adverse childhood experiences (ACEs) among Ugandan university students: its associations with academic performance, depression, and suicidal ideations. BMC Psychol. 2023;11(1):11. 10.1186/s40359-023-01044-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Narvey C, Yang J, Wolff KT, Baglivio M, Piquero AR. The interrelationship between empathy and adverse childhood experiences and their impact on juvenile recidivism. Youth Violence Juvenile Justice. 2021;19(1):45–67. 10.1177/1541204020939647. [Google Scholar]
- 19.Quas JA, Dickerson KL, Matthew R, Harron C, Quas CM. Adversity, emotion recognition, and empathic concern in high-risk youth. PLoS ONE. 2017;12(7):e0181606. 10.1371/journal.pone.0181606. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Van Doorn G, Dye J, Teese R. The influence of adverse and positive childhood experiences on facets of empathy. Child Abuse Negl. 2024;155:106993. 10.1016/j.chiabu.2024.106993. [DOI] [PubMed] [Google Scholar]
- 21.Walsh D, McCartney G, Smith M, Armour G. Relationship between childhood socioeconomic position and adverse childhood experiences (ACEs): A systematic review. J Epidemiol Commun Health. 2019;73(12):1087–93. 10.1136/jech-2019-212738. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Zheng Y, Hu D, Li X, Yin M, editors. Research on the relationship between empathy, belief in a just world, and childhood trauma in pre-clinical medical students. Healthcare. (2022).10(10), 1989. 10.3390/healthcare10101989 [DOI] [PMC free article] [PubMed]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.