Adverse Childhood Experiences and Interpersonal Violence Among College Students: Does a Relationship Exist?

Abstract

Adverse Childhood Experiences (ACEs) are linked to negative health outcomes and increased rates of adult intimate partner violence (IPV). Previous research found women who experience eight or more ACEs are 3.5 times as likely to be victims of adult IPV. This study examined the relationship between ACEs and IPV (physical violence, sexual violence, psychological violence, and stalking) among college students. Undergraduate students (N=2,900) completed a web-based survey addressing self-reported ACEs and violence that occurred within the current academic year. Chi-square tests and logistic regression models were used to evaluate the relationship between ACEs and violence. College students with higher ACE scores were more likely to experience violence. Students with ACE scores of four or higher were between 1.9–4.9 times more likely to experience violence. A dose response relationship was found between ACE score and experiences of violence. Campus violence prevention programs may benefit from incorporating discussion of ACEs into programming.

Introduction

Adverse Childhood Experiences (ACEs) are recognized as significant contributors to negative health outcomes throughout the lifespan.¹ The ACE Study is an ongoing collaborative investigation led by the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente’s Health Appraisal Clinic in San Diego, California.² The study observes the prevalence and effects of ten categories of ACEs including: childhood abuse (emotional, physical, or sexual), childhood neglect (emotional or physical), and household dysfunction (witnessing domestic violence, substance abuse, mental illness, incarceration, or separation and divorce).¹ From this work, a dose response relationship has been identified between a number of categories of ACEs experienced during childhood and many diseases, disorders, and social problems later in life.^3,4

The negative health outcomes associated with ACE scores include, but are not limited to: smoking, obesity, physical inactivity, depression, suicide attempts, alcoholism, drug abuse, sexual promiscuity, sexually transmitted diseases, heart disease, cancer, and hepatitis.^1,3–5 Additionally, ACEs have been linked to increased rates of adult intimate partner violence (IPV) and sexual victimization.^6,7 For example, women who experience eight or more ACEs during childhood are 3.5 times as likely to be victims of IPV as an adult, and a childhood sexual abuse experience has been found to be a strong predictor of adult sexual victimization.^8–10

Surveys distributed across higher educational institutions demonstrate that victims of various types of violence are unlikely to report serious incidents, making prevalence rates difficult to account for.¹¹ Despite this limitation, the Association of American Universities found that 11.7% of college students experienced nonconsensual sexual contact, 47.7% reported sexual harassment, 9.8% reported IPV and 4.2% experienced stalking within the academic year.¹¹ Prevalence rates have wide ranges between self-reported gender identities; for instance, sexual assault occurred at a rate of 176 per 1,000 female undergraduates versus 53 per 1,000 male undergraduates during the 2014–15 academic year.¹² Other studies have shown that a quarter of women experience unwanted sexual contact or assault and 82% report psychological violence.^13–15 Furthermore, long-term health consequences from experiencing IPV include increased likelihood of depression, suicidal thoughts, sexually transmitted diseases, chronic pain, seizures, headaches, and substance abuse.¹⁶

Existing research has shown a relationship between childhood physical and sexual abuse or neglect and adult re-victimization.¹⁷ A relationship has also been observed between childhood trauma and sexual abuse later in life. A 2007 study found that 75% of the surveyed women who reported childhood sexual abuse also reported a non-consensual sexual experience in adulthood, noting that college-aged women were particularly susceptible to sexual violence with some populations reporting a prevalence rate of 19% since being in college.^18,19 Studies have documented that an early sexual abuse experience increases one’s risk of adult sexual victimization; indeed, researchers have found that compared to women without a history of victimization, women with a history of sexual victimization were between 1.5 and 2 times more likely to be sexually victimized during a 3-month follow-up period.²⁰ Similarly, women with a history of childhood physical or sexual abuse were 3.5 times more likely to experience IPV in adulthood and were also more likely to participate in risky sexual behavior.²⁰ The same researchers found that among college students, those with a history of past IPV were more likely to experience IPV in current relationships, with those having a history of childhood physical and verbal abuse being the highest at risk.

A 2005 study examined several categories of childhood abuse separate from the ACE questionnaire, and evaluated rates of sexual assault among college students.²⁰ They found that physical abuse by the father during childhood left college-aged women more vulnerable to sexual victimization later in life, and called for discussion of protective strategies and further research. Another study from 2007 observed the relationship between childhood sexual assault and re-victimization among college women using the Child Sexual Assault (CSA) Trauma Questionnaire.¹⁸ The CSA questionnaire is designed to assess emotional neglect, emotional abuse, physical neglect, physical abuse, and sexual abuse through a 28-question retrospective survey.¹⁸ Of all respondents, 22% reported a childhood trauma, and 75% of the women who reported a CSA also reported experiencing a non-consensual sexual experience in adulthood.¹⁸

Research also supports a relationship between high-risk behavior, such as substance use and victimization from various types of violence.^21–24 Furthermore, those who partake in risky behavior such as alcohol use in adolescence, may be more at risk for interpersonal and sexual victimization.^25,26 Recent publications have reviewed the association between ACE score and negative health behaviors including drug and alcohol use among a college-aged population. One study by Forster et al. looked at the relationship between family based ACEs and substance use and found that between 50–75% of students involved in substances use were exposed to ACEs, with a significant dose response relationship identified.²⁷ A second study reviewed the relationship between college student’s ACE score and negative health behaviors found that as ACE scores increase, rates of depressive symptoms, ADHD symptoms, cigarette use, alcohol use, marijuana use also increase.²⁸

Previous research has examined the potential relationship between ACEs and interpersonal victimization among the college-aged population. Nikulina and colleagues recently investigated this topic among 284 undergraduates at a northeastern public university in the United States.²⁹ The researchers assessed the relationship between 9 childhood ACEs: specifically emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect, witnessing domestic violence, living with a mentally ill individual, substance abuse, or incarcerated household member, and rates of adult IPV perpetration and victimization. The most prevalent ACE was physical abuse, reported by 35% of their study population, followed by mental illness of a household member (29%) and emotional abuse (26%). The results showed that the most common type of IPV victimization reported was psychological aggression at a rate of 60%. Victimization of physical aggression was reported at a rate of 24%. The study found specific ACEs to be correlated with an increased risk of adult IPV, but there was no overall dose response relationship between ACE score and IPV.²⁹ Further research in the area was recommended.

With the limited research on the relationship between ACEs and IPV among the college-aged population within the US, further study on the matter is needed. Therefore, the purpose of this study is to investigate the relationship between number of ACEs and rates of physical, sexual, psychological, and stalking violence victimization among college students between the ages of 18–24 in the US. Given the negative health impacts associated with ACEs, including increased rates of lifetime IPV, and the high rate of victimization on college campuses, we hypothesize that a positive association will be found between childhood ACE scores and likelihood of interpersonal victimization as a college student.

Methods

Design and Study Sample

This study focused on investigating interpersonal victimization among undergraduate students. The study utilized a cross-sectional survey design and collected data by sending the same web-based survey to a randomized group of 10,000 (5,000 per school) undergraduate students between the age of 18–24 at two large, state-funded universities in the U.S. Participants were selected by a random sample obtained from the registrar at each university. Each survey took 25 minutes to complete and contained 172 items. Items included: Likert scales; select all that apply; single answer multiple choice; and free response. Links to a SurveyMonkey questionnaire were emailed out to a random sample of 2,500 students in each year in school, evenly split by gender. Participants in University One were offered $5 gift cards and those in University Two were offered $10 gift cards as incentives. Participants in University Two were compensated more because in previous studies this university had a low response rate compared to other universities. Increasing the compensation amount, equalized the number of responses across the universities. Following the initial communication, five scheduled email reminders were sent over the four week data collection timeframe. Of the 10,000 invitations sent out at the two universities, 128 emails were returned to sender or not functional due to the user opting out of SurveyMonkey software. Out of the 4,063 recipients who clicked the link to participate, 3,969 respondents agreed to participate in the survey. This resulted in a 40.6% response rate, with 97% of those who clicked on the link completing the survey. Of this sample, those over the age of 24, missing control demographics, or missing ACE score or violence questions were excluded, yielding a final analytic sample size of 2,900 students. Response rates between the two universities remained similar, with 1,345 (46.4%) surveys completed from University One and 1,555 (53.6%) completed from University Two. The Institutional Review Board (IRB) at the University of Kentucky approved this study (protocol: 44378).

Measures

Control Variables.

A review of the past research found gender, race, parent’s level of education, self-reported sexual identity, current relationship status, and year in school to all be potential confounding variables, and were therefore controlled for in final analysis.^30–33 Gender was divided into two categories: (1) male and (2) female. Race was also divided into two categories: (1) white and (2) other. Parent education level were categorized by (1) elementary, middle or high school; (2) high school diploma or GED; (3) vocational school; (4) some college; (5) college graduate; (6) master’s degree or above. Sexual identity was divided into categories of (1) heterosexual and (2) lesbian/gay/bisexual/questioning. Relationship status was broken down into five categories: (1) casually dating; (2) sexual relationship only; (3) not dating but have within the last semester; (4) not currently dating but have in the past; and (5) living with partner/married. Year in school was separated into (1) freshman; (2) sophomore; (3) junior; and (4) senior.

Independent variable.

The survey included the complete Adverse Childhood Experiences Survey (ACEs), developed by Kaiser Permanente and the CDC, which is comprised of questions on negative experiences including psychological, physical, and sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned, which occurred prior to the student turning 18.¹ The ACE survey’s psychometric properties have been assessed in many studies and found to have good face validity, test retest kappa statistic of .52–.72, and Intraclass correlations coefficient of .65 or higher across all 10 items.^34,35 Total ACE scores were calculated by summing the number of individual ACEs reported on the survey. Frequency distributions were generated on individual ACEs items as well as overall ACE Score that was summed according to total number of ‘yes’ responses (Table 2). Students were then collapsed into the following categories in concordance with previous literature: (1) 0 ACEs experienced; (2) 1–3 ACEs experienced; (3) 4–7 ACEs experienced; and (4) 8 or more ACEs experienced.

Table 2.

Prevalence (%) of Individual Adverse Childhood Experience (ACEs) and ACE Scores in Study Population (N=2,900).

Individual ACEs	Study n (%)
Parental Separation or Divorce	782 (27.00)
Household Mental Illness	455 (15.7)
Emotional Abuse	437 (15.1)
Emotional Neglect	387 (13.3)
Household Substance Abuse	319 (11.0)
Physical Abuse	193 (6.7)
Sexual Abuse	148 (5.1)
Mother Experienced Violence	122 (4.2)
Incarcerated Household Member	105 (3.6)
Physical Neglect	84 (2.9)
ACE Score
0 ACEs	1576 (54.34)
1 ACE	625 (21.55)
2 ACEs	291 (10.03)
3 ACEs	136 (4.69)
4 ACEs	110 (3.79)
5 ACEs	82 (2.83)
6 ACEs	30 (1.03)
7 ACEs	27 (0.93)
8 or more	23 (0.79)

Dependent variables.

Self-reported violent experiences within the current academic year were identified through a series of survey questions. Questions were developed by the research team based off of measures used in previous studies of violence on college campuses (Coker et. al. 2011, 2016). These questions assessed how frequently participants had experienced physical, psychological, or sexual violence or stalking in the current academic year.

To assess physical violence, students were asked the following questions regarding the last 12 months: (1) My partner pushed or shoved me; (2) My partner threw something at me that could hurt; (3) My partner punched or beat me up; and (4) My partner used a knife, gun, or something that could hurt me. The above statements were collapsed into a single physical violence measure where students who answered yes to any were coded as experiencing physical violence in the year.

To assess sexual violence, students were asked if any of the following had occurred within the current academic year : (1) Had unwanted sexual activities with someone because they threatened to hurt you or end your relationship if you didn’t, or you felt pressured by someone’s arguments or begging or someone promised to reward you?; (2) Had unwanted sexual activities with someone because you were passed out, asleep, or too drunk or high on drugs to consent or stop what was happening?; and (3) Had unwanted sexual activities because someone threatened to use or used physical force (twisting your arm, holding you down, etc.)? These questions were collapsed into a single sexual violence measure where students who answered yes to any of the questions listed were coded as experiencing sexual violence in the year.

For psychological violence, the following questions were asked regarding the current academic year: (1) My partner shouted, yelled, or swore at me; (2) My partner posted mean, insulting, or humiliating comments about me either online or in emails, text or instant messages, or voicemails; (3) My partner threatened to hit, throw something at, or otherwise physically hurt me; (4) My partner destroyed something that belonged to me on purpose; and (5) My partner tried to control me by always checking up on me, telling me who I could be friends with or telling me what I could do and when. These questions were again collapsed into a single psychological violence measure where students who answered yes to any of the questions listed were coded as experiencing psychological violence in the year.

Stalking was assessed by asking two questions regarding the current academic year: (1) Someone showed up where you live, work, or go to school when you did not want them to; and (2) You received unwanted phone calls, emails, text or instant messages, comments/pictures posted on social networking sites, or unwanted gifts. These questions were also collapsed into a single stalking measure where students who answered yes to any of the questions listed were coded as experiencing stalking in the year.

Data Analysis.

Using the analytic sample of 2900 respondents, representing those with complete data on all measures, Chi-square analysis was performed between all independent, dependent and control variables. Mann-Whitney tests and logistic regression was used to analyze the relationship between ACE score and rates of (1) physical, (2) sexual, (3) psychological violence, and (4) stalking among college students. These analyses included the control variables of gender, race, year in school, sexuality, relationship status, and parental education. All analyses were conducted using SAS Version 9.3.

Results

The sample demographics were consistent with the universities at large, with respondents reporting 85.14% white ethnicity and 14.6% reporting otherwise (Table 1). Year in school was fairly evenly distributed. The majority of survey participants were female (58.6%). Students were asked about their current relationship status, with 11.6% reporting casually dating, 7.9% stating they were involved in a sexual relationship, only 10.2% reporting not currently be dating, but in a relationship within the last semester, 19.6% currently in a committed relationship, and 7.5% currently living with their partner or married. Sexual identity was assessed as well, with 85.1% of respondents identifying as heterosexual (Table 1).

Table 1.

Sample Demographics (N=2,900)

Gender	n (%)
Male	1202 (41.45)
Female	1698 (58.55)
Race
White	2469 (85.14)
Other	431 (14.86)
Year in School
Freshman	774 (26.69)
Sophomore	686 (23.66)
Junior	732 (25.24)
Senior	708 (24.41)
Relationship Status
Casually dating	335 (11.55)
Sexual relationship only	228 (7.86)
Not dating but have within the last semester	297 (10.24)
Not currently dating but have in the past	568 (19.59)
Living with partner/married	218 (7.52)
Sexuality
Heterosexual	2469 (85.14)
Bisexual/Gay/Lesbian/Questioning/Other	431 (14.86)
Parent’s Education	Mother	Father
Elementary, Middle or High School	31 (1.07)	60 (2.07)
High School Diploma or GED	442 (15.24)	511 (17.62)
Vocational School	67 (2.31)	120 (4.14)
Some College	595 (20.52)	415 (14.31)
College Graduate	1127 (38.86)	1059 (36.52)
Master’s Degree or Above	638 (22.00)	735 (25.34)

Rates of each category of ACE were calculated. The most frequent individual adverse experience reported by students were parental separation or divorce (27.0%), household mental illness (15.7%), and emotional abuse (15.1%) (Table 2). A majority of students, 54.3%, reported zero ACEs. One in five students reported one ACE, and almost one in ten students reported four or more ACEs (Table 2).

Rates of interpersonal violence also were reviewed during the initial study analysis. Of the 2,900 survey participants, 203 (7.0%) reported experiencing physical violence within the past 12 months. Sexual violence occurred in 9.7% of the surveyed population, while psychological abuse and stalking occurred at significantly higher rates of 31.9% and 38.6% respectively (Table 3). Chi square analysis was completed on each of the four types of violence and total ACE score. While only 25.7% of students with zero ACEs reported psychological violence, 60.9% of students with eight or more ACEs reported psychological violence. In all four analyses, a statistically significant increase in rates of violence was reported as ACE scores increased. Physical violence was the only variable that did not display the highest rate in the category of eight or more ACEs, though few respondents indicated this category on the survey and the dose response relationships is present up to seven ACEs. Each test showed a consistent increase in violence as one’s overall ACE score increased (Table 3).

Table 3.

Chi Square Test: ACE Score vs. Experienced Violence in Past 12 Months (N=2,900)

ACE Score	Physical Violence n (%)	Psychological Violence n (%)	Sexual Violence n (%)	Stalking n (%)
Total Experience Violence	203 (7.0)	924 (31.86)	280 (9.66)	1120 (38.62)
0 ACEs	83 (5.27)	405 (25.7)	21 (7.68)	520 (32.99)
1 ACE	56 (8.96)	213 (34.08)	69 (11.04)	255 (40.8)
2 ACEs	14 (4.81)	113 (38.83)	45 (15.46)	129 (44.33)
3 ACEs	14 (10.29)	66 (48.53)	26 (19.12)	64 (47.06)
4 ACEs	14 (12.73)	46 (41.82)	25 (22.73)	59 (53.64)
5 ACEs	11 (13.41)	38 (46.34)	15 (18.29)	45 (54.88)
6 ACEs	4 (13.33)	16 (53.33)	8 (26.67)	16 (53.33)
7 ACEs	5 (18.52)	13 (48.15)	8 (29.63)	15 (55.56)
8 or more	2 (8.7)	14 (60.87)	6 (26.09)	17 (73.91)
Chi Square Test Statistic	33.55	84.44	76.17	68.08
p-value	<0.0001	<0.0001	<0.0001	<0.0001

A Mann-Whitney test was performed to measure the mean ACE score of those who had and had not experienced any of the four types of violence over the last 12 months (Table 4). Those who responded negatively to experiencing physical violence in the last 12 months had a mean rank of 1433.79, while those who responded positively had a rank of 1672.45. This indicated that those who experienced any form of interpersonal violence had a higher average mean ACE score than those who did not. Each variable exhibited this trend (Table 4), with statistically significant differences in ACE scores by experiences of violence.

Table 4.

Mann-Whitney Test: ACE Score rank and Violence Experienced in last 12 months (N=2,900).-Whitney Test: ACE Score rank and Violence Experienced in last 12 months (N=2,900)

Type of Violence	Experienced Violence in last 12 months	N (%)	Mean Rank	Sum of Ranks	Mann-Whitney Test Statistic	p-value
Physical
	No	2697 (93.0)	1433.79	3866942.00	4.303	<0.001
	Yes	203 (7.0)	1672.45	339508.00
Sexual
	No	2620 (90.34)	1411.26	3636808.50	7.833	<0.001
	Yes	280 (9.66)	1763.60	569641.50
Psychological
	No	1976 (68.1)	1365.61	2698451.00	8.772	<0.001
	Yes	924 (31.9)	1632.03	1507999.00
Stalking
	No	1780 (61.4)	1363.62	2427244.00	7.740	<0.001
	Yes	1120 (38.6)	1588.58	1779206.00

Finally, a logistic regression was performed on each of the violence variables, in order to assess the likelihood of experiencing violence based on ACE score (Table 5). College students with higher average ACE scores are more likely to experience all four types of violence, with a strong dose-response relationship being found between ACE score and experience of sexual, psychological, and stalking violence while in college. Specifically, those with an ACE score of 4–7 were 2.6 times more likely to have experienced sexual violence in the last 12 months compared to those with an ACE score of 0. Further, it was found that those with an ACE score of 8 or more were 4.2 times more likely to experience psychological violence and 4.9 times more likely to have experienced stalking in the last 12 months than those with an ACE score of 0. A dose response relationship was seen between ACEs and stalking violence where students reporting 1–3 ACEs had a 37% higher risk of violence, those reporting 4–7 ACEs had a 1.9 times higher risk, and students in the highest category of ACES (8+) reporting 4.5 times the risk of sexual assault (Table 5). Similar trends were seen with psychological and sexual violence, where violence dramatically increased as the number of ACEs rose (Table 5). A dose-response relationship was not seen between ACEs and physical violence, with only those students reporting 4–7 ACEs having a significant association. This may have been influenced by sample size, as rates of physical violence were the lowest reported (7.0%) compared to psychological (31.9%), sexual violence (9.7%) or stalking (38.6%).

Table 5.

Logistic Regression: Violence Experienced in last 12 months vs ACE Score (N=2,900)

	ACE Score 1–3 vs ACE Score 0 Odds ratio+ (95% CI)	ACE Score 4–7 vs ACE Score 0 Odds ratio+ (95% CI)	ACE Score 8+ vs ACE Score 0 Odds ratio+ (95% CI)
Physical Violence in last 12 months	1.510 (1.09–2.09)	2.604 (1.66–4.09)	1.335 (0.286–6.23)
Sexual Violence in last 12 months	1.617 (1.24–2.12)	2.674 (1.84–3.89)	3.505 (1.265–9.71)
Psychological Violence in last 12 months	1.663 (1.39–1.99)	2.177 (1.63–2.92)	4.919 (1.929–12.26)
Stalked in last 12 months	1.370 (1.16–1.62)	1.927 (1.45–2.56)	4.501 (1.705–11.89)

Note. + adjusted for gender, race, parent’s level of education, self-reported sexual identity, current relationship status, and year in school

Discussion

To the best of our knowledge, this is the first study to find a dose-response relationship between number of ACEs and rates of physical, sexual, psychological violence and stalking in the previous twelve months among college students. The results from this study found that there is a positive relationship between ACES and interpersonal violence; college students who reported a high ACE score also reported significantly higher rates of all four types of violence within the year. Furthermore, a strong dose response relationship was found between ACEs and three of the four types of violence. Specifically, rates increased by 50–60%, depending on violence type, for students reporting 1–3 ACEs when compared to those reporting zero. Students reporting experience with four to seven ACEs during adolescence reported more than double the rate of all four types of violence. Students reporting eight or more ACEs were 3.5 times more likely to have experienced sexual violence, 4.2 times more likely to experience psychological violence, and 4.9 times more likely to have been stalked within the last twelve months.

Interestingly, the rates of each category of ACE appear to differ in this sample of college students from what has been found nationally. The CDC reports that the most common ACE in the general population is physical abuse, which is reported to occur in 28.3% of those surveyed.^36,37 Physical abuse was reported in only 6.7% of the current study population. The most frequent individual adverse experience reported by students were parental separation or divorce (27%), household mental illness (15.7%), and emotional abuse (15.1%). Further, while only 36.1% of the national sample experienced zero ACEs, over half of the college students in this study experienced zero ACEs. This means that individuals who attend college may be different than those who do not, and may also indicate that college students with high ACE scores need additional support to help ensure they are successful.

As a study spanning two large state-funded universities, the results of this cross-sectional study are informative. Previous research has found that undergraduate college students who experience violence are more likely to perform poorly in classes, have a lower cumulative GPA, change majors, or transfer to another school compared to students who have not experienced violence.^38,39 Further, adults who have experienced violence have increased rates of many significant negative health outcomes such as chronic pain, disability, PTSD, and suicidal behavior, among others.³⁶ Given the prevalence of interpersonal violence among college students, having a more informed idea of the type of students who may be at a higher risk of victimization is extremely important.¹⁷

A previous study examined common underlying factors of college student violence to see who might be at an increased risk, and identified dating violence, hazing, and prejudices as factors commonly related to violent events.⁴⁰ Their multifaceted approach to violence prevention emphasized identifying the populations at risk and targeting violence at primary, secondary, and tertiary levels across the institution. Other groups identified sexual violence as a common theme, and suggested engaging more men to intervene as allies, and training resident advisors in bystander intervention.^41,42 To date, these interventions have seen little to no success in reducing rates of violence among the college student population.

A review of the current literature found no information on universities utilizing the ACEs questionnaire as a risk assessment measure for students. Yet, our study is not the first to reveal an association between ACEs and risk of victimization and perpetration of violence among college students. Nikulina and colleagues found that students who were exposed to domestic violence in their youth had an increased risk of IPV victimization and IPV perpetration.²⁹ They also found that growing up with an incarcerated household member was associated with an increased risk of physical and psychological aggression, and that experiencing sexual abuse as a child was associated with increased rates of psychological aggression among the same population. This information, combined with our study’s findings of a dose response relationship between ACEs and victimization, may be useful in the development of programs focused on preventing many of the negative health outcomes associated with ACEs, including IPV.

There are several limitations to the current study. Due to the cross-sectional nature of the survey, it is possible that some pieces of information could be missed or left out due to recall bias. In addition, the limited sample included few students reporting eight or more ACEs, which caused rates of violence among those in this group to appear lower than the average at times. There is also a concern that additional adverse experiences may have occurred during childhood that were not captured on the standard ACEs survey. Further, neither the extent of exposure, nor the age of exposure were measured, both of which may impact the overall impact of each experience. Potential unmeasured confounding variables may also have affected final study results.

Given the identified dose response relationship between ACE score and violence among college students, campus violence prevention programs could benefit from incorporating discussion of ACEs into their curriculum. Research has found ways to reduce the negative impact of ACEs, including: sleep, regular exercise, nutrition, mindfulness, mental health, and health relationships.^43,44 Continuing to incorporate wellness programs that promote these behaviors on college campuses may be useful in mitigating some of the effects of ACEs. Further, administering screenings through student support services such as student health or campus counseling centers may be an avenue for more targeted interventions and connection to resources within universities. Additional research is suggested to better understand the relationship of ACEs and physical, sexual, psychological and stalking violence, specifically among the college population. Further, it is recommended that future studies assess the relationship between ACE score and violence perpetration among college students, which may provide additional insight into risk factors for violent behavior. Additional study is also recommended in ways ACE scores may be utilized as a preventative screening tool to reduce rates of violence on college campuses.