Adverse childhood experiences
This study shows that the frequency of reported child maltreatment and other ACEs is relatively high in this population of Hungarian adolescents: almost half of this sample reported some intrafamilial adversity during their 12 to 17-year-long life, one-fourth of the students reported ≥ 2 categories of childhood adversity exposures, and 7.4% reported experiencing ≥ 4 types of ACEs.
The most prevalent forms of reported child maltreatment were emotional neglect (15.5%) and emotional abuse (14.5%). The most frequently reported dysfunctional household condition was parental divorce or separation (23.8%). The rest of all reported adversities were below 10%. Out of all adversities physical neglect was the least frequent (3.9%), which also shows that only a small proportion of the Hungarian adolescents we studied suffers from not living in appropriate material/physical environment conditions.
As the duration of exposure to ACEs is shorter than 18 years, the data on prevalence must inevitably be lower than in studies conducted in adults.
Every type of ACE (except for incarcerated household member) was more prevalent in girls than boys, and the same was true for cumulative score. To account for this significant difference across genders (emotional neglect is triple, emotional abuse is double in girls than boys), we may assume girls be more sensitive to emotional attitude and related deficiencies, and expect more/warmer interactions. Girls talk more about the emotional aspect of their experiences than boys. In addition, girls use more emotional words when discussing scary events than boys . Girls are also more willing to disclose/express negative emotions such as sadness and fear .
In general, girls seem to be more liable to recognise and/or admit experiencing ACEs. Furthermore, systematic links were found between adolescent problem status and parent approaches to emotion socialisation . These claims are also supported by our own clinical experiences. Considering the unexpected and unjustifiable difference between genders in terms of the frequency of household substance abuse and household mental illness, we can again assume that girls are more disposed to report, and this must have prevailed in case of all the adversities.
Our sample was taken from a country where—unlike in the USA—the awareness of the population has not been raised toward this problem; there is no education provided and no research has been done in the topic. Regarding child maltreatment, it is only the area of sexual abuse where research has consistently confirmed a higher proportion of female victims than males [4, 47].
Unfortunately, we have found few comparable data in Central Eastern European adolescent population in relation to ACEs; most research has been conducted in adult samples. Considering the research done in neighboring countries—which are also post-Soviet countries—we have found that two studies in Romanian adolescents described a higher prevalence of ACEs. It must be mentioned, though, that the measure they used differed from ours [9, 10]. A Slovakian study in adolescents published data on the prevalence of ACEs, which are quite similar to the Hungarian data . As for the Czech study, in which university students were included, we again saw similar results regarding reported emotional abuse, sexual abuse and parental divorce; the rest of adversities (with the exception of incarcerated household member) appeared in higher percentages in the sample .
Studying the research data (some data were collected again from samples of older individuals) from eight Eastern European Countries (Albania, Latvia, Lithuania, Montenegro, Romania, Russian Federation, The former Yugoslav Republic of Macedonia, Turkey), it becomes clear that in terms of ACEs Hungary is a middle-ranking country . At the same time, our data regarding emotional neglect, emotional abuse and parental divorce are less favorable, which should definitely raise our awareness. These results are summarised in Additional file 1: Table S2—A comparison of prevalence rates of child maltreatment reported by children, adolescents and adults in selected European countries. The table can be found among the Additional file 1: Table S2.
Social, emotional, and behavioural symptoms
Every sixth adolescent reported emotional symptoms (the questions mostly assessed the presence of certain features of anxiety and depression), and nearly one-fifth of the sample reported conduct problems. Hyperactivity/inattention problems were outlined by 15.0% of the sample. The prevalence rate of subthreshold ADHD according to international studies is wide-ranging (0.8–23.1%), the comorbidity of subthreshold ADHD is high, and there are several areas where subthreshold ADHD has a meaningful impact on functioning . Nearly one-fifth of adolescents had peer relationship problems. The presence of friends and peer relationships is a matter of cardinal importance in adolescence; their absence or dysfunction might later lead to severe consequences.
Regarding gender differences, behavioural symptoms are significantly more common in boys, whereas peer relationship and emotional problems are more frequent in girls, as expected. Our results on gender differences are consistent with previous study results [38, 50].
In order to test the comparability of our results, we searched the literature for data in other European countries regarding the prevalence rates of self-reported SEB symptoms based on SDQ. We found detailed data in Austria and Poland, and Czech, French, Greek, Dutch, Spanish, Swiss and British data were also available regarding total difficulties [51, 52]. Concerning total difficulties, our present Hungarian sample is a middle-ranking one among the 10 studied European countries.
Subjective health complaints
Over half of students experienced at least one subjective health complaint multiple times a week. More than 50% reported fatigue, and over one-third reported nervousness. Three out of 10 students complained of feeling low, and over a quarter of them experienced headaches and suffered from sleeping difficulties. Other subjective health complaints also appear in the examined sample.
Apart from sleeping difficulties, all the assessed SHC was significantly more frequent among girls than boys, as could be expected. This may be due to the fact that girls are more likely to report, or because the tendency to somatize is more common among women in several cultures .
Results show that a significant percentage of the adolescents we examined struggles with several SHC, as well as social, emotional, and behavioural symptoms.
We also examined what role the directly and indirectly experienced intrafamilial adversities play in the prevalence of symptoms.
Association between adverse childhood experiences and social, emotional, behavioural symptoms, and subjective health complaints
Our findings suggest that adverse childhood experiences have a significant impact on adolescents’ mental health status and subjective health. The results show a dose–response relationship between ACEs and SEB where the multiple accumulation of ACEs is associated with more SEB. Multiple accumulation of ACEs also shows a strong dose–response relationship with the frequency of mood-related complaints, with more ACEs having a more pronounced impact. Similarly, the impact of ACEs on the frequency of headache, irritability and sleeping difficulties complaints has also been found to be strong and nearly cumulative. Frequent dizziness complaints were strongly associated with ACEs; however, it was only true when ACEs were severely accumulated (four or more ACEs). Having three ACEs was a very strong predictor of the frequency of stomachache, backache and nervousness, and could also strongly predict the frequency of fatigue complaints. Nevertheless, these relationships are not that graded when ACE is increased to four or more; there the association become less pronounced. Similar data have been published on associations between adverse childhood experiences and social, emotional, behavioural symptoms, and subjective health complaints [10, 11].
Furthermore, a number of longitudinal studies are available on correlations between child maltreatment and adolescent development or subsequent psychiatric morbity in adulthood [54,55,56].
The prevalence of ACEs, emotional, conduct, and peer relationship problems, and subjective health complaints indicates that adolescents (in our sample) need to face several (previous and/or current) intrafamilial challenges, and mental and health problems at an age when the developmental challenges of adolescence themselves pose a demanding challenge.
These results clearly suggest that the population should be widely informed about the potential adverse consequences of childhood adversities.
Both the subthreshold and suprathreshold social, emotional, and conduct problems, and subjective health complaints require special interventions aimed to reduce these symptoms.
In line with earlier international research, our study reveals that the accumulation of ACEs is associated with more SEB and SHC symptoms. A further triggering factor may be the fact that adolescents exposed to ACEs will probably be less prepared to meet the challenges posed by school and peer relationships.
The main strength of our study is that it was the first study to examine Hungarian adolescents using a validated and internationally recognized measure for the assessment of ACEs, SEB and SHC.
Our results provide further support for research aimed at disclosing the association between ACEs and SEB or SHC in adolescents. A novel feature of our study is that besides SEB it also assessed SHC, which provides a more comprehensive view on the possible consequences of ACEs.
A further strength of our study lies in the fact that it studies adolescents. Evidence shows that it is necessary and justified to include children and adolescents in such research, and the gained data are suitable for analysis [57, 58]. It is also important to get schools involved in prevalence studies, which might result in more detailed and more reliable data.
Like all studies, our study has limitations. Firstly, the fact that it is a cross-sectional study limits the interpretability of data. Secondly, the assessment of not only ACEs, but also SEB and SHC was based on self-report, which might bias results, especially the ones related to externalizing symptoms. The parent and teacher version of the SDQ questionnaire are also available, and their use would have obviously been useful for the aims of our study. Unfortunately, we had to accept we could not use them as we did not possess the Ethics Committee approval required for students’ identification, which would have been necessary for coupling the questionnaires.
Thirdly, the ACE Score Calculator is a short retrospective 10-item measure, which may result in reported ACEs getting lost or biased. Next, when interpreting SEB symptoms, we also incorporated the borderline category into our interpretation. Finally, the sample cannot be regarded representative even though adolescents from a wide range of social backgrounds were included. This, however, makes our sample suitable to capture the current situation in large sections of our society.