Adverse Childhood Experiences Among Medical Students And Its Relationship With Executive Functioning And Aggression

Objective:This study aimed to investigate the prevalence of adverse childhood experiences (ACE) among medical students at a university in Jinan City; the relationship of ACE, executive functioning and aggression; the mediating effect of ecological and neuropsychological executive functioning respectively in the relationship between ACE and aggression.Methods:There were two stages in this study. The first stage was a questionnaire survey conducted during October,2011among medical students (all medical undergraduates of Grade2011) at a university in Jinan City.538questionnaires were distributed and502were returned back, of which492were regarded as valid ones after removing questionnaires with missing items exceeding15%of all the items, and thus the valid return rate was91.45%. Measurements used in stage one included self-administered general information questionnaire, Adverse Childhood Experiences Questionnaire (ACEQ),12-item Aggression Questionnaire (AQ), Behavior Rating Inventory of Executive Function-Adult Version (BRIEF). Stage two was to assess the neuropsychological executive functioning. There were three groups in this stage, cumulative adversity group (ACE>2in stage one, n=50), single adversity group (ACE=1in stage one, n=50) and control group (ACE=0in stage one, n=50). The last two groups were matched with cumulative adversity group in age, sex and intelligence. Measurements in stage two included Raven Standard Progressive Matrices Test and Cambridge Neuropsychological Test Automated Battery which included Motor Screening test, Big/Little Circle, Intra/Extradimensional Set Shift (IED), Stop Signal Task (SST), and Spatial Working Memory (SWM).Results:Results of stage one: (1) The most prevalent ACE was emotional neglect (25.0%), and sexual abuse (11.2%) was following behind. The prevalence of physical abuse (0.8%) was lowest.46.5%medical students had at least one type of ACE, and4.7%reported three or more ACE.(2)43.6%of those reporting physical neglect reported emotional neglect. Among those who have experienced domestic violence or parental separation or divorce, the prevalence of emotional neglect and sexual abuse increased to43.8%/40.0%, and31.2%/17.8%respectively. Participants who have mental illness in household reported a high rate of parental separation or divorce (47.6%), and domestic violence (31.2%).(3) There were significant differences of scores on physical aggression, anger, hostility and total AQ among participants with0,1,2, and3or more ACE (F=3.93～29.58, all P<0.05). By using spearman rank correlation analysis, score of ACE was positive related to physical aggression, verbal aggression, anger, hostility and total AQ (rs=0.091-0.195, P<0.05). Linear regression analysis also showed that score of ACE positively predicted the scores on the four subscales and total AQ with R2ranging from13.9%to39.8%.(4) Except organization subscale, scores on the other8subscales of BRIEF, Metacognition index, Behavioral regulation index, and Global Executive Composite were higher in participates with1,2,3or more ACE (differences were not significant among these3groups except scores on plan subscale) than those without ACE (F=3.06～9.53, all P<0.05).(5) GEC positive predicted the scores on the four subscales and total AQ with R2ranging from13.9%to39.8%.(6) Two structure equation models were derived from hypothesis and were tested. Results showed that the model in which ecological executive functioning partially mediated the relationship between ACE and aggression (χ2=10.488, df=6, P=0.106, CFI=0.994, NFI=0.986, RMSEA=0.039) was better than the model in which ecological executive functioning played as a full mediator in the relationship between ACE and aggression (χ2=25.753, df=8, P=0.001, CFI=0.975, NFI=0.965, RMSEA=0.067), Δχ2=15.265, Δdf=2, P<0.01.Results of stage two:(7) Three principle components were derived by conducting principle component analysis with six variables from IED, SST, and SWM, which were named as inhibition control, working memory and cognition flexibility respectively. (8) There were no significant differences of inhibition control, working memory and cognition flexibility among cumulative adversity group, single adversity group and control group (F=0.036-0.764, all P>0.05). Among cumulative adversity group, the spearman rank correlation analysis showed that ACE score was not significantly related to inhibition control, working memory and cognition flexibility (rs=-0.008-0.100, all P>0.05).(9) Among cumulative adversity group, inhibition control positively related to physical aggression (r=0.334, P<0.05).(10) Among cumulative adversity group, spearman rank correlation analysis showed that the score of ACE was not significantly correlated with aggression (rs=-0.058--0.241, all P>0.05), and linear regression analysis showed that ACE could not predict aggression.Conclusions:(1) The cumulative effect of ACE on aggression is in a linear paradigm. The reduction of every single ACE would be effective to decrease the risk of aggression.(2) Ecological executive functioning partially mediates the relationship between ACE and aggression.(3) There is no significant difference of neuropsychological executive functioning and aggression among medical students with cumulative adversity, single adversity and medical students without ACE. There might be saturation effect between ACE and neuropsychological executive functioning and aggression when ACE is more than2.(4) Inhibition control is positively related to aggression. The worse the inhibition control is, the more serious aggression is.