children

Article
Adverse Childhood Experiences: Mental Health Consequences
and Risk Behaviors in Women and Men in Chile
Sofía Ramírez Labbé 1 , María Pía Santelices 1,2, * , James Hamilton 2,3 and Carolina Velasco 4

1 Escuela de Psicología, Pontificia Universidad Católica de Chile, Vicuña Mackenna 4860, Macul,
Santiago 7810000, Chile
2 Centro de Investigación del Abuso y la Adversidad Temprana, CUIDA, Santiago 7810000, Chile
3 Departamento de Salud Pública, Escuela de Medicina, Pontificia Universidad Católica de Chile,
Santiago 7810000, Chile
4 Escuela de Trabajo Social, Pontificia Universidad Católica de Chile, Santiago 7810000, Chile
* Correspondence: msanteli@uc.cl

Abstract: Studies conducted worldwide indicate that adverse childhood experiences (ACEs) are
among the most intense and frequent sources of stress, considerably influencing mental and physical
health while also resulting in risk behaviors in adulthood. Methodology: We used data from the Pilot
National Survey of Adversity and Sexual Abuse in Childhood (2020), conducted by CUIDA UC, which
comprises the Adverse Childhood Experiences International Questionnaire [ACE-IQ] (Adapted).
The cross-sectional methodology used made it possible to directly calculate the prevalence of adverse
childhood experiences in the population sampled, at a single point in time. We performed a bivariate
and univariate descriptive analysis, a correlation analysis, and a multivariate analysis, all of which will
be detailed in the section entitled “General Data Analysis Procedure”. Results: We found equally high
rates of adverse childhood experiences in men and women, with community violence exhibiting the
Citation: Ramírez Labbé, S.;
highest prevalence. We found significant low- to moderate-sized associations between the multiple
Santelices, M.P.; Hamilton, J.; types of ACEs considered and mental health problems, substance use problems, criminal behaviors,
Velasco, C. Adverse Childhood and intrafamily violence (IFV), which differed between men and women. Significant correlations
Experiences: Mental Health were detected between the ACE score and mental health, substance use, criminal behaviors, and IFV
Consequences and Risk Behaviors in in both men and women. Importantly, ACEs were found to be predictors of all of these variables,
Women and Men in Chile. Children with differences observed between men and women. Conclusions: Nearly all participants reported
2022, 9, 1841. https://doi.org/ having had at least one ACE and more than half reported had four or more ACEs. Those who had
10.3390/children9121841 had four or more ACEs were more likely to report problems throughout their life. Having an ACE of
Academic Editor: Dora Isabel any type was found to be a better predictor of mental health problems and IFV in men than in women
Fialho Pereira and might be a stronger risk factor for substance use and criminal behaviors in women than in men.

Received: 15 September 2022

Keywords: adverse experiences; childhood; mental health; risk behaviors; adulthood
Accepted: 14 November 2022
Published: 28 November 2022

Publisher’s Note: MDPI stays neutral

with regard to jurisdictional claims in 1. Introduction
published maps and institutional affil-
Mental health problems are the main source of burden of disease for adults in Chile
iations.
(20–44 years of age) [1]. This means that, in our country, mental disorders or neuropsy-
chiatric conditions (uni and bipolar depressive disorders, schizophrenia, alcohol/drug
dependency and use, anxiety disorders, epilepsy, dementia, Parkinson’s disease, migraines,
Copyright: © 2022 by the authors. cerebral palsy in children, and attention-deficit/hyperactivity disorder) constitute the lead-
Licensee MDPI, Basel, Switzerland. ing cause of years of healthy life lost due to disability (YLD), which is associated in the
This article is an open access article long term with a major decrease in the quality of life, physical health problems, and high
distributed under the terms and rates of premature mortality [2,3]. In adults, the burdens associated with neuropsychiatric
conditions of the Creative Commons conditions are mainly influenced by mood disorders and alcohol dependency. In women,
Attribution (CC BY) license (https:// unipolar depressive disorders, anxiety disorders, and assault are among the main five
creativecommons.org/licenses/by/ causes of YLDs; for men, the main causes are problems related to alcohol use and unipolar
4.0/).

Children 2022, 9, 1841. https://doi.org/10.3390/children9121841 https://www.mdpi.com/journal/children

Children 2022, 9, 1841 2 of 16

depressive disorders [2]. That is, the risk factors that impact health, and greatly decrease
people’s well-being.
The latest Longitudinal Social Protection Survey conducted in Chile [4], which em-
ployed the “Patient Health Questionnaire” (PHQ-9), revealed that depression rose in the
general population from 6.9% in 2015 to 16.32% between December 2019 and March 2020.
These country-level findings, which demonstrate how mental health problems and risk be-
haviors impact people’s quality of life, stress the importance of studying and exploring the
implications of certain factors that might affect mental health and behavior in adulthood.
Adverse childhood experiences (ACEs) are among several risk factors with major
mental health consequences in adulthood. They have been defined as factors to which
children are frequently exposed in childhood and which can interrupt development and
have a negative impact on health in later years [5].
ACEs are factors with a considerable influence on both the mental and physical
health in adulthood [6,7] and have been extensively studied in North America and Europe.
They are internationally regarded as the most intense and frequent stress sources that
children experience early in life [5,8]. A person’s history of ACEs increases their risk of
suffering from emotional and behavioral problems as an adult, with its effects being deemed
as adverse outcomes or consequences throughout their life [9,10]. These consequences
can be varied, affecting physical health, mental health, and risk behaviors [11] in both
adolescence and adulthood [12].
Even though some studies have found sex-related differences in the number of re-
ported ACEs [13–15] and their mental health consequences [16,17], more evidence is needed
to assert that the mental health effects of each type of adversity are not the same for men
and women [18,19].
The current research on ACEs in Latin America is scarce. As of this writing, there is one
epidemiological study on ACEs, family strengths, and their relationship with health-related
risk factors in Argentina [20], as well as ongoing research in Chile aimed at validating and
adapting the questionnaire to the sociocultural context of the country. In Chile, we have
very few investigations regarding the prevalence of ACEs and their impact on the popu-
lation. Therefore, and considering the impact of the consequences of adverse childhood
experiences during a person’s life, it is relevant to study the association between ACEs and
their effects on mental health and risk behaviors in our country while also exploring any
possible sex-related differences regarding the types of adversities affecting women and
men and their consequences on mental health and risk behaviors in adulthood. For this
reason, this study will only include a Chilean sample.
This study was conducted as part of the 2020 Pilot National Survey of Adversity and
Sexual Abuse in Childhood, carried out by CUIDA UC (Center for research on abuse and
early adversity). We sought to determine the prevalence of ACEs in a sample of Chilean
adults, residing in the 5th Region of Chile. Furthermore, we explored the association be-
tween ACEs and self-reported mental health throughout the life cycle while also examining
the relationship between ACEs and various health-related risky behaviors, analyzing the
differences between men and women. Risk behaviors will be defined as voluntary or
involuntary actions performed by an individual or community which can have negative
consequences, and which are also multiple and may be bio-psycho-social in nature, such as
substance abuse and behaviors ultimately leading to injuries and violence [21]. These will
be taken to include alcohol and substance use, criminal behaviors, and intrafamily violence.

ACEs and the Differences between Men and Women

A meta-analysis conducted in 2018 [18] showed that there are no significant differences
in sex in the association between abuse in childhood and mental health consequences in
adulthood. Yet, it is worth pointing out that this study only included five articles that
examined the physical and sexual abuse as causes of depressive and anxious disorders,
leaving out other adverse experiences, since only these types of abuse coincided with
the comparative variables of maltreatment/abuse and sex. Therefore, this evidence is
Children 2022, 9, 1841 3 of 16

insufficient for answering and solving the question of whether significant sex-related
differences exist regarding physical and sexual abuse experiences or other types of early
adverse experiences [19], and to establish whether significant differences exist in the
association between ACEs and mental health problems in adulthood.
In 2020, a study on the role of sex in the relationship between ACEs and substance
use and criminal behaviors in adolescents found no differences by sex in either the overall
ACE scores or ACE accumulation, with both men and women experiencing at least one
adverse experience. As for adverse experience types, no significant differences were
found between men and women, except for physical abuse, which was—on average—
more commonly reported by men. The correlation between ACEs and substance use was
significant only for women, whereas the correlation between ACEs and criminal behaviors
was significant for men [21]. Using a Brazilian cohort (n = 4230), researchers found that
the occurrence of ACEs is positively associated with the use of alcohol, tobacco, and illicit
drugs (e.g., marijuana, cocaine) in adolescents and that there are differences between men
and women, with young women who have had three or more ACEs exhibiting a greater
prevalence of tobacco and illicit drug use than their male peers, but with alcohol use not
differing significantly between the sexes [22]. However, when studying the association
between childhood trauma and alcohol dependency in adulthood (n = 280 patients and
137 control subjects), no significant differences were found between men and women,
suggesting that emotional abuse experiences predict dependent alcohol use in adults
of both sexes but without helping to establish the effect of sex and the emergence of
significant differences in larger samples [23]. Using an adult sample (n = 34,653), authors
examined the association between physical, emotional, and sexual abuse, physical and
emotional neglect, and substance use (alcohol, sedatives, opiates, amphetamines, cocaine,
amphetamine, cannabis, heroin, hallucinogens, and nicotine), finding that these five types
of adverse experiences were associated with an increase in the problematic use in both
men and women, except for physical neglect and heroin use in men and emotional neglect
and amphetamine and cocaine use in men [22]. These findings are in line with previous
studies that highlight the effect of abuse experiences in childhood, which have been shown
to be significantly associated with the use of psychoactive drugs in adult women and
men [24]. In this line of research, the authors studied the link between ACEs and alcohol
use in a sample of 7279 subjects, also analyzing the moderating role of psychological
stress in men and women [25]. This study found a high prevalence of substance use
in both men and women who had experienced any of the ACEs considered as well as
significant differences between the sexes in the association between alcohol consumption
and the type of adverse experience that had affected the subjects. The authors stress that,
in men, physical and sexual abuse, emotional neglect, and household dysfunctions (drug
abuse, mental disease, and incarceration of a member) are linked to self-reported alcohol
problems, whereas in women, emotional, physical, and sexual abuse, neglect (emotional
and physical), and household dysfunctions (parental separation, drug use, and mental
disease of a member) are related to alcohol problems. In addition, women were more likely
to report experiences of emotional and sexual abuse, emotional neglect, parental divorce
or separation, witnessing domestic violence, and having a family member with a mental
disease or incarcerated, whereas men were more likely to report experiences of physical
abuse and neglect [26].
Regarding the differences between men and women in the association between ACEs
and aggressive behaviors, research indicates that men with more experiences of sexual
abuse in childhood exhibit a stronger link to the perpetration of physical intimate partner
violence as well as more antisocial behaviors than women [27]. Antisocial behaviors were
also found to have a moderating effect between the experience of sexual abuse and the
perpetration of violence, with the effect being greater in women than men, which suggests
that the association between early sexual abuse in men and violence exerted against their
partner can be mediated by other factors, such as anger, PTSD symptoms, and substance
use [27]. The authors of a recent study also stressed the importance of considering both
Children 2022, 9, 1841 4 of 16

the advantages and the limitations of ACEs as an instrument, noting that it is inaccurate to
state that all adverse experiences have the same influence and that it is necessary to learn
more about the adverse effects of each individual experience [23].
Considering the latter, it is worth noting that Chile’s alcohol and substance use rates
are high, with one in 10 people having alcohol use problems; furthermore, household drug
use and marijuana dependency symptoms have increased significantly, rising from 14.8%
in 2016 to 20.3% in 2018 [28]. Concerning poly-victimization in adulthood, intimate partner
violence in its multiple manifestations (psychological, emotional, physical, economic, and
sexual) has gained increased recognition as a global problem [29]. In Chile, a regional
study examined the prevalence of this phenomenon, revealing that emotional, physical,
and sexual violence are significantly greater in women [30]; also, the 4th National Survey of
Violence in Family Settings (2020) found that 41.4% of women between 15 and 65 years of
age have experienced IFV (physical, psychological, or sexual) at least once in their lifetime,
with this rate being significantly higher than that found in 2017 [31].
Current research [19,27] has stressed the need to examine the differences between men
and women, regarding the types of adverse experiences affecting them, taking into account
their potential impact on the development of mental health problems and risk behaviors
in adulthood, which include problematic substance use, violent behaviors toward others,
and other criminal behaviors; furthermore, it is necessary to track how this relationship
changes among samples and countries. Considering this, the present study examines the
risk factors whose incidence and prevalence are high in Chile, according to the literature,
such as alcohol and substance use, intrafamily violence, and criminal behaviors.
It is relevant to expand this line of research and apply it to the Chilean context,
bearing in mind the importance of addressing early risk factors and preventing exposure to
adverse experiences in childhood as a way of reducing their impact on the development of
psychopathology in adulthood.
No significant differences are expected to be found in the prevalence of ACEs between
men and women, but rather differences in terms of the type of experiences in childhood.
Regarding sex, differences could be found in terms of mental health problems, use of
OH and/or substances, criminal behavior, and IFV (greater mental health problems and
complaints filed by IFV in women and greater criminal behavior, consumption of OH and
/substances and complaints received by IFV by men). Finally, it is expected that the greater
the number of ACEs, the greater the self-reported mental health problems will be observed
throughout life, a greater number of OH and/or substance use problems, more criminal
behavior, and more domestic violence will be observed.

2. Methodology
2.1. Participants and Instruments
For this research, we used the database from the Pilot National Survey of Adversity
and Sexual Abuse in Childhood (2020), conducted by CUIDA UC and approved by the
university’s institutional review board. The Pilot Survey was administered to an urban
sample (n = 200) composed of 137 women (68%) and 63 men (32%) between 18 and
89 years of age who resided in the 5th Region of Chile (Concón, Quilpué, Quintero, and
Villa Alemana).
Pilot National Survey of Adversity and Sexual Abuse in Childhood: The instrument com-
prises several modules. In this study, we employed the following: the demographic
questionnaire, the adverse childhood experiences module, the sexual abuse module, and
the late adversities module. The latter includes items on mental health, risk behaviors
(criminal behaviors and alcohol and/or substance use), and family life.
The Adverse Childhood Experiences International Questionnaire [ACE-IQ] (Adapted): Retro-
spective questions focused on situations experienced before 18 years of age. The material
used is based on the Adverse Childhood Experiences International Questionnaire (ACE-IQ)
(The ACE-IQ was constructed by Felitti et al. (1998), who modified the conflicts tactic scale
and the National Health Interview Survey (NHIS). Its internal consistency is Cronbach’s
Children 2022, 9, 1841 5 of 16

α = 0.95 [32], produced by the World Health Organization [5]. The instrument covers
13 categories in total, considering the 10 categories of the original questionnaire (physical,
psychological, and sexual abuse, psychological and physical neglect, violence against a
family member, mental disease affecting family members, substance abuse, incarceration of
a family member, and parental separation, loss, or divorce) [6,33], plus two categories incor-
porated following the current research (school bullying and community violence) [34,35]
and one new category of collective violence [5], which refers to contexts of political vio-
lence and armed conflicts. It is worth pointing out that the questions about sexual abuse
were selected from the sexual abuse module and incorporated into the ACE-IQ. Thus, the
questionnaire has 25 items plus two items belonging to the sexual abuse category.
Self-administered Sexual Abuse Questionnaire: Self-administered instrument, based on
the NIS-3 [36,37] (Third National Incidence Study of Child Abuse and Neglect.), which
classifies abuse into three types: with physical contact and penetration/rape (oral, anal, or
genital penetration with the penis or anal or genital penetration with fingers or any other
type of penetration), with physical contact and without penetration (acts involving any type
of genital contact), and with no genital contact (caresses, exposure, or other unspecified acts
with no genital contact). Based on this questionnaire, we selected items that matched the
sexual abuse category of the ACE-IQ. Two questions were included: At any point in your
life, has anyone groped, fondled, or kissed you through manipulation, deceit, submission,
or obligation, and/or forced you to do so? Was there oral, anal, or vaginal penetration
with the penis, fingers, or any other object, through manipulation, deceit, submission, or
obligation and/or were you forced to do so?
Late adversities questionnaire: This instrument considers the modules mental health
throughout the life cycle, family life, and risk behaviors (criminal behaviors and alcohol
and drug use problems involving marijuana, cocaine, and cocaine paste). In the men-
tal health throughout the life cycle section, the participants were asked to report which
psychopathologies they had ever been professionally diagnosed with. The following psy-
chopathologies were included in this section: depression, schizophrenia, post-traumatic
stress, nervous anorexia or bulimia, generalized anxiety disorder, borderline personality
disorder, suicidal ideation, non-suicidal self-harm, and learning disorders. Regarding the
family life module, two intrafamily violence (IFV) items were considered: having lodged
an intrafamily violence complaint and having been reported for such acts at least once.
The questions about criminal behaviors covered the following seven problems: intention-
ally hurt someone in a fight, had to drop out of school or was expelled, committed theft or
robbery, sexually abused or assaulted someone, trafficked or sold drugs, has been convicted
by a court, has had to serve a prison sentence of more than three months. As for alcohol
and/or substance use problems, the participants were asked to answer “yes” or “no” to the
following statements: has had problems with alcohol, has used marijuana somewhat fre-
quently, has used cocaine or cocaine paste, even infrequently. For this study, the following
dependent variables will be considered: mental health problems, alcohol and/or substance
use, criminal behaviors, and intrafamily violence.

2.2. Statistical Analyses

First, we constructed an ACE score for a binary version, according to the guidelines
for analyzing the ACE-IQ [5]. The construction of the binary version of the ACE consists
in assigning one point per category if the participant answers affirmatively (once, several
times, or many times). These points are then added up, yielding a scale with scores ranging
from 0 to 13. The construction of the ACE index will make it possible to conduct the
necessary analyses for observing the relationships between ACE scores and their impact
on mental health and health risk factors. This process was carried out using STATA 15.1.
We performed descriptive bivariate and univariate analyses, correlation analyses, and
multivariate analyses of the full sample, plus separate analyses for men and women.
We used the chi-squared test to check for significant differences between the variables:
ACEs, mental health, substance use, criminal behaviors and intrafamily violence, and sex.
Children 2022, 9, 1841 6 of 16

To analyze the association between the variables, we used the Mathews correlation
coefficient (or Phi), also considering the effect size and the significance of the relationship
(p-value). This coefficient was used to analyze the association between each category of
ACEs and each dependent variable (mental health, alcohol and/or substance use, crimi-
nal behaviors, and IFV) in the overall sample as well as in men and women, separately.
To analyze the correlations between the independent variables (ACEs) and the dependent
variables, we used Spearman’s correlation coefficient, given the non-normal distribution of
the sample. To do so, we constructed an index for three of the dependent variables so that
it would yield the number of problems of the following types reported by the participants:
mental health, alcohol and/or substance use, and criminal behaviors. For the intrafamily
violence (IFV) variable, we constructed a dichotomous indicator to measure the presence
or absence of violence and victimization (i.e., has lodged an intrafamily violence complaint
or has been legally accused of such acts). This decision was made, due to the small N of
responses to these items.
Lastly, we produced a set of regression models, according to the multiple variables
analyzed, considering the sex differences. We used Poisson regressions for the count vari-
ables (number of mental health problems, substance use problems, and criminal behaviors)
since they are response variables with a Poisson distribution. Furthermore, we employed
logistic regressions for the dichotomous variable IFV to predict the result of this categorical
variable concerning the predictor variable (ACEs). It is important to emphasize that for
this investigation, the 13-item ACE was used, and we incorporated the 10-item ACE to
compare the prevalence with other studies that only used 10 items.

3. Results
The participants were 63 men (31.5%) and 137 women (68.5%), over 18 years of age.
Out of a total of 200 participants, 196 completed the adapted ACE-IQ. Table 1 shows the
prevalence of ACEs considering the 13 categories used in this study [5], revealing that
nearly all of the participants (88.9%) reported having had at least one adverse experience in
childhood and that more than half of the participants (54.6%) reported having had four
or more ACEs. Regarding the prevalence of adverse experiences by sex, no significant
differences were found between men and women (p > 0.05), with 50.8% of the men and
56.4% of the women reporting four or more ACEs.

Table 1. Prevalence of ACEs.

Men N = 63 Women N = 133 Total N = 196

% % %
ACE
0 9.50% 10.50% 10.20%
1 12.70% 10.50% 11.20%
2 17.50% 10.50% 12.80%
3 9.50% 12.00% 11.20%
1 or more 90.5% 89.5% 88.9%
4 or more 50.80% 56.40% 54.60%
Note: The table shows the prevalence of adverse childhood experiences by sex in the full sample, considering the
13 categories. Differences between men and women are not significant.

To compare the prevalence rates with international results, we considered the 10

categories of the original questionnaire (physical, emotional, and sexual abuse, physical
and emotional neglect, parental divorce/separation, violence against a household member,
family member with substance use problems, family member with severe mental health
problems, incarcerated family member.) [6,33]. Table 2 shows that 80.8% of the participants
reported having had at least one early adverse experience, with 76.2% of the men and 83%
Children 2022, 9, 1841 7 of 16

of the women reporting at least one type of ACE. No significant differences were found
between men and women; 34.8% of the participants reported four or more ACEs, with
27% of the men and 38.5% of the women having had four or more adverse experiences in
childhood. No significant differences were found between the sexes.

Table 2. Prevalence of ACEs considering the 10 categories.

Men N = 63 Women N = 135 Total N = 198

% % %
ACE
0 23.8% 17.0% 19.2%
1 14.3% 20.0% 18.2%
2 20.6% 10.4% 13.6%
3 14.3% 14.1% 14.1%
1 or more 76.2% 83.0% 80.8%
4 or more 27.0% 38.5% 34.8%
Note: The table shows the prevalence of adverse childhood experiences by sex in the full sample, considering the
10 categories. Differences between men and women are not significant.

3.1. Type of Adverse Childhood Experiences by Sex

A comparison between the types of ACEs affecting men and women reveals some
differences in the sample (Figure 1). Men (31.7%) report more experiences of physical
neglect, community violence (63.5%), having a family member with alcohol and substance
use problems (22.2%), and collective violence (33.3%), than women. For their part, women
report more experiences of sexual abuse (40.1%), physical abuse (34.3%), emotional abuse
(46%), emotional neglect (24.1%), bullying (47.1%), parental absence or separation/divorce
(41.9%), witnessing violence in the household (48.2%), having incarcerated family members
Children 2022, 9, x FOR PEER REVIEW 8 of 17
(7.3%), and having family members with mental disease (16.1%). Even though these results
indicate that early adverse experiences differ by sex, the differences are only significant for
sexual abuse.

70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%

Men N=63 Women N=133 Total N=196

Figure 1. Adverse Childhood Experiences in Men and Women. p > 0.0001 ***.
Figure 1. Adverse Childhood Experiences in Men and Women. p > 0.0001 ***.
Positive and statistically significant associations were found between ACEs and re-
Positive
porting andone
at least statistically significant
mental health associations
problem, were found
one substance between and
use problem, ACEs at and
leastre-
one
porting at least one mental health problem, one substance use problem, and at
criminal behavior in one’s lifetime. Importantly, 70.1% of the participants who reportedleast one
criminal behavior
four or more ACEs,inhad
one’s
hadlifetime.
at leastImportantly, 70.1% disorder
one mental health of the participants who reported
in their lifetime, 37.4% had
four or more ACEs, had had at least one mental health disorder in their lifetime, 37.4%
had had alcohol and/or substance use problems, and 33.6% reported having had at least
one criminal behavior.
The relationship between ACEs and intrafamily violence was not found to be statis-
tically significant. Of those who reported four or more ACEs, 18.7% had lodged an IFV
complaint in their lifetime, while only 2.8% had been reported for IFV (Table 3).
Children 2022, 9, 1841 8 of 16

had alcohol and/or substance use problems, and 33.6% reported having had at least one
criminal behavior.
The relationship between ACEs and intrafamily violence was not found to be statis-
tically significant. Of those who reported four or more ACEs, 18.7% had lodged an IFV
complaint in their lifetime, while only 2.8% had been reported for IFV (Table 3).

Table 3. Adverse Childhood Experiences and at least one Mental Health Problem, Substance Use
Problem, Criminal Behavior, and IFV.

ACE
0 1 2 3 4 or More Total ACE
Mental Health Problems
Yes 15.00% 18.20% 20.00% 36.40% 70.1% 48.50%
No 85.00% 81.80% 80.00% 63.60% 29.90% 51.50%
Substance use Problem
Yes 5.00% 13.60% 20.00% 27.30% 37.40% 28.10%
No 95.00% 86.40% 80.00% 72.70% 62.60% 71.90%
Criminal Behavior
Yes 0.00% 9.10% 12.00% 36.40% 33.60% 25.00%
No 100.00% 90.90% 88.00% 63.60% 66.40% 75.00%
Filing IFV Complaint
Yes 0.00% 4.50% 12.00% 13.60% 18.70% 13.80%
No 100.00% 95.50% 88.00% 86.40% 81.30% 86.20%
Receiving IVF Complaint
Yes 0.00% 0.00% 0.00% 0.00% 2.80% 1.50%
No 100.00% 100.00% 100.00% 100.00% 96.30% 98.00%
Note: The figure shows the percentage of participants who reported 4 or more ACEs and at least one mental health
problem, at least one substance use problem, at least one criminal behavior, and IFV in their lifetime.

3.2. Correlation between the Adverse Childhood Experiences and the Indexes of Mental Health,
Substance Use, Criminal Behavior, and IFV
An index was created for each dependent variable that indicated the number of
problems reported by the participants. The index of mental health problems indicates the
number of mental health problems reported by each participant. Given the characteristics
of the sample, this index ranged from 0 to six mental health problems. The index of
alcohol and/or substance use problems indicates the number of problems reported by
the participants, which ranged from 0 to three types of problematic use. The index of
criminal behaviors indicates the number of such behaviors, ranging from 0 to eight reported
behaviors. Furthermore, we considered the intrafamily violence variable as a dichotomous
(yes/no) variable that indicates whether the participants had lodged an IFV report or had
been reported for IFV at least once in their life.
Significant correlations were found between the number of ACEs and the number of
problems reported in the full sample. A positive, moderate, and statistically significant
correlation was found between the number of ACEs and the number of mental health
problems. In contrast, a significant but weak correlation was found between the number of
ACEs and the following consequences: alcohol and/or substance use, criminal behaviors,
and IFV (Table 4).
The correlation between the number of ACEs and the number of lifetime consequences
reported is significant for both men and women. For both male and female respondents,
there is a positive, moderate, and significant correlation between the number of ACEs
and the number of mental health, as well as a positive, weak, and significant association
between the number of ACEs and the number of alcohol and/or substance use problems,
criminal behaviors, and IFV events (Tables 5 and 6).
Children 2022, 9, 1841 9 of 16

Table 4. Correlation between ACEs and consequences for mental health, criminal behaviors, alcohol
and/or substance use, and IFV in the full sample.

ACE Mental Health Substance Use Criminal Behaviors IVF

ACE 1.0
Mental health 0.55 *** 1.0000
Substance use 0.2692 *** 0.2052 ** 1.0000
Criminal behaviors 0.2929 *** 0.2576 ** 0.4309 *** 1.0000
1.0000
IVF 0.2930 *** 0.1621 * 0.0130 0.0725
Note: The table indicates Spearman’s correlation coefficients and significance. p > 0.0001 *** p < 0.001 ** p < 0.01 *.

Table 5. Correlation between ACEs and impact on mental health, criminal behaviors, alcohol and/or
substance use, and IFV in men.

ACE Mental Health Substance Use Criminal Behaviors IVF

ACE 1.0000
Mental health 0.4566 *** 1.0000
Substance use 0.3073 * 0.2156 1.0000
Criminal behaviors 0.3706 ** 0.2829 * 0.4089 *** 1.0000
1.0000
IVF 0.3833 ** 0.2137 0.0424 0.2556
Note: The table indicates Spearman’s correlation coefficients and significance. p > 0.0001 *** p < 0.001 ** p < 0.01 *.

Table 6. Correlation between ACEs and impact on mental health, criminal behaviors, alcohol and/or
substance use, and IFV in women.

ACE Mental Health Substance Use Criminal Behaviors IVF

ACE 1.0000
Mental health 0.5816 *** 1.0000
Substance use 0.3119 *** 0.2656 ** 1.0000
Criminal behaviors 0.3142 *** 0.3352 *** 0.4311 *** 1.0000
1.0000
IVF 0.2607 ** 0.1334 0.0128 0.0008
Note: The table indicates Spearman’s correlation coefficients and significance. p > 0.0001 *** p < 0.001 **.

3.3. Regression Models for the ACEs and the Impact on Mental Health and Health Risk Behaviors
We employed a Poisson regression model for the following count variables: mental
health problems, alcohol and/or substance use, and criminal behaviors, and a logistic
regression model for the dichotomous variable IFV.
The mental health problems model indicates that, for each ACE, the number of lifetime
mental health problems increases by 22% in the full sample, with women exhibiting 65%
more mental health problems (Table 7).

Table 7. Poisson model for the mental health problems.

b SE Exp (b)
Intercept −1.36 *** 0.2 0.26
ACE 0.20 *** 0.02 1.22
Sex (women) 0.50 *** 0.19 1.65
Note: p > 0.0001 ***.

Table 8 presents the alcohol and/or substance use problems model, which indicates
that, for each ACE, the number of alcohol and/or substance use problems increases by 19%
in the full sample, with women exhibiting 56% less alcohol and/or substance use problems.
Children 2022, 9, 1841 10 of 16

Table 8. Poisson Model for the alcohol and/or substance use problems.

b SE Exp (b)
Intercept 1.34 *** 0.25 0.26
ACE 0.17 *** 0.04 0.19
Sex (women) −0.82 ** 0.24 0.44
Note: p > 0.0001 *** p < 0.001 **.

Regarding the criminal behaviors model, for each ACE, the lifetime number of criminal
behaviors increases by 22%; in contrast, the association is negative for women, as they
exhibit 64% fewer criminal behaviors (Table 9).

Table 9. Poisson model for criminal behaviors.

b SE Exp (b)
Intercept −1.39 *** 0.26 0.25
ACE 0.2 *** 0.04 1.22
Sex (women) −1.01 ** 0.24 0.36
Note: p > 0.0001 *** p < 0.001 **.

Lastly, the IFV model indicates that, for each ACE, the likelihood of having lodged an
IFV report or having been reported for IFV increases by 34% in the full sample (Table 10).

Table 10. Logistic regression model for intrafamily violence.

b SE Odds Ratio
Intercept −3.27 *** 0.54 0.04
ACE 0.29 *** 0.07 1.34
Sex (women) 0.09 ** 0.47 1.1
Note: p > 0.0001 *** p < 0.001 **.

3.4. Regression Model for Men and Women

A Poisson regression model was used for the count variables and a logistic regression
model for the dichotomous variables to analyze the effect of ACEs on mental health prob-
lems, alcohol and/or substance use, criminal behaviors, and IFV, in both men and women.
The model of mental health problems by sex indicates that, for each ACE, the lifetime
number of mental health problems in men increases by 27% (Table 11). In women, for each
ACE, the lifetime number of mental health problems increases by 22%. This means that
early adverse experiences are a better predictor of mental health consequences in men than
in women.

Table 11. Poisson model for mental health problems by sex.

b SE Exp (b)
Intercept −1.57 *** 0.36 0.2
ACE Men 0.24 *** 0.06 1.27
Intercept −0.82 *** 0.17 0.44
ACE Women 0.2 *** 0,02 1.22
Note: p > 0.0001 ***.

The model of alcohol and/or substance use problems by sex indicates that, for each
ACE, the number of such problems increases by 15% in men (Table 12), with the increase
for women reaching 21%.
 Children 2022, 9, 1841 11 of 16

Table 12. Poisson model for alcohol and/or substance use problems by sex.

b SE Exp (b)
Intercept −1.19 *** 0.33 0.3
ACE Men 0.14 * 0.06 1.15
Intercept −2.29 *** 0.35 0.1
ACE Women 0.19 *** 0.05 1.21
Note: p > 0.0001 *** p < 0.01 *.

The model of criminal behaviors by sex indicates that, for each ACE, the lifetime
number of criminal behaviors increases by 18% in men (Table 13). In contrast, for each ACE,
the number of criminal behaviors increases by 24% in women. This means that ACEs are a
better predictor of criminal behaviors in women than in men.

Table 13. Poisson model for criminal behaviors by sex.

b SE Exp (b)
Children 2022, 9, x FOR PEER REVIEW 12 of 17
Intercept −1.24 *** 0.34 0.29
ACE Men 0.17 ** 0.06 1.18
Intercept −2.54 *** 0.38 0.08
ACE Women
ACE Women 0.22 ******
0.22 0.05
0.05 1.24
1.24
Note: p >p 0.0001
Note: > 0.0001***
***pp<<0.001
0.001 **
**.

Figure 2 shows
Figure 2 showsthethe
Poisson regression
Poisson models
regression modelsforfor
men and
men women,
and women,revealing that
revealing that
consequences in terms of mental health, substance use, and criminal behaviors, depend
consequences in terms of mental health, substance use, and criminal behaviors, depend
onon
ACEs.
ACEs.

Figure
Figure 2. Regression
2. Regression models:
models: impact
impact onon mental
mental health,
health, alcohol
alcohol and/or
and/or substance
substance use,
use, andand criminal
criminal
behaviors in men and women. p < 0.0001 *** p < 0.001 ** p < 0.01
behaviors in men and women. p < 0.0001 *** p < 0.001 ** p < 0.01 *. *.

Lastly, the intrafamily violence model indicates that, as ACEs increase, the likelihood
Lastly, the intrafamily violence model indicates that, as ACEs increase, the likelihood
of having lodged an IFV report or having been reported for IFV, increases by 59% in men.
of having lodged an IFV report or having been reported for IFV, increases by 59% in men.
In contrast, an increase in ACEs for women only increases by 28% the lifetime probability
In contrast, an increase in ACEs for women only increases by 28% the lifetime probability
of having lodged an IFV report or having been reported for IFV (Table 14).
of having lodged an IFV report or having been reported for IFV (Table 14).

Table 14. Logistic regression model for IFV by sex.

b SE Odds Ratio
 Children 2022, 9, 1841 12 of 16

Table 14. Logistic regression model for IFV by sex.

b SE Odds Ratio
Intercept −1.422 *** 1.03 0.01
ACE Men 0.47 ** 0.16 1.59
Intercept −2.86 *** 0.51 0.06
ACE Women 0.25 ** 0.08 1.28
Children 2022, 9, x FOR PEER REVIEW 13 of 17
Note: p > 0.0001 *** p < 0.001 **.

Figure 3 shows the logistic regression models for intrafamily violence in men and women.

Regressionmodel:
Figure3.3.Regression
Figure model:intrafamily
intrafamilyviolence
violenceininmen
menand womenpp<<0.001**.
andwomen 0.001 **.

4. Discussion
4. Discussion
Both men and women can be affected by ACEs, with no significant differences found
Both them.
between men and women canthe
Furthermore, be affected
prevalenceby ACEs, with no
rate is high, withsignificant
most of the differences found
sample (54.6%)
between them. Furthermore, the prevalence rate is high, with
reporting four or more ACEs. The most reported issues are community violence (58.9%), most of the sample (54.6%)
reporting
witnessing four or more
violence ACEs.
against The mostofreported
a member issues (46.5%),
the household are communityand being violence
bullied(58.9%),
(43.7%).
witnessing violence against
The high prevalence a member
of community of the household
violence experienced (46.5%), and being
in childhood bulliedthe
matches (43.7%).
results
The high
of the prevalence
first NationalofSurveycommunity violence experienced
of Poly-Victimization in childhood
in Chilean Children matches the results
and Adolescents
of the first
(2017), whichNational
indicates Survey
that theof Poly-Victimization
most prevalent problem in Chilean
is exposure Children and Adolescents
to community violence.
(2017), which indicates that the most prevalent problem
This prompts the need to identify specific characteristics of the sociocultural is exposure to community
context wherevio-
lence. This prompts the need to identify specific characteristics of the
children are growing up, at a regional and national level, given their exposure to high rates sociocultural context
where children
of violence from are
angrowing
early age. up, at a regional and national level, given their exposure to
high rates of violence
It is relevant fromthat
to note an this
earlystudy
age. analyzed the prevalence of the 10 categories of the
It is questionnaire
original relevant to note thatand
[6,33] thisthe
study analyzed
prevalence ofthe prevalence[5],
13 categories of incorporating
the 10 categories twoofof
the
theoriginal
adversities questionnaire
considered [6,33] and the prevalence
by Finkelhor of 13 categories
et al. (community violence [5],
andincorporating two
bullying) [34,35]
of the aadversities
plus new category considered
belonging by to
Finkelhor et violence
collective al. (community
(havingviolence
experiencedand bullying) [34,35]
wars, political or
plus
ethnica new category
conflicts, belonging
or torture). to collective
A high prevalenceviolence
of ACEs (having experienced
is observed in bothwars, political
cases, which
oris ethnic conflicts,
consistent with orthetorture).
researchAconducted
high prevalence
to date.ofStudies
ACEs isindicate
observed in both
that mostcases, which
interviewees
isreport at least
consistent onethe
with type of ACEconducted
research [6,20,38], with slightly
to date. over indicate
Studies half of thethatrespondents reporting
most interviewees
four or
report atmore ACEs
least one type[39].
of In
ACE the[6,20,38],
present study, nearly over
with slightly all participants reported having
half of the respondents had
report-
at least
ing four or onmoreadverse
ACEs childhood
[39]. In the experience, considering
present study, nearly all both the original
participants questionnaire
reported having
with
had at 10
leastACEs and thechildhood
on adverse adapted instrument with 13 ACEs.
experience, considering bothHowever,
the original when analyzing
questionnaire
the prevalence of four or more ACEs considering the
with 10 ACEs and the adapted instrument with 13 ACEs. However, when analyzing 10 categories, the rate decreases.
the
Specifically,
prevalence of with
four or 10more
categories, 34.8% of thethe
ACEs considering participants
10 categories, report fourdecreases.
the rate or more adverse
Specif-
childhood
ically, with 10 experiences,
categories, but 34.8% when we
of the consider all
participants 13 categories,
report four or more more than childhood
adverse half of the
participants (54.6%)
experiences, but when report
we four or more
consider ACEs,
all 13 which can
categories, be ascribed
more than half toofthethe
high prevalence
participants
of community violence affecting the participants from an early
(54.6%) report four or more ACEs, which can be ascribed to the high prevalence of com- age, a current issue in the
Chilean society.
munity violence affecting the participants from an early age, a current issue in the Chilean
society. When considering the 13 ACE categories, the positive and significant correlations were
foundWhen between adverse the
considering childhood
13 ACEexperiences
categories,and the the indexes
positive andof significant
mental health problems,
correlations
alcohol/substance
were found between use, criminalchildhood
adverse behaviors,experiences
and IFV, both andin the
the full sample
indexes of and in men
mental and
health
women, separately. Importantly, the strongest correlation exists
problems, alcohol/substance use, criminal behaviors, and IFV, both in the full sample and between ACEs and mental
in men and women, separately. Importantly, the strongest correlation exists between
ACEs and mental health problems. It is of moderate size, being the strongest one for both
the full sample and for men and women, separately. It can be observed that the partici-
pants with four or more ACEs tend to encounter more problems in their lifetime than
Children 2022, 9, 1841 13 of 16

health problems. It is of moderate size, being the strongest one for both the full sample and
for men and women, separately. It can be observed that the participants with four or more
ACEs tend to encounter more problems in their lifetime than those who report fewer ACEs.
Among the participants who reported four or more ACEs, 70.1% have had at least one
mental health problem in their life, that is, at least one mental health disorder diagnosed by
a professional (these included: depression, generalized anxiety disorder, post-traumatic
stress disorder, anorexia, bulimia, personality disorder, learning disorder, suicidal ideation,
and non-suicidal self-harm). This is an alarming figure that stresses the association between
ACEs and the presence of mental health problems in the Chilean population. Chile also
exhibits high depression rates, above the world average; even more so, reports of mental
health problems have increased during the current pandemic [40].
The findings presented in this article are partly consistent with other studies. For in-
stance, in line with prior research [13–15,18,19], we found differences in the frequency of
ACEs, with women reporting significantly more sexual abuse experiences. Even though
men tend to report more physical neglect, community violence, collective violence, and
having had a family member with alcohol and/or substance use problems at home, these
differences are not significant. This stands in contrast with other studies that have indeed
found significant differences between men and women [17,41]. Our findings are relevant,
since the literature indicates that women report two or even three times as many adverse
experiences as men [20]. We did not observe this, as both men and women reported similar
ACE frequencies across all categories except for sexual abuse, which was more commonly
reported by women. These findings can lay the groundwork for a discussion on the gender
stereotypes that highlight women’s vulnerability to adverse and traumatic experiences,
suggesting that, beyond sex and gender, childhood is a stage when both boys and girls are
at risk of experiencing a similar degree of violence. Therefore, it is important to determine
which cultural, social, familial, and upbringing factors are impacting the occurrence of
adversities and the violation of children’s rights.
Considering that, to date, research has not yielded conclusive findings regarding the
effect of ACEs and the differences between men and women, we analyzed the effect of
adverse childhood experiences on mental health, substance use, criminal behaviors, and
intrafamily violence and victimization, both in the full sample and in men and women,
separately. This analysis revealed that ACEs are a significant predictor of mental health
problems, substance use, criminal behaviors, and IFV in both men and women. These
findings are supported by the literature and prior research, which indicate that experiences
of physical, emotional, and sexual abuse, as well as neglect and household dysfunctions, are
strong predictors of the development of mental health disorders and risk behaviors [11,42].
With respect to substance use problems, as prior research shows, early adversities are
associated with a greater vulnerability to emotional dysregulation and problematic use,
especially when children experience abuse, household dysfunctions, and violence [22,24,43].
This is consistent with the significant associations found in the full sample, regarding
experiences of sexual abuse, living with someone with severe mental health problems,
bullying, and collective and community violence. Interestingly, and consistent with the
literature [9,22,44], violence and substance abuse in the household is associated with
alcohol and/or substance use problems in men, for whom the present study also revealed a
significant association between such problems and having lived with someone with mental
health problems. In contrast, and in line with the literature, sexual abuse and parental
absence or separation are associated with substance use problems in women [44], for whom
this study also found a significant link between being bullied and substance use problems.
Regarding criminal behaviors, the above is in line with prior research, which indicates
that people who have committed criminal acts exhibit a greater prevalence of ACEs [45],
with the latter two experiences having significant associations with criminal behaviors in
the present study. Concerning the impact on intrafamily violence, it is worth noting that the
literature indicates that physical, sexual, and emotional abuse have a significant predictive
Children 2022, 9, 1841 14 of 16

effect regarding the perpetration of intimate partner violence and victimization [27,46].
In line with this, our study also revealed a predictive effect when considering all ACEs.
A relevant finding with respect to the impact of ACEs is that they are better predictors
of mental health problems and intrafamily violence in men than in women, while also
being better predictors of substance use problems and criminal behaviors in women than
in men. This suggests that other intervening and moderating factors may influence and
predict consequences and risk behaviors affecting health in addition to adverse childhood
experiences. Certainly, these factors should be examined in future studies.
Lastly, it is necessary to highlight that being a woman and having had an ACE can
produce a mental health impact comparable to being a man and having had an ACE; even
more so, the effect may even be weaker. This is relevant for clinical practice and at a
theoretical-comprehensive level, regarding the historical biases associated with gender,
which have led to the mistaken belief that being a woman is a risk factor for suffering
adverse experiences and being affected by negative health consequences. The evidence
produced by this study can be greatly relevant for illustrating the scope of the effects
of adverse experiences on mental health and risk behaviors in a population of adults in
Chile. Furthermore, our findings stress the need to analyze which other intervening factors
could explain these types of health consequences, both in men and women, while also
considering people’s subjective experience and the singular effect that an ACE can have
on each individual. We expect that these findings will improve our knowledge about the
prevalence of early adverse experiences and their effect on people’s quality of life in Chile,
thus enriching public policy by informing prevention and reparation strategies.

Author Contributions: Formal analysis, S.R.L., M.P.S., J.H. and C.V.; Investigation, S.R.L., M.P.S., J.H.
and C.V.; Writing—original draft, S.R.L., M.P.S., J.H. and C.V.; Writing—review & editing, S.R.L.,
M.P.S., J.H. and C.V. All authors have read and agreed to the published version of the manuscript.
Funding: This work was funded by the Early Adversity and Abuse Research Center, CUIDA. Funding
number 26082020.
Institutional Review Board Statement: The Pilot National Survey of Adversity and Sexual Abuse
in Childhood (2020) was approved by the Institutional Review Board for the Social Sciences, Arts,
and Humanities of the Universidad Católica. As an ethical criterion, sensitive items (questions about
sexual abuse and victimization) were self-administered by the participants in private. The participants
received a letter presenting the study and signed an informed consent. The study was conducted
in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board
(or Ethics Committee) of Pontificia Universidad Católica de Chile (protocol code 200428004, date of
approval 26 August 2020.
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: The data presented in this study are available upon request from the
corresponding author.
Conflicts of Interest: The authors declare no conflict of interest.

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