The mediating role of frequent mental distress in the relationship between adverse childhood experiences and cognitive disability in emerging adults

doi:10.21203/rs.3.rs-3612927/v1

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The mediating role of frequent mental distress in the relationship between adverse childhood experiences and cognitive disability in emerging adults

https://doi.org/10.21203/rs.3.rs-3612927/v1

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published 29 Nov, 2024

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Background

Adverse Childhood Experiences (ACEs) may have an impact on cognitive disability through multiple pathways. Frequent Mental Distress (FMD) usually makes people more susceptible to cognitive dysfunction through different aspects.

Methods

A cross-sectional analysis of aged 18–25 years in the 2020 and 2021 Behavioral Risk Factor Surveillance System (BRFSS) was performed. Weighted multivariate logistic regression models were used to assess the association of ACEs with FMD and cognitive disability. Mediation effects was used to investigate FMD as mediation between ACEs and cognitive disability in emerging adulthood.

Results

Among the 10,309 respondents, the prevalence of cognitive disability was 15.2% (n = 1567), and 73.5% (n = 7578) of the total respondents experienced ACEs. In model 2 without mediation, ACEs was significantly associated with cognitive disability (OR: 4.05, 95%CI: 2.47, 6.66). After adjusted for covariates with mediation, ACEs (OR: 3.08, 95%CI: 1.84, 5.17) and FMD (OR: 5.61, 95%CI: 4.33, 7.28) were also significantly associated with cognitive disability.

Conclusion

Our study indicated a strong association between ACEs and cognitive disability. It also demonstrated that FMD was a mediation through which ACEs may be linked to cognitive disability.

Biological sciences/Psychology

Health sciences/Neurology

Adverse Childhood Experiences (ACEs)

Frequent Mental Distress (FMD)

Cognitive Disability

Cognitive disability, self-reported difficulty with concentration, memory and/or decision making¹ is the second most common type of disability in the United States². Cognitive issues are particularly important to diagnose and treat in emerging adults, with a frequency of 24.1%, according to the 2016 Behavioral Risk Factor Surveillance System (BRFSS)³. Emerging adulthood, the period between 18 and 25 years of age⁴, has been recognized as a separate developmental stage that is increasingly being examined. It is commonly a time of newly acquired independence from caregivers, further education, or entry into the workforce, as well as an investigation of a variety of potential life courses in terms of belief systems, interpersonal connections, and job pathways. They depend on optimum cognitive functioning to properly perform their duties (such as controlling behavior, adjusting to changes, and handling unfamiliar, complicated, and/or less organized surroundings)⁵.Given that preventing cognitive disability is critically important for improving overall population health, there must be sufficient knowledge about the biological, psychological, and social factors that may reduce the risk of cognitive disability in emerging adults or provide protection against its emergence.

A variety of circumstances, such as adverse childhood experiences (ACEs), such as growing up in a dysfunctional family or experiencing physical, emotional, or sexual abuse as a young child (under the age of 18)⁶, may have an impact on cognitive disability. Emerging adulthood in particular may be a potent period for ACE effects, and studies indicate that 73% of emerging adults encounter an ACE at least once⁷. ACEs may influence cognitive disability through multiple pathways including acquired and traumatic brain injuries⁸ and a decrease in plasma neuropeptide-Y(NPY) levels may be one of the biochemical mechanisms of the memory impairment as well⁹. Previous research, though not focused on emerging adults, highlights the role of ACEs in cognitive disability. Participants who had endured emotional and physical neglect performed worse on tests of spatial working memory in healthy adults and the latter was linked to weaknesses in pattern recognition memory¹⁰. Cumulative effects from multiple risk factors have been shown to be more predictive of compromised early cognitive development among vulnerable adults in US than any one risk factor alone¹¹.

Frequent mental distress (FMD), defined as 14 or more self-reported mentally unhealthy days in the past 30 days, is a particularly consequence of emerging adulthood¹². ACEs are complex early stressors that have the potential to interfere with the development of adaptive emotion control mechanisms by altering psychological interpretations and beliefs¹³.Long-term exposure to dangerous, unfavorable environments causes self-denial in children, which raises their chance of developing mental health issues as emerging adults. This harmful psychological condition frequently makes people find it challenging to keep their bodies in a state of homeostasis, increases the loss of neuronal function and structure, amplifies pathological damage, and makes them more susceptible to cognitive dysfunction. Fiorenzato et al. found a favorable correlation between changes in mental health and changes in subjective cognition in 1215 respondents from all around Italy¹⁴. Additionally, seasonal affective disorder has a major impact on cognitive function, making those who suffer from it more prone than those who are not depressed to experience daily cognitive failures¹⁵. Therefore, this study suggests that the association between ACEs and cognitive disability in emerging adulthood is mediated by FMD.

A large number of studies have investigated the relationship of FMD with either ACEs or cognitive disability. Yet, most research has not formally tested the role of FMD as a mediating mechanism through which ACEs may become biologically embedded and increase the risk of cognitive disability. Understanding the relationships between ACEs, cognitive disability and FMD is important for the design of future interventions to reduce ACEs and prevent cognitive disability across emerging adults. Using cross-sectional data from the 2020 and 2021 Behavioral Risk Factor Surveillance System (BRFSS) data, this study investigated: 1) the association between self-reported ACEs and cognitive disability and 2) the mediate effect of mental health between ACEs and cognitive disability.

2.1 Study design and sample selection

The data were obtained from the Behavioral Risk Factor Surveillance System (BRFSS) in 2020 and 2021. BRFSS is a nationally representative, cross-sectional, random-digit-dialed telephone survey collected at the state/territory level on behalf of the Centers for Disease Control and Prevention (CDC)¹⁶. The target population of the BRFSS survey is non-institutionalized adults aged 18 years or older. It also assesses health conditions, health behaviors, and behavioral risk factors among adults in the United States annually¹⁷. Standardized questionnaires are designed by CDC and state public health departments, includes standard core sections, optional modules and state-added questions¹⁸. As BRFSS is a publicly available dataset, the data is being updated now, and detailed information about the survey may be found at the CDC's website at https://www.cdc.gov/brfss/.

In our present study, 22,194 participants aged 18–25 years that chose the full ACEs module in 2020 and 2021.After excluded participants with missing values (n = 968) in Cognitive Disability, missing values (n = 325) in mental health and missing values or refusals/don't know/not sure (n = 10,592) on one or more of the ACEs questions. Finally, a final sample size of 10,309 participants was involved, and the process of sample selection is shown in Fig. 1.

2.2 Adverse Childhood Experiences

Exposed to ACES were based on the CDC's uniform questions in ACEs module questions. In the ACEs module, 11 questions were used to evaluate whether a respondent experienced ACEs. According to the questions, 9 types of ACEs were categorized, Household Mental Illness, Household Alcoholism, Household Drug Abuse, Incarceration History in Home, Parental Separation/Divorce, Parental Intimate Partner Violence, Physical Abuse, Emotional Abuse, Sexual Abuse (Table 1).

Table 1

Adverse childhood experiences questions included in the 2020 Behavioral Risk Factor Surveillance System
Adverse Childhood Experiences	Survey question(s)#	Operational Definition
Household Mental Illness	1.Did you live with anyone who was depressed, mentally ill, or suicidal?	No vs. Yes
Household Alcoholism	2.Did you live with anyone who was a problem drinker or alcoholic?	No vs. Yes
Household Drug Abuse	3.Did you live with anyone who used illegal street drugs or who abused prescription medications?	No vs. Yes
Incarceration History in Home	4.Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility?	No vs. Yes
Parental Separation/Divorce	5.Were your parents separated or divorced?	No vs. Yes
Parental Intimate Partner Violence	6.How often did your parents or adults in your home ever slap, hit, kick, punch or beat each other up? Was it…	Never vs. At least once
Physical Abuse	7.Not including spanking, (before age 18), how often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? Was it...	Never vs. At least once
Emotional Abuse	8.How often did a parent or adult in your home ever swear at you, insult you, or put you down? Was it…	Never vs. At least once
Sexual Abuse	9.How often did anyone at least 5 years older than you or an adult, ever touch you sexually? Was it…	Never vs. At least once
	10.How often did anyone at least 5 years older than you or an adult, try to make you touch them sexually? Was it…	Never vs. At least once
	11.How often did anyone at least 5 years older than you or an adult, force you to have sex? Was it…	Never vs. At least once
# All questions refer to the time before respondent aged 18 years old and were prefaces with the phrase 'Now, looking back before you were 18 years of age...'

We encoded all ACEs answers as binary variables based on the contents 11 question. The questions reflected the individuals' ACEs type, and each measure is coded as "yes" if the respondent agrees with the content of the question. If an individual answered "yes" to one or more of the 11 questions, the individual was considered to have experienced ACEs. As for the ACEs score (ranged from 1 to 9, higher scores indicating fiercer exposure), it was calculated based on the cumulative number of ACEs types that reported affirmably. Then it could be categorized as 0, 1, 2, 3, and ≥ 4.

2.3 Mental Health

For the condition of mental health, respondents were asked to answer a question in Core Section of BRFSS. “Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?” Then the respondents who reported no less than 14 days of poor mental health were classified as experienced Frequent Mental Distress (FMD). This reliable definition is a measure of the respondents’ mental health and has been widely used in previous studies^19,20.

2.4 Cognitive Disability

As one of the six disability types, cognitive disability was classified as respondents who reported affirmative responses to the question in Core Section. “Because of a physical, mental or emotional condition, do you having serious difficulty concentrating, remembering, or making decisions?” Although this measure of cognitive disability is limited by its self-reported nature, which has been used in numerous studies and was considered reliable^21–23.

2.5 Covariates

In our analysis, we included gender (male/female), age (continuous variable), race/ethnicity (non-Hispanic, White; non-Hispanic, Black; Hispanic and Other race), education level (high school or below, more than high school), marital status (married/unmarried couple, divorced/widowed/separated, never married), income (<$15,000, $15,000-$24,999, $25,000-$34,999, $35,000–$49,999 and ≥$50,000), insurance and urban/rural status. These variables were considered as possible confounders with ACEs, mental health and cognitive disability according to previous literature.

2.6 Statistical analysis

In our study, IBM SPSS 24.0 software was used for statistical analysis. All analyses used survey sampling weights that accounted for the sampling strategy used by the BRFSS study. The survey weights were adjusted to reflect the mean population totals during the period for which these data were collected.

For continuous and normally distributed variables, mean values and standard deviations were calculated, then weighted t tests was used to compare for differences among different mental health groups. For categorical variables, counts and percentages were presented and weighted Chi-square tests was performed. P < 0.05 on both sides was considered statistically significant.

We use standard descriptive statistics to report frequencies for each categorical variable. Then prevalence of ACEs, FMD and cognitive disability were calculated. In addition, logistic regression models were used to evaluate the risk of FMD and cognitive disability with ACEs, ACE score and different types of ACEs, adjusted for covariates and mediation. Logistic regression based on the KHB method proposed by Holm et al²⁴ was used to conduct the mediation analysis, which resulted in the total effect (the effect of treatment variable X on outcome variable Y without mediating variable M) being divided into direct effect (the effect of treatment variable X on outcome variable Y when controlling for mediating variable M) and indirect (mediating) effect (the effect of treatment variable X on outcome variable Y through mediating variable M).

3.1 Descriptive analyses and study population

The total sample in our study was composed of 10,309 respondents, and they were averaged 21.31 ± 0.08 years old. In our entire sample, nearly all of the covariates were statistically significantly between the respondents with or without cognitive disability, except for race/ethnicity, insurance and urban/rural status. The characteristics of the respondents were summarized in Table 2.

Table 2

Baseline characteristics of the study participants in 2020 and 2021 BRFSS.
Characteristics	Cognitive Disability		P-value
Characteristics	No (N = 8742)	Yes (N = 1567)	P-value
Gender, n(%)			< 0.001
Male	4905 (55.3)	712 (40.0)
Female	3837 (44.7)	855 (60.0)
Age, years, mean ± SD	21.32 ± 0.09	21.23 ± 0.18	0.037
Race/Ethnicity, n(%)			0.054
Non-Hispanic, White	5513 (51.2)	1021 (58.6)
Non-Hispanic, Black	734 (13.5)	95 (10.1)
Hispanic	1383 (25.0)	263 (23.2)
Other race	1112 (10.3)	188(8.1)
Education, n(%)			< 0.001
High school or below	3837 (47.9)	856 (58.4)
More than high school	4903 (52.1)	709 (41.6)
Income, n(%)			< 0.001
<$15,000	591 (8.6)	161 (17.4)
$15,000-$24,999	1211 (17.1)	264 (19.9)
$25,000-$34,999	816 (12.0)	180 (17.4)
$35,000-$49,999	1114 (15.7)	178 (15.8)
≥$50,000	2899 (46.7)	324 (29.5)
Marital Status, n(%)			0.049
Married/unmarried couple	1805 (18.4)	324 (20.8)
Divorced/Widowed/Separated	138 (1.3)	48 (2.5)
Never married	6721 (80.2)	1183 (76.6)
Insurance, n(%)			0.923
Yes	6966 (79.4)	1217 (79.7)
No	1393 (20.6)	280 (20.3)
Urban/Rural Status, n(%)			0.425
Urban status	7515 (91.6)	1352 (90.8)
Rural status	1227 (8.4)	215 (9.2)
ACE status, n(%)			< 0.001
No	2586 (31.9)	145 (10.3)
Yes	6156 (68.1)	1708 (89.7)
ACE score, n(%)			< 0.001
0	2586 (31.9)	145 (10.3)
1	2082 (23.9)	210 (10.9)
2	1322 (14.6)	227 (13.4)
3	884 (9.8)	200 (12.2)
≥ 4	1868 (19.9)	785 (53.2)
Household Mental Illness, n(%)			< 0.001
No	6335 (76.2)	660 (44.3)
Yes	2407 (23.8)	907 (55.7)
Household Alcoholism, n(%)			< 0.001
No	6832 (80.7)	959 (59.4)
Yes	1910 (19.3)	608 (40.6)
Household Drug Abuse, n(%)			< 0.001
No	7484 (86.7)	1073 (67.4)
Yes	1258 (13.3)	494 (32.6)
Incarceration History in Home, n(%)			< 0.001
No	7415 (85.7)	1105 (72.2)
Yes	1327 (14.3)	462 (27.8)
Parental Separation/ Divorce, n(%)			< 0.001
No	5443 (61.7)	711 (43.2)
Yes	3299 (38.3)	856 (56.8)
Parental Intimate Partner Violence, n(%)			< 0.001
No	7430 (85.2)	1041 (62.0)
Yes	1312 (14.8)	526 (38.0)
Physical abuse, n(%)			< 0.001
No	7035 (80.6)	892 (54.1)
Yes	1707 (19.4)	675 (45.9)
Emotional abuse, n(%)			< 0.001
No	5150 (62.2)	474 (27.8)
Yes	3592 (37.8)	1093 (72.2)
Sexual abuse, n(%)			< 0.001
No	7930 (90.4)	1145 (70.0)
Yes	812 (9.6)	422 (30.0)
Frequent mental distress, n(%)			< 0.001
No	7483 (85.8)	770 (49.3)
Yes	1259 (14.2)	797 (50.7)

The prevalence of cognitive disability in the overall sample was 15.2% (n = 1567). As for ACEs, 73.5% (n = 7578) of the total respondents experienced at least 1 type of ACEs, especially 20% (n = 2653) experienced no less than 4 types of ACEs. Of those who responded they had been classified as cognitive disability, 50.7% (n = 797) also reported having frequent mental distress, compared to 14.2% (n = 1259) for those without cognitive disability.

3.2 Associations between the ACEs and frequent mental distress

ACEs were positively associated with FMD (OR: 3.73, 95%CI: 2.84, 4.91) in Model 1. And having experienced 2 types of ACEs (OR: 3.06, 95%CI: 2.16, 4.33), 3 types of ACEs (OR: 3.79, 95%CI: 2.71, 5.32) and 4 or more types of ACEs (OR: 7.16, 95%CI: 5.32, 9.64) were also associated with higher risks of FMD compared with those not experienced ACEs. And each type of ACEs was significantly associated with FMD, the associations were shown in Table 3.

Table 3

Multivariate analysis between the type of ACEs and frequent mental distress.
	Model 1^a		Model 2^b
	OR (95% CI)	P	OR (95% CI)	P
ACEs status	3.73 (2.84, 4.91)	< 0.001	3.64 (2.48, 5.35)	< 0.001
ACE score
0	1.00 (reference)		1.00 (reference)
1	1.39 (1.00, 1.92)	< 0.001	1.48 (0.96, 2.28)	< 0.001
2	3.06 (2.16, 4.33)		3.00 (1.84, 4.89)
3	3.79 (2.71, 5.32)		3.90 (2.52, 6.04)
4+	7.16 (5.32, 9.64)		6.62 (4.39, 10.00)
Type of ACEs
Household Mental Illness	4.33 (3.62, 5.17)	< 0.001	3.60 (2.91, 4.44)	< 0.001
Household Alcoholism	2.60 (2.15, 3.16)	< 0.001	2.16 (1.74, 2.69)	< 0.001
Household Drug Abuse	3.10 (2.50, 3.84)	< 0.001	2.67 (2.13, 3.35)	< 0.001
Incarceration History in Home	2.17 (1.77, 2.66)	< 0.001	2.12 (1.67, 2.69)	< 0.001
Parental Separation/Divorce	2.03 (1.71, 2.42)	< 0.001	1.81 (1.46, 2.26)	< 0.001
Parental Intimate Partner Violence	2.54 (2.07, 3.13)	< 0.001	2.31 (1.83, 2.91)	< 0.001
Physical abuse	2.90 (2.40, 3.52)	< 0.001	2.78 (2.24, 3.44)	< 0.001
Emotional abuse	3.96 (3.30, 4.74)	< 0.001	3.58 (2.86, 4.49)	< 0.001
Sexual abuse	3.35 (2.61, 4.29)	< 0.001	2.92 (2.22, 3.84)	< 0.001
a.Crude model.
b.Adjusted for gender, age, education, race/ethnicity, income, marital status, insurance and urban/rural status.

However, after controlled for all covariates in Model 2, ACEs remained positively associated with risks of frequent mental distress (OR: 3.64, 95%CI: 2.48, 5.35). Compared to those without ACEs, the more types of ACEs they experienced, the higher risks of frequent mental distress. The associations appeared to follow a dose–response relationship, with the greatest magnitude of association observed were those who reported experienced 4 or more types of ACEs (OR: 6.62, 95%CI: 4.39, 10.00). For each type of ACEs, the relationship remained significant after adjusted for covariates. The strongest associations with frequent mental distress were seen for Household Mental Illness (OR: 3.60, 95% CI: 2.91, 4.44), Emotional abuse (OR: 3.58, 95%CI: 2.86, 4.49), and Sexual abuse (OR: 2.92, 95%CI: 2.22, 3.84).

3.3 Associations between the ACEs and cognitive disability

Table 4 showed the unadjusted and adjusted relationships in models with and without mediation. In the unadjusted model without mediation, ACEs was significantly associated with cognitive disability (OR: 4.08, 95%CI: 2.97, 5.60). Compared to those without ACEs, having experienced 2 types of ACEs (OR: 2.85, 95%CI: 1.95, 4.16), 3 types of ACEs (OR: 3.85, 95%CI: 2.63, 5.63) and 4 or more types of ACEs (OR: 8.30, 95%CI: 5.88, 11.71) were also associated with higher risks of cognitive disability. And each type of ACEs was significantly associated with cognitive disability. However, after adjusted for covariates, all the associations remained statistically significant.

Table 4

Mediation model for the relationship between type of ACE and cognitive disability
	Model 1 without mediation ^a				Model 2 with mediation ^b
	Unadjusted		Adjusted ^c		Unadjusted		Adjusted ^c
	OR (95%CI)	P	OR (95%CI)	P	OR (95%CI)	P	OR (95%CI)	P
ACEs status	4.08 (2.97, 5.60)	< 0.001	4.05 (2.47, 6.66)	< 0.001	3.00 (2.15, 4.17)	< 0.001	3.08 (1.84, 5.17)	< 0.001
ACE score
0	1.00 (reference)		1.00 (reference)		1.00 (reference)		1.00 (reference)
1	1.41 (0.98, 2.04)	< 0.001	1.52 (0.89, 2.62)	< 0.001	1.34 (0.93, 1.94)	< 0.001	1.46 (0.84, 2.54)	< 0.001
2	2.85 (1.95, 4.16)		3.04 (1.73, 5.33)		2.26 (1.53, 3.35)		2.51 (1.41, 4.49)
3	3.85 (2.63, 5.63)		3.61 (2.08, 6.28)		2.92 (1.98, 4.29)		2.78 (1.57, 4.92)
4+	8.30 (5.88, 11.71)		7.53 (4.54, 12.48)		5.42 (3.74, 7.86)		5.12 (3.01, 8.74)
Type of ACEs
Household Mental Illness	4.04 (3.25, 5.04)	< 0.001	3.36 (2.59, 4.36)	< 0.001	2.78 (2.23, 3.47)	< 0.001	2.43 (1.84, 3.20)	< 0.001
Household Alcoholism	2.85 (2.26, 3.59)	< 0.001	2.13 (1.64, 2.75)	< 0.001	2.20 (1.70, 2.88)	< 0.001	1.74 (1.29, 2.33)	< 0.001
Household Drug Abuse	3.15 (2.42, 4.12)	< 0.001	2.72 (2.04, 3.62)	< 0.001	2.30 (1.68, 3.16)	< 0.001	2.10 (1.50, 2.95)	< 0.001
Incarceration History in Home	2.30 (1.77, 3.01)	< 0.001	2.09 (1.56, 2.79)	< 0.001	1.86 (1.34, 2.58)	< 0.001	1.72 (1.21, 2.44)	0.002
Parental Separation/Divorce	2.12 (1.71, 2.61)	< 0.001	1.74 (1.33, 2.27)	< 0.001	1.75 (1.39, 2.20)	< 0.001	1.50 (1.20, 2.01)	0.007
Parental Intimate Partner Violence	3.54 (2.77, 4.52)	< 0.001	2.72 (2.05, 3.60)	< 0.001	2.85 (2.13, 3.82)	< 0.001	2.22 (1.59, 3.11)	< 0.001
Physical abuse	3.54 (2.81, 4.46)	< 0.001	3.29 (2.48, 4.20)	< 0.001	2.71 (2.08, 3.53)	< 0.001	2.51 (1.86, 3.37)	< 0.001
Emotional abuse	4.28 (3.49, 5.25)	< 0.001	4.31 (3.30, 5.64)	< 0.001	3.09 (2.46, 3.87)	< 0.001	3.23 (2.41, 4.33)	< 0.001
Sexual abuse	4.05 (3.04, 5.39)	< 0.001	3.80 (2.78, 5.20)	< 0.001	2.97 (2.08, 4.24)	< 0.001	2.94 (2.07, 4.18)	< 0.001
Frequent mental distress					6.22 (4.96, 7.80)	< 0.001	5.61 (4.33, 7.28)	< 0.001
a.Showed the association between ACE and cognitive disability.
b.Added frequent mental distress based on Model 1.
c.Adjusted for gender, age, education, race/ethnicity, income, marital status, insurance and urban/rural status.

As for the Model 1 with mediation, ACEs (OR: 3.00, 95%CI: 2.15, 4.17) and FMD (OR: 6.22, 95%CI: 4.96, 7.80) were significantly associated with cognitive disability, respectively. And having experienced 2 types of ACEs (OR: 2.26, 95%CI: 1.53, 3.35), 3 types of ACEs (OR: 2.92, 95%CI: 1.98, 4.29) and 4 or more types of ACEs (OR: 5.42, 95%CI: 3.74, 7.86) were also associated with higher risks of FMD compared with the reference. Each type of ACEs was significantly associated with cognitive disability. In Model 2 with mediation, ACEs (OR: 3.08, 95%CI: 1.84, 5.17) and FMD (OR: 5.61, 95%CI: 4.33, 7.28) were still statistically significantly associated with cognitive disability, other associations remained statistically significant.

3.4. Mediation effects

The results of the mediation analysis are shown in Table 5. After adjusting for the confounding factors, the mediation effect of FMD was found in all ACEs types. The total effect of ACEs status on cognitive disability was 1.36 (95%CI: 1.18,1.54), the indirect effect of ACEs status through FMD was 0.27 (95%CI: 0.24,0.30), and the proportion of mediating effect was 19.65%. The total effect of ACEs score on cognitive disability was 0.47 (95%CI: 0.43,0.52), the indirect effect of ACEs status through FMD was 0.11 (95%CI: 0.09,0.12), and the proportion of mediating effect was22.30%. Similarly, the mediation proportion of Household Mental Illness, Household Alcoholism, Household Drug Abuse, Incarceration History in Home, Parental Separation/Divorce, Parental Intimate Partner Violence, Physical abuse, Emotional abuse, Sexual abuse, Frequent mental distress, respectively was 29.16%, 32.98%, 29.33%, 31.55%, 24.04%, 25.52%, 24.22%, 23.72%, 29.25% respectively.

Table 5

Mediation effect of ACEs
ACEs	Direct effect(Full)		Indirect effect(Diff)		Total effect(Reduced)
	β	95%CI	β	95%CI	β	95%CI	Mediation (%)
ACEs status	1.09	(0.91,1.28)	0.27	(0.24,0.30)	1.36	(1.18,1.54)	19.65
ACEs score	0.37	(0.33,0.41)	0.11	(0.09,0.12)	0.47	(0.43,0.52)	22.30
ACEDEPRS1	0.89	(0.77,1.01)	0.37	(0.33,0.41)	1.26	(1.14,1.38)	29.16
ACEDRINK1	0.52	(0.39,0.64)	0.25	(0.22,0.29)	0.77	(0.65,0.89)	32.98
ACEDRUGS1	0.69	(0.56,0.82)	0.29	(0.24,0.33)	0.98	(0.84,1.11)	29.33
ACEPRISN1	0.55	(0.41,0.68)	0.25	(0.21,0.30)	0.80	(0.66,0.93)	31.55
ACEDIVRC1	0.48	(0.37,0.60)	0.15	(0.12,0.18)	0.64	(0.52,0.76)	24.04
ACEPUNCH1	0.78	(0.65,0.91)	0.27	(0.22,0.31)	1.05	(0.92,1.18)	25.52
ACEHURT2	0.89	(0.76,1.01)	0.28	(0.24,0.32)	1.17	(1.05,1.29)	24.22
ACESWEAR1	0.90	(0.78,1.02)	0.28	(0.25,0.31)	1.18	(1.06,1.30)	23.72
ACESEX1	0.90	(0.75,1.05)	0.37	(0.32,0.43)	1.27	(1.12,1.42)	29.25

This study promotes our knowledge of the relationship between ACEs as an essential determinant of cognitive disability in emerging adults using data from a nationally representative sample. Our findings confirm the evidence linking ACEs to mental distress and cognitive disability by showing that higher levels of cumulative ACE exposure were linked to increased mental distress and cognitive disability. According to the mediation analysis, emotional anguish had a role in how ACEs were linked to cognitive dysfunction.

As expected, the cumulative ACE score had a direct effect on cognitive disability in emerging adults, demonstrating that the aggregation of risk factors is linked to impaired cognitive development. This finding is in line with previous research on cognitive disability and cognitive issues^25,26. Adversities experienced throughout childhood are significant stressors that contribute to the growth of the stress response and brain function so the absence of ACEs will significantly impair cognitive function and result in cognitive disability in emerging adults. Firstly, the body's natural stress response may be more active in a youngster experiencing adversity than is beneficial or adaptive since their surroundings may constantly pose a threat to their existence. As a result, the normal stress response becomes dysregulated and the allostatic load (i.e., biological adaptive responses that aid in stress recovery) rises over time. Secondly, smaller prefrontal volumes in children have been linked to early life stress, which may hinder their capacity to control their emotions, reflect abstract gain and loss information, and alter stimulus-response linkages^27,28. Therefore, in addition to multiple sources of stress, ACE survivors always begin to face permanent impairments in a number of socio-emotional and cognitive functions, and they are more prone to experience cognitive handicap as emerging adults. Future study on the relationship between ACEs and cognitive dysfunction can be informed by these findings, and new interventions can be developed to lessen the negative effects of this public health issue.

Numerous studies have investigated the relationship of FMD with ACEs or cognitive disability. However, very limited research has assessed these associations amongst emerging adults and formally tested the possible mediation role of FMD. FMD may have an indirect impact on the development of cognitive disability in emerging adults because it decreases the person's cognitive and psychological resources and impairs their ability to effectively fend off intrusive external events. According to the Strength Model of Self-Control, the exertion of self-control appears to depend on a limited resource²⁹. Mental distress lowers a person's cognitive and psychological resources, and it is difficult to make quick, accurate decisions when dealing with external affairs, which ultimately results in cognitive disability. For instance, as a very damaging interpersonal event, childhood maltreatment enhances negative emotion regulation and coping mechanisms including emotional suppression and rumination. Emotional suppression is a cognitively demanding form of self-regulation that may impair incidental recall of information presented during inhibition³⁰, resulting in cognitive disability in emerging adulthood. If pathways can be disrupted through effective treatment of mental distress, the impact of childhood abuse on the development of cognitive disability in emerging adulthood may be reduced.

FMD is also a sign of family dysfunction survivors, because early experiences with parent-child relationships impact mental health and social functioning in many different ways. Early relationship experiences, in accordance with Bowlby (1969/1997), contribute to the development of attachment orientations, which have an impact on how we interpret circumstances, control our emotions, and interact with others. Consider family substance misuse as an example. According to community-based family research³¹, relatives of drug-dependent people are eight times more likely to develop drug abuse problems than the general population and this high frequency may be inherited. First, brain circuits that have been linked to working memory^32–34 and attentional control^35–37 are major contributors to addiction. Stimulant dependency frequently co-occurs with anxiety and affective disorders and affect-related psychopathologies are also prevalent in families with substance abuse issues^38,39. According to the Conservation of Resources (COR) model^{40 41}, people should work to acquire, maintain, and improve their own resources. A person with FMD may lack the necessary psychological resources and find it challenging to interact with their surroundings^40,41, which can lead to stress reactions and cognitive disability.

Our study indicated a strong association between ACEs and cognitive disability, the associations appeared to follow a dose–response relationship. It also demonstrated that FMD was a mediation through which ACEs may be linked to cognitive disability. The results could provide some support of guide intervention development, including multifaceted approaches to treat FMD. Additionally, other unaccounted factors may be more important than FMD.

Data Availability

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

Author contributions

All authors took part in the process of completing the first draft. Y.S. and S.Q. designed, analyzed, and drafted the manuscript. Z.L. designed and drafted the manuscript, too. W.Z. constructed the tables and figures. S.S. and Y.M. designed and reviewed the manuscript. S.Z., N.L., H.S. and K.T. reviewed the data. X.Z. and Y.Y. supervised and reviewed the manuscript.

Additional Information

Funding sources: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Competing interests: The authors declare no competing interests.
Consent to participate: Confirm that informed consent has been obtained from all participants and/or their legal guardians. We confirm the confidentiality of each participant’s answer, and the data will be treated with complete confidentiality, and only for research and statistical purposes only.
Consent for publication: The corresponding author confirms that the manuscript has been read and approved for submission by all the named authors.

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The mediating role of frequent mental distress in the relationship between adverse childhood experiences and cognitive disability in emerging adults

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Journal Publication

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Abstract

Background

Methods

Results

Conclusion

Figures

1. Introduction

2. Methods

2.1 Study design and sample selection

2.2 Adverse Childhood Experiences

2.3 Mental Health

2.4 Cognitive Disability

2.5 Covariates

2.6 Statistical analysis

3. Results

3.1 Descriptive analyses and study population

3.2 Associations between the ACEs and frequent mental distress

3.3 Associations between the ACEs and cognitive disability

3.4. Mediation effects

4. Discussion

5. Conclusion

Declarations

References

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Supplementary Files

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