Early adversity and prosocial behavior in adolescents from Bogotá: a cross-sectional study

doi:10.21203/rs.3.rs-4103840/v1

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Early adversity and prosocial behavior in adolescents from Bogotá: a cross-sectional study

https://doi.org/10.21203/rs.3.rs-4103840/v1

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Background

The association between Adverse Childhood Experiences (ACEs), prosocial behavior, and depression (like other negative mental health outcomes) has not been thoroughly understood. This study aimed at evaluating their simultaneous association while controlling for key confounding variables.

Methods

A cross-sectional study was carried-out with 2,918 secondary school students from seven charter schools located in low-resourced neighborhoods in Bogota (Colombia), 54.12% were female, and mean age was 13.81 years. The self-report instrument included demographic variables, well-being, mental health, risk behaviors and symptoms of psychopathology. Assessment of ACEs was done by a series of yes/no questions, prosocial behavior was evaluated with the corresponding subscale in the Strengths and Difficulties Questionnaire, and depression was assessed with the Self-Reporting Questionnaire. Associations were tested using the Spearman correlation coefficient, Z tests and Chi-square tests, and all primary outcome analyses were adjusted for potential confounding variables through multivariate logistic regression using depression as outcome.

Results

Mean exposure to ACEs was 3.15 events; those exposed to four or more obtained lower scores in well-being, satisfaction with life and family functioning, and higher scores in symptoms of psychopathology. For the prosocial behavior scores, 64.35% were classified as close to the average, 17.51% as slightly lowered, 11.91% as low, and 6.23% as very low; participants with higher levels of prosocial behavior showed lower scores in symptoms of psychopathology. ACEs and prosocial behavior were not simultaneously associated with depression, and prosocial behavior did not modify the association between ACEs and depressive symptoms (Odds Ratio 2.20, 95% confidence interval 1.66–2.93).

Conclusions

Novel studies should further elucidate the developmental pathways involving positive and negative mental health constructs to better understand the actual effectiveness of interventions that use these constructs in their design.

Early Adversity

Well-being

Depression

Youth

Student

Mental health

Adverse Childhood Experiences (ACEs) are a cluster of potentially traumatic events that occur in childhood and adolescence (1, 2). ACEs can be defined as “those experiences which require significant adaptation by the developing child in terms of psychological, social and neurodevelopmental systems, and which are outside of the normal expected environment” (3). They include exposure to several forms of abuse and neglect, such as physical violence or emotional neglect, and some forms of household dysfunction, such as substance misuse and divorce, among others (1, 4). ACEs are associated with risky behaviors, transmissible and non-transmissible diseases, injuries, and mental health issues, through direct and indirect pathways (5). Regarding mental health illness, ACEs are associated with depressive symptoms, drug use, and conduct disorders, among others (6, 7).

ACEs affect a high proportion of the population. According to a retrospective study in twenty-three states of the United States, 61.55% of adults reported at least 1 ACE and 24.64% reported 3 or more ACEs (8). In Latin America and the Caribbean, a study of violence against children found a prevalence of 30–60% for physical and emotional violence by caregivers, 17–61% for physical violence by students and 60 to 92% for emotional violence (9). Similarly, in Colombia, an upper middle-income country from Latin America, it was found that adults have a prevalence of 64% for at least one ACE and 23% for four or more ACEs (10), and 29.3% of adolescents have suffered at least one traumatic event (11). As for mental health outcomes, the most frequent illness related to ACEs is depression, with a risk increase of 2.7 times in women and 2.5 in men in comparison to those who have not been exposed (12). Other associated mental health outcomes are use of psychotropic medication, tobacco dependence, and post-traumatic stress disorder (6, 13).

The developmental pathway from early adversity to depression has not been understood thoroughly yet. There are many ways trauma can influence the development of mental disorders, and its association with prosocial behavior has not been looked at in depth. ACEs may delay the development of prosocial behavior, increasing psychosocial adjustment problems (14). For example, young adults who experienced childhood or adolescent maltreatment are more likely to exhibit psychopathic traits and less altruistic attitudes (15), and physical abuse is a positive predictor of deviant behaviors (16). Besides, evidence suggests that childhood adversity can lead to prosocial behaviors in adulthood through motivations like enhanced empathy, attempts to ameliorate the consequences of ACEs, finding a sense of purpose, and helping others with similar experiences (17).

Prosocial behavior is the action of empathy and responsibility for the well-being and needs of others, it can be expressed as caring, volunteering or helping others (18, 19). The evidence reveals that acting in a prosocial and altruistic manner could increase someone's self-concept (18), and a good self-concept in early adolescence will lead to better decisions during the transition to adulthood (20). Further, elevated levels of prosocial behavior have been associated with better peer acceptance and academic achievement (21), have been reciprocally and directly associated with a positive affect (22), and negatively associated with both aggression and delinquency, even in early and late adolescence (23). Moreover, a negative association between prosocial behavior and depressive symptoms has been reported in adolescents (24), however, adolescents with major depressive disorder seem to have increased prosocial behavior, which might be influenced by gender, relief from negative emotions or social-evaluative concern (24).

The evidence described above shows why it is needed to better understand the direct and indirect pathways leading to a major mental health outcome, such as depression. Both ACEs and prosocial behavior are associated with negative and positive outcomes regarding mental health and well-being in adulthood and adolescence. Nonetheless, the interaction between these variables and their role as protective or risk factors for the mental health of adolescent population is not well understood. Particularly, depression is associated with ACEs but there are mixed results regarding prosocial behavior, thus, understanding these paths could lead to the development of prevention strategies. Therefore, in the present study, we aimed to identify the relationship between ACEs, prosocial behavior and depression in adolescents from urban schools in low-resourced neighborhoods from Bogota, Colombia. We hypothesized that 1) ACEs had a positive association with depressive symptoms, 2) prosocial behavior had a negative association with both ACEs and depressive symptoms, and 3) prosocial behavior could modify the association between ACEs and depression after controlling for other variables.

A cross-sectional study was carried out through a virtual, anonymous, self-administered survey with secondary school students from seven charter schools located in low-resourced neighborhoods in Bogota (Colombia). The project was reviewed and approved by the Research Ethics Committee at the School of Medicine, Universidad de los Andes, Colombia (N20190726). At the time of recruitment (second term, 2019), there were a total of 3,710 secondary school students who were eligible to participate, and we estimated that at least 600 students were needed to detect differences of 5 percentage points in the prevalence of the outcomes of different groups with a level of statistical significance of 5% in two-tailed hypothesis tests.

There were no exclusion criteria and all secondary school students were invited to participate. A total of 2,918 adolescents participated (response rate of 77.45%), and 1,576 of these were female (54.12%). 2,724 students reported their age, with a mean of 13.81 years (Standard Deviation [SD]: 1.82, Interquartile Range [IQR]: 12–15). 2,910 participants reported their school grade, 607 (20.86%) were in 6th grade, 598 (20.55%) in 7th grade, 483 (16.6%) in 8th grade, 410 (14.09%) in 9th grade, 482 (16.56%) in 10th grade, and 330 (11.34%) in 11th grade.

The questionnaire included screening instruments validated in Spanish, and many have been used in Colombia. They measure well-being, mental health, risk behaviors and symptoms of psychopathology. The questions were reviewed by the researchers and members of the schools to ensure their acceptability for the participants and informed consent was obtained from all participants and their legal guardians. The questionnaire was administered in the computer rooms of the educational institutions, and it was supervised by teachers and counselors who participated in the survey review process. Demographic variables included were age, sex, school, and education grade at enrollment (sixth to eleventh grades in our education system).

Assessment of ACEs was done by a series of yes/no questions about 19 different experiences (see Box 1 in Additional file 1), and prosocial behavior was evaluated with the Strengths and Difficulties Questionnaire (SDQ) – Prosocial subscale (25). The prosocial score was calculated using five items (e.g., I am helpful if someone is hurt, upset or feeling ill), 0–2 points per item (not true, somewhat true or certainly true), and ranked as follows: 7–10, close to the average; 6, slightly lowered; 5, low and 0–4, very low (26).

Other instruments and variables assessed in this study were:

World Health Organization-Five Well-Being Index (WHO-5): A five-item questionnaire (e.g., over the last two weeks, I have felt cheerful and in good spirits?) using a 6-point Likert scale (from ‘all of the time’ to ‘at no time’), 0–5 points per item, with total scores ranging from 0–25. A total score of < 13 or a score ≤ 1 in any item indicates poor well-being (27). Versions with a 4-point Likert scale have been studied in Colombian samples with acceptable overall psychometric performance (28, 29).
Satisfaction With Life Scale (SWLS): A five-item questionnaire (e.g. In most ways my life is close to my ideal), using a 7-point Likert scale (from ‘Strongly agree’ to‘Strongly disagree’), 1–7 points per item, with total scores ranging from 5–35. Ranked as follows: 31–35, very satisfied; 26–30, satisfied; 21–25, a little satisfied, 20, neutral, 15–19, a little dissatisfied, 10–14, dissatisfied, and 5–9, very dissatisfied (30, 31).
Family Adaptability, Partnership, Growth, Affection, and Resolve (Family APGAR): A five-item questionnaire (e.g., I find that my family accepts my wishes to take on new activities or make changes in my life-style) using a 5-point Likert scale ( from ‘almost always’ to ‘hardly ever’) (0–4 points per item), with total scores ranging from 0–20. Ranked as follows: 0–9 indicates severe dysfunction; 10–13, moderate dysfunction; 14–17, mild dysfunction, and ≥ 18 is considered good functioning (32, 33).
Strengths and Difficulties Questionnaire (SDQ) – Difficulties scores: The 20-item self-report SDQ items were divided between 4 subscales of 5 items each (0–2 points per item): Hyperactivity (e.g., I am restless, I cannot stay still for long), Emotional Symptoms (e.g., I have many fears, I am easily scared), Conduct Problems (e.g., I take things that are not mine from home, school or elsewhere), and Peer Problems (e.g., Other children or young people pick on me or bully me). Each item score from 0 to 2 (not true, somewhat true, or certainly true), each scale has a score ranging from 0 to 10, and all scores are summed up to generate a total difficulties score from 0 to 40 (25). The scores for total difficulties were ranked as close to the average (0–14), slightly raised (15–17), high (18–19) and (20–40) very high (26).
Self-reporting questionnaire, 20-item version (SRQ-20) (34): A 20-item questionnaire using a yes/no format, with possible total scores ranging from 0–20 (positive screen ≥ 8), as well as an anxiety subscale score (0–10 points, positive screen ≥ 5) and a depression subscale score (0–13 points, positive screen ≥ 7). Some example items are: ‘Do you sleep badly?’, ‘Are you easily tired?’, ‘Do you feel unhappy?’. This is a widely used screening instrument for anxiety/depressive disorders, and the present study adopted the cut-off points used in the Colombian National Mental Health Survey (NMHS) 2015 (35, 36).
Self-injurious behavior: life-prevalence of non-suicidal and suicidal types, and number of episodes per type (once, 2–5 times, 6 or more times).

A STATA® database was generated, and the quality and veracity of the information was checked. Most variables had complete data for more than 95% of the sample, and therefore missing values were excluded from each analysis. Central tendency and dispersion measures, as well as graphical inspection of the data, were used to detect possible extreme values and unexpected distributions. Internal consistency of the scales was evaluated using Cronbach's alpha.

Association was tested using the Spearman correlation coefficient, one-way ANOVA tests, Z tests and Chi-square tests. To reduce bias, all primary outcome analyses were adjusted for potential confounding variables through multivariate logistic regression using depression as outcome. Crude Odds Ratios (OR) were obtained in these regression models, and the interaction term for ACEs and prosocial behavior was tested separately as well.

Table S1 (Additional file 1) displays the distribution of all mental health indicators for the whole sample, with internal consistency for total scores and subscales. All scales and subscales used had a good internal consistency, except some of the SDQ subscales. Only 361 respondents reported no exposure to ACEs, 2,557 (87.63%) reported one or more, and 1,087 (37.25%) reported four or more ACEs. On average, participants reported being exposed to 3.15 ACEs (SD: 2.55, median: 3, IQR: 1–5). For all ACEs, missing data was less than 5%, except for the question on partner violence as 1,038 (35.57%) have not had a partner ever. As shown in Table S2 (Additional file 1), the most prevalent ACE was witnessing violent acts in their neighborhood or near the school, followed by parents separated or divorced and lack of support, love, or protection. As for the prosocial behavior, 2,872 students had a mean score of 7.12 (SD: 1.75, median: 7.0, IQR: 6–8). Out of those, 1,848 (64.35%) were classified as close to the average; 503 (17.51%) as slightly lowered; 342 (11.91%) as low; and 179 (6.23%) as very low. Finally, the SRQ-20 showed a high proportion of the sample had seven or more depression symptoms (19.00%).

Tables 1 and 2 show association tests between our main variables (ACEs in Table 1, and prosocial behavior in Table 2) and the other mental health indicators. Exposure to ACEs was associated to all tested variables, with higher levels of exposure to adversity among women. Similarly, prosocial behavior was associated with most variables, except the SDQ subscale on emotional problems and the prevalence of suicide attempts. Lower levels of prosocial behavior were found among men. The groups with higher levels of ACEs exposure and low prosocial behavior scores were simultaneously associated with older adolescents, and those with lower levels of well-being and satisfaction with life, higher levels of internalizing and externalizing symptoms, and higher prevalence of self-injurious behaviors.

Table 1

**Association between Adverse Childhood Experiences, demographics, and mental health indicators**.
Variable	n^a	ACEs < 4	ACEs ≥ 4	Test^b	p-value
Female (%)	2912	51.07	59.25	χ² =18.34	< 0.001
Age (mean, SD)	2724	13.68 (4.20)	14.03 (1.84)	Z= -4.662	< 0.001
Higher Grades 9–11 (%)	2910	39.22	46.64	χ² =19.41	0.002
WHO-5 (mean, SD)	2859	18.00 (4.20)	15.05 (4.84)	Z = 15.999	< 0.001
SWLS score (mean, SD)	2873	26.24 (6.40)	23.17 (6.05)	Z = 14.687	< 0.001
SWLS adjusted score (mean, SD)	2873	3.74 (0.91)	3.31 (0.86)	Z = 14.687	< 0.001
Family APGAR (mean, SD)	2855	16.53 (3.63)	13.27 (4.50)	Z = 19.804	< 0.001
SDQ – total difficulties (mean, SD)	2662	10.60 (5.09)	14.48 (5.30)	Z= -18.064	< 0.001
SDQ – emotional symptoms (mean, SD)	2832	2.86 (2.11)	4.35 (2.37)	Z= -16.129	< 0.001
SDQ – conduct problems (mean, SD)	2845	2.02 (1.59)	2.90 (1.76)	Z= -13.579	< 0.001
SDQ – hyperactivity (mean, SD)	2847	3.60 (2.00)	4.32 (2.02)	Z = − 9.022	< 0.001
SDQ – peer problems (mean, SD)	2849	2.20 (1.66)	2.92 (1.81)	Z= -10.531	< 0.001
SDQ internalizing (mean, SD)	2773	5.05 (3.09)	7.28 (3.41)	Z= -16.860	< 0.001
SDQ externalizing (mean, SD)	2783	5.62 (3.04)	7.22 (3.15)	Z= -12.606	< 0.001
SRQ-20 – total score (mean, SD)	2677	3.84 (3.66)	7.80 (4.63)	Z= -22.329	< 0.001
SRQ-20 – anxiety (mean, SD)	2792	1.82 (1.96)	3.57 (2.45)	Z= -19.631	< 0.001
SRQ-20 – depression (mean, SD)	2752	2.56 (2.56)	5.40 (3.30)	Z= -22.735	< 0.001
Self-injury behaviors – any (%)	2918	19.01	49.13	χ² =293.40	< 0.001
Self-injury behaviors – non-suicidal (%)	2910	18.20	46.69	χ² =269.14	< 0.001
Self-injury behaviors – suicidal (%)	2899	3.74	18.87	χ² =182.55	< 0.001
^aEach question has a different total number of respondents as participants could answer freely. ^b Z score corresponds to a Mann-Whitney test and χ² corresponds to a Pearson's χ² test. Family APGAR: Family Adaptability, Partnership, Growth, Affection, and Resolve. SDQ: Strengths and Difficulties Questionnaire. SRQ-20: Self-reporting questionnaire, 20-item version. SWLS: Satisfaction With Life Scale. WHO-5: World Health Organization-Five Well-Being Index.

Table 2

Association between Prosocial Behavior, demographics, and mental health indicators.
Variable	n^a	Prosocial behavior		Test^b	p-value
Variable	n^a	Score 6–10	Score 0–5	Test^b	p-value
Female (%)	2868	58.85	45.25	χ² =48.98	< 0.001
Age (mean, SD)	2684	13.74 (1.83)	13.98 (1.81)	Z= -3.434	< 0.001
Grades 9–11 (%)	2866	40.76	44.66	χ² = 4.11	0.043
WHO-5 (mean, SD)	2817	17.53 (4.44)	15.73 (4.86)	Z = 9.72	< 0.001
SWLS score (mean, SD)	2832	25.79 (6.40)	23.89 (6.31)	Z = 8.642	< 0.001
SWLS adjusted score (mean, SD)	2832	3.68 (0.91)	3.41 (0.91)	Z = 8.64	< 0.001
Family APGAR (mean, SD)	2815	15.87 (4.03)	14.32 (4.53)	Z = 9.289	< 0.001
SDQ – total difficulties (mean, SD)	2638	11.38 (5.33)	13.34 (5.56)	Z= -8.46	< 0.001
SDQ – emotional symptoms (mean, SD)	2799	3.43 (2.35)	3.40 (2.29)	Z = 0.126	0.8994
SDQ – conduct problems (mean, SD)	2805	2.08(1.61)	2.81 (1.77)	Z= -10.76	< 0.001
SDQ – hyperactivity (mean, SD)	2807	3.67 (2.01)	4.24 (2.04)	Z= -7.059	< 0.001
SDQ – peer problems (mean, SD)	2808	2.23 (1.67)	2.90 (1.81)	Z= -9.87	< 0.001
SDQ internalizing (mean, SD)	2743	5.66 (3.33)	6.31 (3.46)	Z= -4.758	< 0.001
SDQ externalizing (mean, SD)	2746	5.74 (3.06)	7.06 (3.20)	Z = − 10.162	< 0.001
SRQ-20 – total score (mean, SD)	2638	5.07 (4.38)	5.74 (4.61)	Z= -3.736	< 0.001
SRQ-20 – anxiety (mean, SD)	2752	2.37 (2.28)	2.66 (2.36)	Z= -3.39	< 0.001
SRQ-20 – depression (mean, SD)	2712	3.44 (3.09)	3.93 (3.28)	Z= -3.871	< 0.001
Self-injury behaviors – any (%)	2872	28.52	32.71	χ² = 5.53	0.019
Self-injury behaviors – non-suicidal (%)	2866	27.23	31.11	χ² = 4.82	0.028
Self-injury behaviors – suicidal (%)	2855	8.91	9.96	χ² = 0.86	0.354
^aEach question has a different total number of respondents as participants could answer freely. ^b Z score corresponds to a Mann-Whitney test and χ² corresponds to a Pearson's χ² test. Family APGAR: Family Adaptability, Partnership, Growth, Affection, and Resolve. SDQ: Strengths and Difficulties Questionnaire. SRQ-20: Self-reporting questionnaire, 20-item version. SWLS: Satisfaction With Life Scale. WHO-5: World Health Organization-Five Well-Being Index.

The Spearman correlation coefficient between ACEs and prosocial behavior was − 0.02 (p-value = 1.000), so they were not associated in this sample. The logistic regression models found a significant association of a positive depression screening with ACEs, but not with prosocial behavior (Table 3). These models adjusted the associations for several confounding variables that showed association with ACEs and prosocial behaviors (previously described), and with depression scores (data not shown). Although all variables shown in models have a statistically significant association, some of them have a larger effect size; well-being and general psychopathology have the strongest associations with a positive depression screening.

Table 3

Logistic regression models showing the association of selected variables with a positive depression screening^a.
Variable in model	Model 1^b	Model 2^b	Model 3^b
	OR (CI95%)	OR (CI95%)	OR (CI95%)
Female	2.77*	2.74*	2.74*
Female	(2.10–3.66)	(2.07–3.61)	(2.07–3.63)
Well-being^c: worrisome versus otherwise	4.03*	4.03*	3.96*
Well-being^c: worrisome versus otherwise	(3.08–5.27)	(3.08–5.27)	(3.02–5.20)
Satisfaction with life^d: Dissatisfied versus otherwise	2.05*	2.20*	2.10*
	(1.53–2.74)	(1.64–2.97)	(1.56–2.83)
Family functioning^e: Moderate-to-severe dysfunction versus otherwise	1.75*	2.00*	1.72*
	(1.32–2.32)	(1.52–2.64)	(1.29–2.28)
General psychopathology^f: High to very high scores versus others	4.74*	5.12*	4.66*
	(3.60–6.24)	(3.90–6.72)	(3.53–6.14)
Self-injury: Any versus none	2.58*	3.00*	2.61*
Self-injury: Any versus none	(1.97–3.40)	(2.30–3.93)	(1.98–3.44)
Adverse childhood experiences: ≥4 versus ≤ 3	2.21*		2.20*
Adverse childhood experiences: ≥4 versus ≤ 3	(1.67–2.94)		(1.66–2.93)
Prosocial behavior^g: Low versus otherwise		0.97	0.99
Prosocial behavior^g: Low versus otherwise		(0.73–1.28)	(0.75–1.31)
Constant	0.009*	0.012*	0.010*
Constant	(0.006–0.013)	(0.009–0.018)	(0.007–0.014)
Observations	2,417	2,399	2,399
Chi-square test for model	549.2*	533.5*	548.2*
Pseudo-R-squared	0.379	0.364	0.377
^aSelf-reporting questionnaire, depression subscale ≥ 7 points. ^bAll models had depression as the outcome variable, and the rows show the Odds Ratio (OR) for each independent variable included in the model, and its 95% Confidence Interval (CI95%) computed with robust standard errors. ^cWorld Health Organization-Five Well-Being Index (WHO-5): a total score of < 13 or a score ≤ 1 in any item indicates poor wellbeing. ^dSatisfaction With Life Scale (SWLS): dissatisfied (10–14), and very dissatisfied (5–9). ^eFamily Adaptability, Partnership, Growth, Affection, and Resolve (Family APGAR): total scores ranging from 0–20, 0–9 indicate severe dysfunction; 10–13, moderate dysfunction; 14–17, mild dysfunction. ^fStrengths and Difficulties Questionnaire (SDQ) – Difficulties scores: The scores for total difficulties are ranked as close to the average (0–14), slightly raised (15–17), high (18–19) and very high (20–40). ^gStrengths and Difficulties Questionnaire (SDQ) prosocial behavior subscale: total score of 5 indicates low prosocial behavior and 0–4, very low. * p < 0.01

This study aimed to identify the relationship between ACEs, prosocial behavior, and depression in an adolescent population from urban schools in low-resourced neighborhoods. Many adolescents had been exposed to four or more ACEs, and almost one out of every five teenagers were classified as having a low or very low results in prosocial behavior. The main finding was ACEs were significantly associated with the selected outcome when controlling for confounding variables (well-being, satisfaction with life, family functioning), but prosocial behavior was not associated to ACEs and did not significantly modify their effect on depression. The distribution of all the other variables was consistent with a high-risk urban population, but those data are not shown in this manuscript as they were used as part of the models to control for confounding variables.

Similar association between ACEs, prosocial behavior and mental health outcomes have been documented in several studies. One study identified that adolescents exposed to 8 or more ACEs were more likely to report depression (three times the odds) and post-traumatic stress disorder (four times the odds) than those exposed to 0–3 ACEs (37). Another study conducted an umbrella review of systematic reviews and meta-analyses to identify the association of key ACEs and mental disorders; they found a two-fold increase of suicidality, anxiety disorders, depression, and internalizing disorders (38). Specifically on the topic of suicidality, others found a three-fold increase in rates of suicidal ideation and suicide attempts for adults exposed to three or more ACEs (39). Prosocial behavior has not been as extensively evaluated as ACEs, but there is a meta-analysis for childhood, adolescence, and young adulthood where the authors report and expected association of higher prosocial behaviors with a lower degree of psychopathology (40). The effect size of those associations is like our findings, but ACEs and prosocial behavior have been evaluated separately.

Other studies have found a significant association between depression and prosocial behavior, but they do not include all relevant variables. For example, a statistically significant association between high levels of depression and low levels of both prosocial behavior and resilience was found (41). However, this study did not measure/control confounding variables beyond some demographics and the three main variables. There are other studies that show association between adversity and prosocial behavior (42), showing a statistically significant association between child maltreatment and prosocial behavior, and empathy and gratitude as significant mediators in that association. Nevertheless, that study did not measure psychopathology or any other variables besides demographics and the aforementioned.

We were able to identify at least two other studies that measured both ACEs, prosocial behavior and psychopathology. Bevilacqua et al. (2021) evaluated the association between ACEs, psychopathology and prosocial behavior (14), using the parent-version of the SDQ at ages 3, 5, 7, 11 and 14. The authors found that a higher number of ACEs predicted worse mental health and prosocial outcomes, which were evident by age 3 and persisted until adolescence. This study shows many strengths as it can evaluate the longitudinal relationships between these three areas, their models control for gender, ethnicity, and poverty, and they tested for the effect of specific types of adversity on internalizing and externalizing psycopathology (14). There is another study that evaluated aggressive behavior and prosocial skills in children exposed to intimate partner violence through preschool and early-school years; their results indicated that there was a cross-domain relation between aggressive behavior problems and prosocial skills, exacerbated by early intimate partner violence exposure (43). Preschool-age aggressive behavior negatively influenced prosocial skills development during the early school years. Moreover, preschool-age intimate partner violence exposure was linked to decreased early school-age prosocial skills and increased aggressive behavior problems (43).

Despite the differences in the measures used across studies, it is remarkable how exposure to ACEs and prosocial behavior levels are similar across studies. In a Brazilian study, 33.3% of the 15–19-year-old high school students reported four or more ACEs (44), and 72% of adolescents aged 10–16 years in Malawi reported the same (37). As for the levels of prosocial behavior found in our sample, they are also comparable to those found in similar studies. For example, in a study from Honduras, the authors found a mean score of 7.93 (SD 1.91) in the prosocial behavior subscale of parent-version SDQ (45), and authors in China reported a mean score of 7.24 (SD 2.19) using the same instrument (46). The concordance in ACEs prevalence and prosocial behavior levels with other studies means our results could be valid in adolescents living under different conditions.

Exposure to early adversity plays a key role in depression and other mental health outcomes among adolescent population, and its effects may not be alleviated by the presence or positive mental health constructs like prosociality. When generating models for understanding the complex phenomenon of mental health, these findings support that they should consider multiple variables and their interactions, even more so in the developmental process of children and adolescents. Models generated within the ecological framework could help to better understand the interaction of factors at different levels as well as to help design and carry out effective programs for prevention of mental disorders. As some variables are not modifiable, such as age, sex, and exposure to ACEs, interventions could be directed to improve adolescents' well-being and health by enhancing factors like satisfaction with life, family functionality, and prosocial behavior. That approach might seem logical but may not be the most efficient way to address the problem. Participant charter schools in this study could prioritize their needs and focus their resources on an optimal way for different profiles of their students.

As with any cross-sectional study, our project has some limitations. The measurement of prosocial behavior was performed with a subscale of the SDQ (a screening instrument for general psychopathology); there are other scales that are specifically designed to measure that construct, and they could be considered more thorough, such as the Prosociality Scale (47). Its reduced version has been used in Colombian (48), Argentinian (49) and Japanese (50) adolescents; however, it is designed for young adults (51). There is a widespread need for locally validated measures that allow comparison between populations using the same instruments. Besides, this study has weaknesses inherent to cross-sectional studies, such as the inability to measure incidence, difficulty in making causal inferences, associations that are difficult to interpret, and susceptibility to non-response from the participants. Nonetheless, our response rate was remarkably high in comparison to similar studies on school mental health, and a high response rate allowed us to reduce errors in the estimation of the associations found. Recall bias might be another issue as we asked retrospectively about ACEs using questions adapted from standardized measures available in other studies (52). This is an inevitable limitation, but longitudinal follow-up and assessment of ACEs would be costly in many ways as well. Our instrument captured 19 different ACEs and was reviewed by experts and members of the schools’ communities to ensure it would be appropriate for adolescents. We adapted questions from multiple questionnaires to assess as many ACEs as possible. There are many instruments available as adversity measures, but few of them have been tested in Colombian adolescents (52, 53).

ACEs were significantly associated with a positive depression screening when controlling for prosocial behavior and confounding variables such as well-being, satisfaction with life and family functioning. Thus, implementation of trauma-informed mental health promotion strategies at schools, primary care and community mental health centers, is cornerstone to improve the well-being and positive mental health outcomes during adolescence. Furthermore, acknowledgement of the associations -or their absence- between these variables is key when planning how to prevent mental health illnesses in this population and settle regular follow-ups for those at higher risk, as teens exposed to multiple ACEs.

Finally, in this sample, prosocial behavior was not associated with ACEs nor depressive symptoms and did not significantly modify the association between ACEs and depression. Intervening prosociality in adolescents exposed to multiple ACEs might not be enough to prevent or treat depression, as they may need trauma-focused interventions that address other issues. On the contrary, intervening prosociality in adolescents with low exposure to ACEs might be useful to increase well-being and other positive mental health outcomes. It should be noted that the design and implementation of these interventions requires further research and a multidisciplinary approach, which includes participation of the education sector.

ACEs

Adverse Childhood Experiences

Standard Deviation

IQR

Interquartile Range

SDQ

Strengths and Difficulties Questionnaire

e.g.

"exempli gratia"

WHO-5

World Health Organization-Five Well-Being Index

SWLS

Satisfaction With Life Scale

Family APGAR

Family Adaptability, Partnership, Growth, Affection, and Resolve

SRQ-20

Self-reporting questionnaire, 20-item version

NMHS

National Mental Health Survey

Odds Ratio

Ethics approval and consent to participate: The project was reviewed and approved by the Research Ethics Committee at the School of Medicine, Universidad de los Andes, Colombia (N20190726). The adolescents gave their assent to participate after their legal guardians gave their informed consent.

Consent for publication: Not applicable.

Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests: The authors declare that they have no competing interests.

Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors’ contributions: ACCA, DESA, EMTM, CGR and OLVR contributed to the conception and design of the work, as well as to the acquisition of data. ACCA, DESA, NMA and KAVA contributed to the analysis and interpretation of data. ACCA, NMA and KAVA drafted the work and revised it, and EMTM revised it as well. All authors have approved the submitted version and agreed both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

Acknowledgements: We are grateful to the schools, their personnel, students and families for allowing us to conduct this study with success.

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Early adversity and prosocial behavior in adolescents from Bogotá: a cross-sectional study

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