Prevalence of Childhood Adversities Among Inpatients With Mental Disorders: A Cross-Sectional Study At Neuropsychiatric Referral Hospital in Rwanda

The world is dealing with a signicant socio-economic burden that must be addressed to secure a favourable future.To gure out this problem, there is an urgent need of healthy and well educated adult population to participate effectively in global economy.Indeed, childhood experiences may affect adult health outcome.Responsive caregiving during childhood is associated with good physical and mental health.On the other hand,a strong link was established between Adverse Childhood Experiences (ACEs) and poor adult physical and mental health outcomes.This study assessed the prevalence of ACEs among adult patients with mental disorders admitted to the post-crisis wards at Caraes Ndera Neuropsychiatric Hospital in Kigali, Rwanda.

The world is dealing with a signi cant socio-economic burden that must be addressed to secure a favourable future (Jenkins et al., 2011).To overcome this burden, nations must have healthy and well educated adults; skilled enough to participate effectively in the global economy (O'Donnell & O'Donnell, 2016).Thus, child rearing should focus on raising children who grow up being loved, protected, healthy and well educated in order to become responsible adults able to understand and address various challenges in life (UNICEF Annual Report 2017 | UNICEF Publications | UNICEF, n.d.).
Responsive caregiving during childhood is associated with good physical and mental health (Johnson et al., 2013). Children with a history of insecure attachment and a lack of love and trust are more likely to experience psychosocial problems,including anti-social behaviours (P. M. Miller et al., 2000). These potential traumatic experiences during childhood are known as adverse childhood experiences (ACEs).
ACEs include child abuse and neglect, growing up in a violent community or an unsafe household characterized by domestic violence,having a family member with mental illness, having ajailed family member, experiencing parental separation, or living in a household with drug or alcohol abuse (World Health Organization, 2018).
ACEs may lead to detrimental health outcomes, including physical and mental disorders according to Felitti and other authors (Felitti et al., 1998). The relationship between ACEs and health outcomes is complex.It likely involves both direct physiological damage in terms of disrupted neurodevelopment resulting from unsafe child exposure to stressors as well as indirect effects through adopting risky soothing behaviours as a way of coping with ACEs (Sterling et al., 2018).
The National Scienti c Council on the Developing Child has established three different categories of stress responses in early childhood (National Scienti c Council on the Developing Child, 2014; Shonkoff, 2010). The positive stress response refers to a mild or moderate activation of the stress response system with the availability of a protective adult who helps the child to be at ease so that he can observe, learn, practice coping mechanisms and gain experience.A tolerable stress response refers to exposure to severe adversity in the hands of a responsive caregiver that helps the child to calm down.And lastly,the toxic stress response refers to exposure to frequent, prolonged or high level of adversities in the absence of a soothing and protective adult (Franke, 2014;Szilagyi, 2012).
The main effect of the toxic stress response during the developmental period is to establish the stress response system as a dysregulated pattern. This dysregulation may affect various systems, including the nervous, immune, hormonal, cardiovascular, respiratory and gastrointestinal systems. It may also induce modi cations in the DNA expression (Anda et al., 2006).The toxic stress response may further have intergenerational effects. Individuals with ACEs were found to be more likely engaged in behaviours that might create potential ACEs among their offspring (M. A. Bellis et al., 2014;Renner & Slack, 2006).
ACEs are common worldwide. Surveys conducted across 23 states in the USA have indicated that approximately 62% of adults had been exposed to at least one form of ACE while almost 25% of them had experienced more than three forms of ACEs (Merrick et al., 2018). However, ACEs are unequally distributed between and within countries with the largest proportions found in low-and middle-income countries and among socially disadvantaged groups, including ethnic minorities and poorer communities ACEs remain an unaddressed public challenge that communities are faced with, especially in lowresource settings (Ginocchio, 2018). This may be partly due to the lack of information about ACEs, which contributes to a poor understanding of interventions required for ACE prevention (Oh, Jerman, Silvério Marques, et al., 2018).The aim of this study was to determine the prevalence of ACEs among inpatients with mental disorders. It may contribute to increasing data related to ACEs in Rwanda, where little is known regarding early adverse childhood events and their long-term effect on physical and mental health outcomes.

Methods
Design, population and duration of the study This research is a descriptive cross-sectional study to assess the prevalence of childhood adversities among patients with mental disordersduring a four week period of time, from August to September 2019.Patients included in the study were males and females between the ages of 18 and 64 years and had been diagnosed primarily with psychotic, mood and substance-related disorders.All patients aged 18 years and above,receiving inpatient care during the study period and only those who were able and willing to give informed consent, were included in this research.

Setting
Caraes Ndera Neuropsychiatric Hospital is a national referral hospital for patients with neurologic and psychiatric disorders located in Kigali, Rwanda. It was established by the Congregation of Brothers of Charity in July 1968 and become functional in 1972.It also serves as a teaching hospital for the University of Rwanda and offers a variety of services: psychiatry, neurology, clinical psychology, ergotherapy and physiotherapy.In this hospital, there are two wards for adult patients with critical symptoms and two post-crisis wards for adult patients with remitted symptoms;one for males and another one for females. Patients are transferred from critical wards to post-crisis wards after remission of their symptoms; in order to continue care with psychotherapy and rehabilitation, prepare them to return to their families and to continue outpatient care.

Procedureand ethical consideration
Ethical clearance for this study was requested and obtained from the Institutional Review Board (IRB) of the University of Rwanda (UR)/College of Medicine Health Sciences (CMHS).We used the convenience sampling method to enroll study participants. All participantsreceived a clear explanation about the nature and the purpose of the research project in the language that they understand well; either English or Kinyarwanda.Participation was strictly voluntary and refusal to participate did not affect their treatment or care.A mental status examination was initially conducted on all participants in order to rule out active neuropsychiatric symptoms that could hinder a successful interview. Patients who volunteered to participate signed an informed consent document and completed questionnaires without identifying information.All data collected was used for research purposes only.

Materials and measures
The ACE-IQ was designedfor individuals aged 18 years and above by the WHO to measure ACEs in all countries (World Health Organization, 2018).It has also been validated to measure ACEs in Nigeria (Kazeem, 2015). The socio-demographic section of the ACE-IQ that captures data on variables such as age, sex, ethnic group, marital status, educational level and employment status,was modi ed slightly by removing the variable on ethnic groups as it was not applicable to this study population.Items on the ACE-IQ screen for child exposure to physical, emotional and sexual abuse, physical and emotional neglect, household member treated violently, household member with substance abuse, household member with mental illness, incarcerated household member, having separated/divorced or dead parents, peer violence (bullying), community violence and collective violence.The total score is calculated by summing up the number of events the participant was exposed toand it varies from 0 to 13.

Statistical analysis
Descriptive statistics were used to recapitulate socio-demographic variables and ACEs in terms of frequencies and percentages using the Statistical Package for the Social Sciences (SPSS) version 21.

Sociodemographic characteristics of participants
A total number of 159 patients were admitted to the post-crisis wards over the period of 4 weeks between August and September 2019. All 159 patients were invited to participate in the study and 122 patients (77%) gave their consent and lled out questionnaires ; 4 patients (2%) refused to participate and 33 patients (21%) were not able to give consent due to their unstable mental status. Table 1 displaysthe socio-demographic characteristics of participants: 43.4% were female, 56.6% were male and slightly more than half (51.6%) were single. The majority (61%) of respondents were youth between the ages of 18 and 35 years.The majority of study participants (88.5%) were Rwandan with 25.4% coming from the urban area of Kigali city.Regarding the highest level of education, the majority of our participants (67.2%) did not go beyond primary school. Less than one fth (19.7%) had paid jobs and nearly one third (29.5%) did not work during the last 12 months.    (5) 13.2% (7) 10.1% (7) 18.8% (13) 9 9.8% (12) 26.2% (32) 13.2% (7) 26.4% (14) 7.2% (5)

Correlations between variables
The lack of correlation between the patients'ACE score and their level of education as well as with regard to their work status during the past 12 months is indicated in Table 4.The correlation coe cients were r = -0.143 and r = 0.071 respectively.The p values were p = 0.113 and p = 0.434 respectively.The r values are very close to 0 and p values are above 0.05; there is no correlation between above variables.
However, there was a correlation between household challenges and child maltreatment as indicated in Table 4   Nearly 78% of the study participants experienced at least 4 ACEs.This nding was signi cantly higher than those from an ACE study on outpatients with affective disorders in the Netherlands in which35. The most prevalent ACE in our ndings were adults (64.8%) who had experienced separation,divorce or death of parents during their childhood.This nding was higher than 42% of Brezilian adolescents who reported parental separation and 10.1% of them reported parental death (Soares et al., 2016). Indeed,50% of American children will see their parents' divorce (Oren & Hadomi, 2020). Descriptively, these data provide insight into some households to be at high risk of child maltreatment : a single parent home has been associated with a higher prevalence of child maltreatment, especially child neglect (A et al.,

2015).
Interestingly, emotional abuse was experienced by 58.2% of the current study's participants. These ndings are consistent with a study in Singapore that found similar elevated ACE scores in mental health patients (59.1%) regarding childhood emotional abuse (Devi et al., 2019). On the other hand, less concern has been shown regarding the impact of emotional abuse on future physical and psychological disorders than other ACE types probably due to the common erroneous belief that it is the least damaging form of ACEs. Despite this misperception, previous studies demonstrated the consequences of emotional abuse and signi cant harmful effects with regard to several mental,physical and behavioral health outcomes in comparison to other ACEs .
The prevalence of physical abuse varies not only across continents and countries but also across gender.
Physical abuse was reported by 55.7% of study participants.This prevalence was extremely high compared to the general population in which the global prevalence of childhood physical abuse has been estimated at 25%.There is signi cant variability in the prevalence physical abuse across countries with12.0% and 27.0% for girls and boys respectively in Europe (Moody et al., 2018). However, these ndings for the Rwandan inpatient population are similar to those found in other African countries for the general population.In Zimbabwe 64% of male and 76% females and in Kenya 66% of males and 73% of females respectively experienced physical abuse during childhood (Cui et al., 2018;Moody et al., 2018).
Exposure to collective violence was reported by 53.3% of patients.This nding was signi cantly higher than the global review which found that more than 10% of children are affected by the armed con icts worldwide.During collective violence, children may experience direct consequences of violence such as physical injuries/death, illnesses, disability, exposure to armed con icts, torture or indirect consequences such as altered physical, emotional and cognitive development, displacement, separation from family, becoming orphaned, having limited access to health care and education, being required to assume adult responsibilities, having a lack of access to basic needs such as foods and water, violation of children's child right and child maltreatment (Kadir et al., 2019).
Exposure to a household member who was treated violently was reported by almost half (49.2%) of the study respondents. These ndings supported the results of previous research that found the prevalence of IPV in African countries is estimated to be from 26.5-48% (Taquette et al., 2019). Furthermore, a signi cant relationship between children's health problems and their exposure to their mother being treated violently has been established. Kajeepeta  The ndings of this study did not nd a correlation between an ACE score and the participants'level of education and work status during last 12 months.The data may be interpreted in terms of resilience which is de ned as the capacity to resist or to overcome the damaging effects of adversity. Some participants have resisted adversities for a long period of time; 6.6% have completed a university level of education and 19.7% held paying jobs and were relatively stable in their occupational, social and professional functions before being admitted to the hospital for their symptomatology. Key factors to promote resilience are responsive care giving, fair treatment, good educational experiences, and opportunities to exert valued social roles (M. A. Bellis et al., 2018).
Despite this perspective, the majority of this study population did not achieve a high level of education and 67.2% did not study beyond the primary school level. They were also economically challenged as 42.6% of those who could work, were not employed, 29% were either totally or partially unable to work during the previous 12 months and 1.6% were retired. These alarming ndings highlight the socioeconomic burden for patients with mental disorders.It is true that ACEs may contribute to this problem but further research studies are encouraged in order to delineate other underlying causes.
However, our ndings demonstrated a correlation between child maltreatment and different household challenges as noted in the previous studies (Choudhry et al., 2018).This interrelatedness between ACEs suggests that they cannot be regarded as independent events during ACE studies. Anyway, different forms of ACEs share the same interacting factors at different levels: individual, parental, familial and social (Soares et al., 2016).

Limitations
The results of this study have been interpreted within the context of several possible limitations. The ACEs mentioned in the ACE-IQ are not alone to produce toxic stress response.Other risk factors to toxic stress have been identi ed in recent studies such as separation from a caregiver in foster care, migration and discrimination . Additional considerations such as being born with HIV infection, being born from sex worker parents, teenager and unwanted pregnancy may hypothetically be added to the list given the psychopathology associated with those childhood events in Rwanda.
In addition, similar to other studies on ACEs, the retrospective nature and the self-reported data of the ACE-IQ may limit the ability to document all ACEs with precision. This limitation may be due to the possibility of recall error, overestimation or underestimation of those experiences and other retrospective biases.

Conclusions And Recommendations
This seminal study provides introductory and useful data in advancing our insight on the high prevalence of ACEs in hospitalized patients with mental disorders and the paucity of data on ACEs in Rwanda.Early recognition of ACEs with appropriate interventions can mitigate their negative effects on child development and can lead to better mental and physical health outcomes. If Rwandans had insight into the pernicious effects of ACEs on their mental health,it may empower them to seek preventive mental health care services.This insight may also provide motivation to learn useful parenting skills to help stop the intergenerational cycle of ACE transmission from parents to children.
It is critical to set the stage early for the prevention of ACEs in Rwandan children.Recognition of the lifelong impact of ACEs on normal development of children has been lacking in Rwanda and other developing countries.Identifying and addressing family problems, providing positive parenting programs, Trauma-Informed Care and Trauma-Informed Network of Care, and all interventions that can foster individuals' resiliency have been used in high-income countries with positive outcomes. It is imperative that the healthcare system in Rwanda includes ACE screenings in its general approach to medical healthcare in order to identify children and families at high risk for future mental and physical health problem.

Declarations
Ethics approval and consent to participate : Ethical clearance for this study has been requested and obtained from the Institutional Review Board (IRB) of the University of Rwanda (UR)/College of Medicine Health Sciences (CMHS). Written informed consents were given to the participants during the period of data collection. The meaning of the investigation was explained, and their participation was invited anonymously and voluntarily, resulting in a 77% participation. Subsequently, the questionnaires were distributed on paper. During its completion the main author of the study remained in place with the intention of resolving any doubt or di culties. All methods were carried out in accordance with the ethical principles for medical research involving human subjects.
Consent for publication : Not applicable.
Availability of data and materials : All data and sensitive information are not publicly available. However, under a reasonable requirement, the data can be shared by writing a request to the following email address: vianney2020@gmail.com Competing interests : The authors declare that they have no competing interests.
Funding :This study was funded by the authors themselves and the role of the funding body did not interfere in the study design, data collection and analysis neither in th einterpretation of the results.