APPENDIX-I

PROFORMA FOR APPROVAL OF PROJECT SYNOPSIS (MPCE 016)

Enrolment Number: 2106652472 Course Code : MPCE 016

Name and Address of the Learner: ANKITA TYAGI

303 A WING, NEW PARVATI APARTMENT, NEAR CHETAN BOOK DEPOT, SAI BABA NAGAR,
KATEMANAVALI NAKA, KALYAN EAST, THANE , MUMBAI 421306, MAHARASHTRA

Phone No. 9987527198 Email : [email protected]

Regional Centre: 49:MUMBAI Study Centre: SEVA SADAN COLLEGE OF EDU

Successfully completed MPC-005 & MPC-006 Yes  No

Title of Dissertation:

RELATIONSHIP BETWEEN ADVERSE CHILDHOOD EXPERIENCE AND

DEPRESSION AND ANXIETY IN ADULTHOOD WITH RESPECT TO MARITAL
STATUS AND GENDER

Name, Designation & Address of the Guide*: ..........................................................................

..............................................................................

*Guide is (Please tick mark):

a) Academic counselor b) from Approved list by IGNOU c) Other

Signature of Student: Signature of Guide

Date: Date:

Synopsis (put a tick mark as appropriate):

a) Approved
b) Approved with modifications as suggested
c) Not approved
Signature of Synopsis Evaluator

Name :
Designation
:

Address :
Date :
 APPENDIX-II
FORMAT FOR SYNOPSIS EVALUATION

Suggestion/comments need to be given by synopsis evaluator for each component of the

synopsis as follows:

1. Introduction:
...................................................................................................................................
.

...................................................................................................................................
.

2. Review of Literature:
...................................................................................................................................
.

...................................................................................................................................
.

3. Rationale of the Study:

...................................................................................................................................
.

...................................................................................................................................
.

4. Objectives & Hypotheses:

...................................................................................................................................
.

...................................................................................................................................
.

...................................................................................................................................
.

5. Sample:
...................................................................................................................................
.
 ...................................................................................................................................
.

...................................................................................................................................
.

6. Tools:
...................................................................................................................................
.

...................................................................................................................................
.

7. Data Analyses:
...................................................................................................................................
.

...................................................................................................................................
.

8. References:
...................................................................................................................................
.

...................................................................................................................................
.

(Signature & Name with

Date)
 APPENDIX-III

GUIDELINES FOR SYNOPSIS EVALUATION

(synopsis evaluation to be done by approved evaluator only)

Brief Information about Project in MA Psychology (MAPC)

Project (MPCE 016/026/036) is a compulsory course in the Second year of MA

Psychology (MAPC). The learner is required to take up a particular specialization in the
second year either Clinical Psychology (MPCE 016), or Counselling Psychology (MPCE
026) or Industrial & Organizational Psychology (MPCE 036). Related to the specialization,
the learner will prepare a synopsis for the Project under the supervision of a Guide and
submit the synopsis at the Regional Centre (RC). Detailed guideline alongwith the format
for preparing synopsis is given in the Handbook on Project. The learner is required to
prepare the synopsis as per the guidelines given in the Project Handbook.

Once the synopsis is approved, the learner sends a copy of the Proforma for Approval of
Project Synopsis (Appendix-I) and the suggestions/comments given by the Evaluator
(Appendix-II) to the Discipline of Psychology, IGNOU, New Delhi. The learner also
encloses Appendix-I and II alongwith the approved synopsis in original in the final project
dissertation. Dissertation is submitted at the Regional centre for evaluation and viva-voce
by experts from approved list of Examiners.

Guidelines:

Following are a few guidelines which may kindly be followed while evaluating the synopsis:
1) The synopsis is to be evaluated as per the Format for synopsis evaluation (Appendix-
II) given in the Handbook on Project.
2) Kindly ensure that the synopsis is prepared as per the following sequence:
Introduction, Review of Literature, Rationale of the Study, Methodology (Research
Problem, Objectives, Hypotheses, Operational definition, Sample, Research design,
Tools, Data analysis techniques, and References.
3) Since this is a Masters level course, the topic taken should not be very elementary. It
needs to be relevant and specific.
4) The study may involve quantitative or qualitative or mixed approach. Selection of a
particular approach needs to be justified in the synopsis.
5) The research needs to be conducted with primary data that includes psychological
constructs (preferably with two continuous variables). The study should not be on
secondary data. It should not focus on aspects like finding prevalence, incidence,
awareness, or finding only gender differences or on test construction and adaptation.
Overall, the relevance and importance of the topic need to be seen. It should contribute
something significant to the field of research. In case of any query, the evaluator can
contact the Faculty, Discipline of Psychology by email: [email protected]
6) The Title needs to be specific and should reflect the important variables.

7) Review needs to include studies related to the variables taken in the study. It needs to
be written in a flow discussing the various studies and not in bullet points.

8) Research methodology needs to be appropriate as per the research problem and objectives.

9) Objectives and hypotheses need to be framed appropriately.

10) The sample size needs to be adequate. Suggestion can be given to increase the sample
size. It may be less depending on the design and objectives of the study.

11) Standardized tools need to be used for data collection. If a self-developed

questionnaire is used, the standardization procedure needs to be followed.

12) Techniques for data analysis need to be mentioned.

13) Suggestions and comments need to be given with regard to each component as
mentioned in the Appendix-II.
 14) Evaluation consists of three categories: Approved, Approved with modifications,
and Not approved. Approved refers to when the synopsis is appropriate. Not approved
indicates that the synopsis is not proper and requires major changes in the design and
methodology. Approved with modifications indicates that the synopsis is approved with
minor changes (the learner needs to incorporate the modifications suggested in the final
dissertation).

15) If you have any queries/suggestions with regard to project synopsis evaluation, please
contact the Faculty on [email protected]

APPENDIX-IV

CONSENT LETTER OF GUIDE

This is to certify that the Project titled ____ RELATIONSHIP BETWEEN ADVERSE
CHILDHOOD EXPERIENCE AND DEPRESSION AND ANXIETY IN ADULTHOOD
WITH RESPECT TO MARITAL STATUS AND GENDER for the partial fulfillment
of MAPC Programme of IGNOU will be carried out by Mr./Ms. ANKITA TYAGI
Enrollment No. __2106652472____________, under my guidance.
(Signature)

Name of the Guide:

Designation:

Address:

Date :

Grade card of MPC 005 & MPC 006

RELATIONSHIP BETWEEN ADVERSE CHILDHOOD EXPERIENCE AND
DEPRESSION AND ANXIETY IN ADULTHOOD WITH RESPECT TO MARITAL
STATUS AND GENDER

NAME ANKITA TYAGI

ENROLLEMENT NUMBER 2106652472

STUDY CENTRE Seva Sadan college of education

REGIONAL CENTRE 49: Mumbai

YEAR July 2021

NAME OF GUIDE Dr. Anita Kumar

INTRODUCTION

It is well established fact that the period of childhood is very critical in development of
social, physical and psychological health of an individual. Various school of psychology like
cognitive psychology, psychoanalytical psychology, social psychology, Information
processing theories have emphasised that humans start learning right from the birth and form
schemas. These schemas are formed by experience and are resistant to change. And it is well
known that people rely on their experience (schema) for information processing from the
environment. We rely on the weight of experience to make judgments and decisions. We
interpret the past—what we’ve seen and what we’ve been told—to chart a course for the
future.

For example Sigmund Freud believed that the experience a child has during early childhood
and childhood will shape the personality during adulthood. The cause of any psychological
disorder a person is suffering from depends on his childhood experience.

John Bowlby (1907 - 1990) was a psychoanalyst (like Freud) and believed that mental health
and behavioural problems could be attributed to early childhood.

Bowlby also suggested that children have innate tendencies to form attachment with their
caregivers. And the type of attachment the child will form may predict what will be the
attachment style he/she will develop when he/she become an adult. And there is significant
relationship between the attachment pattern and depression and anxiety. According to a 2019
study1 in the Journal of Sex & Marital Therapy, an estimated 10 to 15% of people have a
fearful-avoidant attachment style, which is thought to be a result of traumatic early
experiences with a caregiver.(Favez & Tissot, 2019)

So it can be said that if early experience get scarred due to any reason then it will have a long
term effect on virtually all aspects of the child’s development including cognitive, social,
emotional and physical development, and lay the foundation for a wide range of outcomes in
later life, including social and emotional competence, mental health and achievement at
school or work (Center on the Developing Child at Harvard University, 2016; Price-
Robertson, Smart, & Bromfield, 2010). So it is very important that child gets a conducive
environment to lead a healthy life ahead.
Unfortunately so many children every year face the different types of adversity during
childhood which stains their experience for life. It has both short term and long term
consequences which often leads to different type of psychological disorders such as
depression, anxiety, dissociation disorder, PTSD etc.

Children who experience toxic levels of stress, for example, through abuse or neglect or
extreme poverty, can experience physiological disruptions that can lead to poorer outcomes
in learning, behaviour, and physical and mental wellbeing (Center on the Developing Child at
Harvard University, 2016).

Adverse childhood experiences (ACEs)

Adverse childhood experiences (ACEs) are events that are extreme stressors experienced by
an individual during development (ages 0-18 years old; Danese & McEwen, 2012) or ACEs
are defined as “stressful or traumatic experiences in childhood.

ACEs can be categorized into two broad groups: maltreatment, which refers to events that are
directly experienced by the individual (e.g., physical abuse, emotional neglect, sexual abuse
etc), or household adversity, which refers to circumstances in the individuals’ environment
that can cause high levels of stress (e.g., household dysfunction, due to substance misuse and
or mental illness amongst family members, violent treatment of mother, separation or divorce
of parents, imprisonment of family member”( Hughes et al., 2017)).

In India lots of children’s face different type of adversities, for example “According to the
National Study on Child Abuse report the prevalence of physical abuse was up to 69% in 13
states of India with higher prevalence among boys (54.68%), sexual abuse (53.22%) with
equal percentage among boys and girls and emotional abuse was 50% with equal prevalence
in both sexes.

Another study in 2019 in the state of Kerala indicated 91% prevalence amongst the youth
who had experienced ≥ 1 ACE, and about 50% of them had experienced ≥ 3 ACEs. Results
show that nine out of ten youth had been exposed to adverse experiences in childhood and
more than half of the sample had experienced three or more ACEs. (Damodaran & K, 2019)
According to standardized measures, an estimated 61.5% of adults and 48% of children in the
United States have been exposed to ACEs, with more than one-third of these having multiple
exposures (Bethell et al., 2019)

After seeing these ACE findings and studies mentioned above it is clear that ACEs are quite
common, even among a middle-class population: more than two-thirds of the population
report experiencing one ACE, and nearly a quarter have experienced three or more.

So it can be said that “positive experiences during childhood, including nurturing and
responsive caregiving environments, are associated with happy, productive, and healthy lives
throughout adulthood”( (Bethell et al., 2019).

Conversely, negative or adverse experiences in childhood have been found to be associated

with detrimental health outcomes (Almuneef et al., 2016; Sachs-Ericsson, Sheffler, Stanley,
Piazza, & Preacher, 2017), increased risky behaviour (Barra, Bessler, Landolt, & Aebi, 2018;
Campbell, Walker, & Egede, 2016; Crouch, Radcliff, Strompolis, & Wilson, 2018; Levenson,
2016), and generally poor outcomes later in life (Anda et al., 2001, 2007; Baiden, Stewart, &
Fallon, 2017; Bellis et al., 2014; von Sneidern, Cabrera, Galeano, Plaza, & Barrios, 2017).

So it is well-established that early life experiences set the foundation for health and
development and have a profound influence on life course trajectories.

Relationship between adverse childhood experience, Depression and Anxiety

Relationship between adverse childhood experience, Depression and anxiety are well
documented in western countries compared to India.

The original ACE study by the Centers for Disease Control and the Kaiser Permanente health
care organization in California on topic Relationship of Childhood Abuse and Household
Dysfunction to Many of the Leading Causes of Death in Adults and many more studies
continue to show the significant relationship between ACE, depression and anxiety in
adulthood. (Felitti et al., 1998)

For example,

According to the study done by Kshirod Kumar Mishra, Ramdas Ransing, Praveen Khairkar,
Sakekar Gajanan on “Association between childhood abuse and psychiatric morbidities
among hospitalized patients” the severity and complexity of child abuse are more in India as
compared to Western countries. Child abuse has distinct potential to increase vulnerability to
psychiatric co-morbidities, severity of illness, treatment failure, and outcome of illness. Thus,
child abuse can leave a lasting signature on the individual's mental health and functional
reorganization of a brain network.(Mishra et al., 2016)

Further, Adverse childhood experiences are common (Thompson & Cui, 2000) and have been
associated with many unfavourable psychological and physiological outcomes such as
depression (Bernet & Stein, 1999; Heim & Nemeroff, 2001; Hovens et al. 2010; Nelson et al.
2012; Colman et al. 2013), post-traumatic stress disorder (PTSD) (Widom, 1999; Heim &
Nemeroff, 2001; Moffitt et al. 2007; Hovens et al. 2010), cardiovascular disease (Dong et al.
2004) and chronic pain.(Thompson & Cui, 2000)

The effect of stress on child mind can be explained by following finding-

Early childhood is a particularly vulnerable time for the neurotoxic effect of prolonged,
unbuffered stress. During the first few years of life, the brain experiences rapid growth and
proliferations of neural connections. It is also the time during which the foundation and
laddering of executive function and self-regulation skills are laid. These cognitive skills,
including working memory, mental flexibility, and self-control, are important elements of
successful adult cognitive functioning. Disruption of neurodevelopment during this time can
lead to lasting effects. (Garner et al., 2012)

According to research published by the American Psychological Association “Exposure to

adversity in childhood is a (Struck et al., 2021)powerful predictor of health outcomes later in
life—not only mental health outcomes like depression and anxiety, but also physical health
outcomes like cardiovascular disease, diabetes, and cancer,” said Katie McLaughlin, PhD, an
associate professor of psychology at Harvard University and senior author of the study
published in the journal Psychological Bulletin.

In 2019 study in the state of Kerala similar to the global studies, this study also found
increased odds of having major depression in adulthood if they have experienced ACE in
childhood. (4 times higher). (Damodaran & K, 2019)

In addition, the study also found that those individuals with family dysfunction had higher
odds (2 times higher) of experiencing antipathy and sexual and psychological abuses
confirming that the impact of ACE goes beyond the present generation.
Another studies suggests “Developmental, behavioural, educational, and family problems in
childhood can have both lifelong and intergenerational effects (Shonkoff & Garner, 2012)

So studying ACE and its effect is very important because it has both lifelong and
intergenerational effects as shown by above studies.

In adverse childhood experience one type is emotional neglect, and it mainly comes in a form
of insecure attachment with the caregiver in childhood. And studies have found that the type
of attachment one has in childhood is likely to determine the type of attachment one forms
when become adult.

The concept of adult attachment was first proposed by Hazan & Shaver (1987). Current
research on adult attachment divides the types of adult attachment into Secure, Dismissing,
Preoccupied, and Fearful based on different self-models and other models.

Bowlby found that the loss of early security attachment was closely related to depression and
insecure attachment gradually led to a pessimistic disappointment and helpless self-intention.
When grown up, the complexity of interpersonal relationships will increase the tendency of
depression. Bifulco A. et al. studied the association between depression and attachment
styles, and the results showed that any type of insecure attachment was significantly
associated with depression. Main & Goldwyn's research confirms that individuals with
insecure attachment are more likely to suffer from depression and are more prone to
depressive symptoms.

A number of studies in human children suggest, for example, that disruptions in early
attachment relationships are associated with disturbances in stress–responsive biological
systems (Hertsgaard, Gunnar, Erickson, & Nachmias, 1995; Meyer, Chrousos, & Gold, 2001;
Nachmias, Gunnar, Mangelsdorf, Parritz, & Buss, 1996; Willemsen–Swinkels, Bakermans–
Kranenburg, Buitelaar, van, & van Engeland, 2000.)

The Study on “ Childhood adversity in patients suffering from depression with a focus on
differences across gender” by Bhumika Shah, Jahnavi Kedare, Fiona Mehta evaluates the
occurrence of childhood adversity in male and female patients diagnosed with depression and
its relationship to the severity of depression. The majority of male (70%) and female (68%)
patients have experienced ACEs. Literature reports that 77.2%–84.61% of depressed patients
have experienced at least one category of childhood adversity. There have been reports of the
cumulative effect of the adverse experiences impacting future depression. Vitriol et al.
reported that 43% and Poole et al. reported 58% of the patients with MDD experience three
or more categories of childhood adversity which is higher compared to our results. Three or
more categories of childhood adversity were present in 24% of their patients. (Shah et al.,
2021)

Research reveals that more than two-thirds of depressed male and female patients have
experienced childhood adversities. In male patients, there was a correlation between the
severity of depression and having more than three adversities.
LITERATURE REVIEW

The term “ACEs” is an acronym for Adverse Childhood Experiences. It originated in

research study conducted in 1995 by the Centres for Disease Control and the Kaiser
Permanente health care organization in California on topic “Relationship of Childhood Abuse
and Household Dysfunction to Many of the Leading Causes of Death in Adults”. Seven
categories of adverse childhood experiences were studied: psychological, physical, or sexual
abuse; violence against mother; or living with household members who were substance
abusers, mentally ill or suicidal, or ever imprisoned. A questionnaire about adverse childhood
experiences was mailed to 13,494 adults. More than half of respondents reported, at least one,
and one-fourth reported more than or equal to 2 categories of childhood exposure to
adversity. Persons who had experienced four or more categories of childhood exposure,
compared to those who had experienced none, had 4 to 12-fold increased health risks for
alcoholism, drug abuse, depression, and suicide attempt. The findings suggest that the impact
of these adverse childhood experiences on adult health status is strong and cumulative. High
levels of exposure to adverse childhood experiences would expectedly produce anxiety,
anger, and depression in children. And it may well continue into adulthood. (Felitti et al.,
1998)

Vincent Felitti, head of Kaiser Permanente's Department of Preventive Medicine in San

Diego, conducted interviews with people who had left the program, and discovered that a
majority of 286 people he interviewed had experienced childhood sexual abuse. The
interview findings suggested to Felitti that weight gain might be a coping mechanism
for depression, anxiety, and fear.

ACEs may include, but are not limited to, physical, sexual and emotional abuse, bullying,
parental death or loss, neglect and poverty (Felitti et al., 1998).

Overwhelming evidence for the impact of ACEs on outcomes in adulthood is also apparent
within mental health literature and it has been estimated that in the absence of childhood
adversity there would be a 22.9% reduction in mood difficulties, 31% reduction of anxiety,
41.6% reduction of behavioural difficulties, 27.5% reduction of substance-related difficulties
(Kessler et al., 2010) and a 33% reduction in psychosis (Varese et al., 2012).

ACEs have also been found, for example, to be associated with severity of hallucinations and
delusions in people experiencing psychosis (Bailey et al., 2018), suicide attempts (Xiang
et al., 2018), and risk of depression along with increased risk of relapse and poorer treatment
response (Nanni et al., 2018).

In a one study depression appears to be often linked to experiences of major loss in adulthood
as a whole and to be particularly susceptible to shortcomings in the quality of ongoing social
support. For anxiety only early adverse experiences appeared to be critical. (However, the
onset of both conditions is often provoked by a severely threatening event in the most recent
period--particularly 'loss' in depression, and 'danger' in anxiety.) Finally the critical role of
early experience for both anxiety and depression explains to a considerable extent why they
so often occur together. (Brown & Harris, 1993)

Study conducted on “Childhood adversity and anxiety versus dysthymia co-morbidity in

major depression” suggest that severe sexual abuse and psychological abuse were
significantly and preferentially associated with co-morbid anxiety, while severe physical
abuse was significantly and preferentially associated with co-morbid dysthymia. Indifference
and antipathy were significantly associated with both co-morbid anxiety and dysthymia.
Multivariate analyses revealed that severe sexual abuse was the adverse childhood experience
most strongly associated with co-morbid anxiety. (Harkness & Wildes, 2002)

A strong association between early parental strain and major depression (independent of
anxiety) was also found. The overall pattern of results suggests that there may be unique
relationships linking particular adversities to particular manifestations of depression and
anxiety disorders later in life. A particularly strong association between early sexual abuse
and co-morbid depression/anxiety was found. (Levitan et al., 2003)

Family dysfunction and abuse adversities were the strongest and most consistent predictors of
all four classes of psychopathologies examined (mood, anxiety, substance use and
externalizing), and for the most part, over all three life course stages (childhood, adolescence
and adulthood), consistent with evidence for the enduring effects of chronic stress on brain
structures involved in many psychiatric disorders and with stress-sensitization models of
psychopathology.(Benjet et al., 2010)

Some studies suggest that women are more impacted by sexual abuse and men by economic
hardship. The absence of childhood adversities was protective, it significantly decreased an
individual's risk for subsequent adult mental illness. The results support the clinical
impression that increased childhood adversity is associated with more complex adult
psychopathology. (Putnam et al., 2013)

Study aimed to systematically review the evidence for an association between adversity
experienced in childhood (≤ 17 years old), and the diagnosis of psychiatric disorder in
adulthood ,there was strong evidence of an association between childhood adversity and later
mental illness, The finding suggests that childhood and adolescence is an important time for
risk for later mental illness, and an important period in which to focus intervention strategies
for those known to have been exposed to adversity, particularly multiple adversities.
(TRIVEDI et al., 2021)

As discussed in the introduction there are many studies pointing out the relationship between
attachment, depression and anxiety. In a study of 438 people in a comprehensive university,
“the study of college students attachment relationship, social support, and depression” has
shown that there is a significant positive correlation between insecure attachment, anxiety
and depression. Secure individuals are less likely to be separated from intimate objects, and
can establish close relationships with partners and maintain individual independence. This
may be because secure attachment means that the individual does not worry about not being
able to attract the attention of the attachment object, and relies on the attachment object to
provide security and protection, and to have relatively non-defensive behaviour and
psychological integration of attachment experience, memory and emotion. This allows secure
attachment individuals to be flexible in dealing with complex interpersonal relationships in
adulthood, that is, to be able to integrate the needs, emotions, and different perspectives in a
relationship for the sake of their own safety and health. Insecure attachment means that the
individual is not confident that he or she can cause attention to the attachment object and can
rely on the attachment object to provide the necessary protection for physical and mental
safety. They intentionally or unconsciously cause advances to fall into pain and potential
disorders. (Chinvararak et al., 2021)

Compared to those reporting no ACEs, respondents reporting four or more ACEs had over
four times the odds of Alcohol or Drug Use, Mental Illness, Depression, and/or Anxiety
outcomes and more than twice the odds of diabetes, hypertension, obesity, and/or smoking
outcomes. (Almuneef et al., 2016)
Other longitudinal studies (e.g., Lewis et al., 2011), systematic reviews and meta-analyses
(Agnew-Blais and Danese, 2016, Maniglio, 2010, Maniglio, 2012) have also found a strong
relationship between ACEs and mental health problems.

Furthermore, a systematic reviews conducted and found that having a history of childhood
sexual abuse was a significant risk factor for developing both depression and anxiety
disorder, regardless of gender of the victim and severity of the abuse. (Maniglio, 2010)

The wide-ranging negative associations between exposure to multiple ACEs and diminished
adult and child health are well documented. Most notable is the especially strong evidence
linking ACEs with adult mental health problems including depression. A robust literature
also exists regarding the effect of ACEs on adult relational health (often assessed by whether
adults report that they get the social and emotional support they need) and how diminished
adult social and emotional support contributes to poorer adult physical and mental health.
(Bethell et al., 2019)

Indeed, a recent paper has characterised early adversity as a violation of environmental

predictability, which has profound consequences for sensitive periods of development
(Nelson III & Gabard-Durnam, 2020). On this account, it is argued that experiences that the
child should expect, such as parental care, are either unreliable or atypical in adverse
households. As such individuals who have been exposed to ACEs may perceive the
environment as unstable (Danese & McEwen, 2012). And it has been suggested that adverse
experiences might lead to atypical learning strategies, which could explain why early
adversity is linked to the onset of emotional disorders such as anxiety and depression (Pulcu
& Browning, 2019).

In cross-sectional study of adults in rural Uganda, the cumulative number of ACEs had
statistically significant associations with depression symptom severity, major depressive
disorder, and suicidal ideation. (Satinsky et al., 2021). 

Conclusions: These results suggest that particular adverse experiences in childhood do set up

specific vulnerabilities to the expression of anxiety versus dysthymia co-morbidity in
adulthood major depression. 

RATIONALE OF STUDY
The first Adverse childhood Experience (ACEs) Study was published just over 20 years ago
(Felitti et al.1998). Since then there is growing number of research articles are being
published. Since 1998 till 2018 more than half (58.2 %) of all ACEs publications occurred in
the last three years of the study period (2016–2018). Substantial increases in the published
ACEs literature are indicative of a thriving multidisciplinary field of research. Now people
are recognizing the impact of ACEs and its economic burden on health system as well
(Struck et al., 2021). Since ACE is a relatively new term there is definitely so much scope for
research on this topic as we have seen it has so much prevalence and impact on people.
Studies on the prevalence of ACEs amongst individuals from diverse geographical, social,
and economic circumstances illustrates the global impact of this growing field of research
(Struck et al., 2021),Burke,Hellman, Scott, Weems, & Carrion, 2011; De Ravello, Abeita, &
Brown, 2008; Ramiro, Madrid, & Brown, 2010; Rossegger et al., 2009) . While most of the
Research studies on ACEs come from developed countries, only a little is revealed about it
from developing countries like India. Reliable statistics on ACEs in the Indian context remain
unavailable as there is lack of surveillance data base and systematic investigations using the
umbrella term “ACEs”. So there is clear need to conduct more research in this area in India.
Also as I myself have gone through one of the ACEs that’s why I am compelled to do my
project on ACEs. This is why I am trying to do my project on this topic.

(Struck et al., 2021)

METHODOLOGY

RESEARCH PROBLEM

The present research aims to study the relationship between Adverse Childhood Experiences
(ACEs) and Depression & Anxiety in Young Adulthood.

OBJECTIVES

1. To find out the effect of ACEs on Young Adults

2. To find out the relationship between ACEs and depression and anxiety among young
adulthood.

3. Find impact of ACEs with respect to gender and marital status of young adults.

HYPOTHESIS

Adverse experiences in childhood will be associated with increased risk of both depression
and anxiety in adult life.

OPERATIONAL DEFINITION

ACEs were operationally defined as “stressful or traumatic experiences of childhood that

the youth might have experienced before their 17th birthday”. These included loss,
antipathy and neglect, and, abuse (physical, sexual and psychological).

Loss was defined as “death of any one parent or both before age 17 or continuous separation
of the youth from parents in childhood”.

Neglect was defined as “parent’s disinterest in material care, health, schoolwork, and
friendships” whereas antipathy included “the hostility, coldness, or rejection including ‘scape
goating’ behaviour shown to the child by parents or surrogate parents”.

Physical abuse was defined in terms of “hitting or punching or kicking or repeated attacks
where implements such as belts or sticks are used with the possibility of causing harm”.

Sexual abuse involved “physical contact or Electronic copy available at:

https://ssrn.com/abstract=3322512 7 approach of a sexual nature by any adult to the child.”

Psychological abuse comprised of “both isolated incidents, as well as a pattern of failure

over time (e.g., the restriction of movement; patterns of belittling, blaming, threatening,
frightening, discriminating against or ridiculing; and other non-physical forms of rejection or
hostile treatment) on the part of a parent or caregiver to provide a developmentally
appropriate and supportive environment.” The current study included all the subscales except
the subscale for “support”.

DEPRESSION- According to DSM-5, Major Depressive Disorder is likely if 5 or more of

the 9 symptoms are present for “most of the day, nearly every day" in the past 2 weeks and
one of the symptoms is depressed mood or little interest or pleasure in doing things
(questions 1 and 2 on the PHQ-9). Any degree of suicidal thoughts counts toward this
criteria. The symptoms must also cause significant distress and loss of function, and the
symptoms must not be better explained by substance use or another medical or psychiatric
condition. “Other” depression is diagnosed if there is significant impairment and/or distress
in major areas of functioning, but the full criteria for any specific depressive disorder are not
met. Here the PHQ-9 is used to diagnose Major Depressive Syndrome, but Major Depressive
Disorder must be diagnosed using additional clinical information (e.g. existence of past
manic/hypomanic episode, bereavement, other mental disorder, effects of a medication or
illness).

Generalized Anxiety Disorder-GAD

Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at
least 6 months, about a number of events or activities (such as work or school performance).

The person finds it difficult to control the worry.

The anxiety and worry are associated with three or more of the following six symptoms (with
at least some symptoms present for more days than not for the past 6 months).

1. Restlessness or feeling keyed up or on edge

2. Being easily fatigued

3. Difficulty concentrating or mind going blank

4. Irritability

5. Muscle tension

6. Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

SAMPLE

The sample is selected to represent the population which we want to study. Since it is
difficult to study the entire population, a sample is selected following different procedure.
The sample selection process depends on the objectives and the nature of the sample.
Purposive sampling method will be used in the present study. Those individuals who are
between 20 to 45 years of age residing in the Mumbai will be taken. Early adulthood is the
stage of our life between the ages of about 20-40 years old. A total of 60 adults between age
20 years and 40 years will be taken for the present study. Out of this, 30 will be male and 30
will be female.

RESEARCH DESIGN

Quantitative Descriptive Cross sectional study using online survey method. Questionnaire is
used to obtain data on ACEs, Depression and Anxiety

TOOLS

Adverse Childhood Experiences – International Questionnaire (ACE-IQ; WHO, 2018).

The ACE-IQ is a self-report measure, consisting of 45 items;14 questions are demographics,
30 items explore adverse childhood experiences and one item is used for clarification
purposes regarding bullying. The items investigate participants’ family environment, parental
neglect, parental loss, verbal abuse,
physical abuse, sexual abuse and violence within a peer setting, community setting or
collective setting. They are rated on a 4-point Likert scale, except for seven items (two rated
on a 5-point Likert scale and five require a “Yes” or “No” answer). Higher scores indicate
greater exposure to childhood adversities. The psychometric properties of this questionnaire
have been discussed in the introduction. Consistent with previous research, the number of
ACEs that the respondents reported having experienced was summed into an ACE count
(range 0–11) and categorised into four groups for analysis: 0 ACE, 1 ACE, 2 ACEs and
3+ACEs.(Adverse Childhood Experiences International Questionnaire (ACE-IQ), n.d.)

Patient Health Questionnaire-PHQ-9 for depression: The Patient Health Questionnaire

(PHQ) is a self-administered measure. The PHQ-9 is the 9-item depression module from the
full PHQ. Scores of PHQ-9 can range from 0 to 27 each of the 9 items can be scored from 0
(not at all) to 3 (nearly every day). Scores of 5, 10, 15, and 20 represent cutpoints for mild,
moderate, moderately severe and severe depression, respectively. The diagnostic validity of
the 9-item PHQ-9 was established in studies involving 8 primary care and 7 obstetrical
clinics. PHQ-9 scores > 10 had a sensitivity of 88% and a specificity of 88% for Major
Depressive Disorder. Reliability and validity of the tool have indicated it has sound
psychometric properties. Internal consistency of the PHQ-9 has been shown to be high. A
study involving two different patient populations produced Cronbach alphas of .86 and .89.
(Patient Health Questionnaire (PHQ-9), n.d.)

Generalized Anxiety Disorder-GAD-7 for anxiety –

The Generalized Anxiety Disorder Scale-7 (GAD-7) is a 7-item, self-rated scale developed
by Spitzer and colleagues (2006) as a screening tool and severity indicator for GAD. The
GAD-7 score is calculated by assigning scores of 0, 1, 2, and 3, to the response categories of
'not at all', 'several days', 'more than half the days', and 'nearly every day', respectively, and
adding together the scores for the seven questions.

Scores of 5, 10, and 15 are taken as the cut-off points for mild, moderate and severe anxiety,
respectively. When used as a screening tool, further evaluation is recommended when the
score is 10 or greater. Using the threshold score of 10, the GAD-7 has a sensitivity of 89%
and a specificity of 82% for GAD. It is moderately good at screening three other common
anxiety disorders - panic disorder (sensitivity 74%, specificity 81%), social anxiety disorder
(sensitivity 72%, specificity 80%) and post-traumatic stress disorder (sensitivity 66%,
specificity 81%). (Generalized Anxiety Disorder 7-Item (GAD-7) Scale, n.d.)

DATA ANALYSIS TECHNIQUES

The inferential analysis will include the “Chi-Square Test” to compare the gender on
different types of ACEs and the “Mann-Whitney U Test,” to compare the gender on different
subscales of the ACEs scale, as data were not normally distributed.

Descriptive characteristics will be compared using Chi-square tests for categorical data and
ANOVAs for continuous data.

We will use linear regression models assuming normally distributed errors and log-linear
Poisson regression models with robust error variance to determine the associations between
ACEs and depression and anxiety.

IBM SPSS v29 will be used for all the data analysis.
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