Child Abuse & Neglect 67 (2017) 338348

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Child Abuse & Neglect

Full Length Article

Associations of adverse childhood experiences with

depression and alcohol abuse among Korean college students
Yeon Ha Kim
Department of Child & Family Studies, College of Human Ecology, Kyung Hee University 26, Kyungheedae-ro, Dongdaemun-gu, Seoul,
02447, Republic of Korea

a r t i c l e i n f o a b s t r a c t

Article history: This study investigated adverse childhood experiences of Korean college students and the
Received 5 September 2016 impact such experiences have on students depression and alcohol abuse. Using an online
Received in revised form 12 March 2017 questionnaire, 939 college students were surveyed regarding their adverse childhood expe-
Accepted 14 March 2017
riences, depressive symptoms and alcohol use habits. About half of the participants claimed
to have experienced at least one adversity in their childhood. Eight percent of partici-
Keywords: pants reported experiencing four or more categories of adversity. The correlations between
Adverse childhood experiences
adverse childhood experiences and depressive symptoms, alcohol abusive behaviors, and
Depression
the comorbid condition of the two outcomes were signicant when students gender, geo-
Alcohol abuse
Korea graphical regions, maternal and paternal education, and family incomes were adjusted.
College students Graded associations of cumulated adverse childhood experiences with the outcome vari-
ables were evident. These ndings strengthen the link between child maltreatment and
adult public health issues carrying socioeconomic burdens, two matters that have not been
extensively studied in Korean contexts.
2017 Elsevier Ltd. All rights reserved.

1. Introduction

In the nearly two decades since the original adverse childhood experiences (ACE) study by the Centers for Disease Control
and Prevention (CDC) and Kaiser Permanente in the United States of America (Felitti et al., 1998), there have been consistent
efforts to examine the associations between adverse and traumatic childhood experiences and health-related outcomes in
later life. Now, researchers have arrived at the consensus that ACEs such as abuse, neglect, and family dysfunctions can lead
to lifelong unwanted consequences. Poor outcomes associated with ACEs have appeared across diverse developmental and
health domains such as substance abuse (Mersky, Topitzes, & Reynolds, 2013), mood or anxiety problems (Sareen et al.,
2013), poor physical health-related indices (Bellis et al., 2014), and socially-unacceptable behaviors (Bellis et al., 2014; Fox,
Perez, Cass, Baglivio, & Epps, 2015). Also, a dose-response relationship is now widely accepted: experiencing accumulating
levels of adversity during childhood increases the possibility of undesirable outcomes in later life (Bellis et al., 2014; Fox
et al., 2015; Mersky et al., 2013).
Initially, most ACE studies were conducted in developed Western countries with low tolerance levels for child maltreat-
ment and high interests in public health. In 2009, the World Health Organization (WHO) and CDC played a leading role
in building a global research network to prevent abuse, neglect, and violence toward children in low- and middle-income
countries. Countries such as China, Saudi Arabia, and Vietnam participated in this project in effort not only to understand

E-mail address: yeonhakim@khu.ac.kr

http://dx.doi.org/10.1016/j.chiabu.2017.03.009
0145-2134/ 2017 Elsevier Ltd. All rights reserved.
 Y.H. Kim / Child Abuse & Neglect 67 (2017) 338348 339

the long-term risks and associated consequences of ACEs in their own cultural contexts but also to prevent these adversities
from affecting future generations (World Health Organization, 2009). As the rst step in undertaking global surveillance
of ACEs, the WHO developed the Adverse Childhood International Questionnaire (ACE-IQ), a measurement that enables
international researchers to make cross-cultural comparisons of the prevalence of ACEs and their associations with public
health matters (World Health Organization, 2011). The ACE-IQ includes comprehensive categories of childhood adversities.
Its validity as a tool has been demonstrated by testing its psychometric properties in several countries (Bellis et al., 2014).
Recently, ACEs have become a global academic topic. Researchers in diverse countries have explored the prevalence of
ACEs in their own domestic contexts and studied associations with various outcomes in adulthood. For example, Ramiro,
Madrid, and Brown (2010) found that, of 1068 people residing in urban communities in Philippines, 75% reported at least
one incident of ACE. They found strong graded relationships between number of ACEs, health-risk behaviors and poor health
among Philippine people. In Saudi Arabia, Almuneef, Qayad, Aleissa, and Albuhairan (2014) investigated the links between
ACEs and health-related issues in adulthood. Among 931 subjects, about 82% reported at least one incident of ACE. Almuneef
et al. (2014) suggested that being exposed to four or more ACEs increased the risk of having chronic diseases and risky health
behaviors. In Japan, Isumi and Fujiwara (2016) explored inter-generational transmission of ACEs by studying associations
between caregivers own ACEs and their shaking and smothering behaviors toward their infants. The researchers found a
link between a specic type of ACE (witness of intimate partner violence) and infant shaking behaviors. However, no graded
relationship of ACEs with abusive caregiver behaviors (shaking and smothering) was found.
South Korea did not participate in the global surveillance of ACEs. However, child abuse and neglect are known to be
common in this context. Several Korean domestic studies have explored the associations between traumatic experiences in
childhood and outcomes in later life. The viewpoints and methods of existing Korean domestic childhood trauma studies are,
to some extent, different from those of international ACE studies in three key respects. First, few Korean studies deal with
a comprehensive scope of childhood traumas at the same time. Most Korean domestic childhood trauma studies address
a particular type of childhood trauma such as emotional neglect (Cho & Lee, 2014) or sexual abuse (Choi, 2009). Second,
the graded associations of cumulative ACEs with outcomes in the general population have not been properly explored
in a Korean context. Many studies have undertaken two-group comparisons (i.e., outcomes from people with childhood
trauma versus outcomes from people without trauma) (Kim, Kim, & Park, 2006; Kim, Chung, & Lee, 2009) or correlational
approaches (Kim & Han, 2015; You & Heo, 2012). Third, there is a lack of evidence regarding health-related outcomes as
consequences of ACEs among the general Korean population. Most outcomes addressed in childhood adversity studies are
socio-emotional, such as interpersonal problems (Bae & Cho, 2014), impaired empathetic ability (Kim & Han, 2015), and
subnormal life satisfaction (You & Heo, 2012). Aside from this, childhood trauma among outpatients of mental clinics has
been often studied (Sohn, Lee, Song, Sakong, & Lee, 2001). The differences between the international ACE studies and Korean
domestic studies are mainly due to Korean researchers lack of instruments, which has restricted them from measuring
diverse types of childhood adversities and calculating the cumulative ACEs in valid manners.
In order to address these research gaps, the present study explores the prevalence of ACEs among Korean college students
using a valid instrument enabling international comparisons. This study tests the links of ACEs to depression, alcohol abuse,
and the co-occurrence of depression and alcohol abuse among Korean college students. Depression and alcohol abuse are
two of the most prevalent mental health problems among the Korean population. The socioeconomic costs of depression
and alcoholism are a serious issue in Korea (Kim et al., 2007; Kim, Lee, Kang, & Choi, 2013).
The present study focuses on college students for several reasons. Previous studies have shown that depression and
substance problems often emerge in early adulthood (Kessler et al., 2007), and that the co-occurrence of these two problems
in early adulthood is notably high (Brire, Rohde, Seeley, Klein, & Lewinsohn, 2014). Several studies conducted in Western
contexts found that the destructive impacts of ACEs are obvious on young adults mental health through disorders such
as depression (Bellis et al., 2014; Mersky et al., 2013), and health-risk behaviors such as alcohol abuse (Bellis et al., 2014;
Mersky et al., 2013), teen pregnancy (Hillis et al., 2004), and drug use (Bellis et al., 2014; Dube et al., 2003; Mersky et al.,
2013). Emerging in early adulthood as consequences of ACEs, these issues may extend or augment the inuences of ACEs
throughout individuals lifetimes if no proper understanding is reached and interventions made at the issues onset (Mersky
et al., 2013; Nurius, Green, Logan-Greene, & Borja, 2015). To date, no academic attempt has been made to understand mental
health issues of young Korean adults as consequences of their childhood adverse experiences. By investigating the link of
ACEs with depression and alcohol abuse in college students, the present study intends to provide meaningful information
and implications for public health in Korean contexts.
This is the rst Korean study employing the scopes and methods of global ACE surveillance. The current investigation
has three objectives: to investigate the prevalence of ACEs among Korean college students using an valid instrument cor-
responding to international ACE surveillance; to explore the links of ACEs to depression, alcohol abuse, and the comorbid
condition of depression and alcohol abuse; and to examine the graded associations of cumulative ACEs with depression,
alcohol abuse, and the comorbid condition of depression and alcohol abuse.
340 Y.H. Kim / Child Abuse & Neglect 67 (2017) 338348

2. Methods

2.1. Study population and data collection

This study employed a cross-sectional online survey design. The researcher surveyed college students via the internet
because recent works have reported that online surveys are comparable to paper-and-pencil surveys in validity and reliability
of data (Shapka, Domene, Khan, & Yang, 2016; Weigold, Weigold, & Russell, 2013). In addition, young participants have
been found to prefer web-based survey methods over paper-and pencil questionnaires or interviews when addressing
sensitive topics (Barratt, 2012). As the country with the highest rate of smartphone ownership, South Korea has a particularly
well-developed infrastructure for online surveying: 88% of Koreans use smartphones (Poushter, 2016).
The researcher developed an online survey using Google Forms including question items regarding adverse childhood
experiences, depressive symptoms, and alcohol use habits. Then, the link was spread to college students using social network
services (SNS) and messenger services such as Facebook and KaKaoTalk. The researcher initiated spreading the link, employ-
ing rsthand networks. They mainly included undergraduate student council members and volunteer research assistants
of a social science research center afliated with **** University. All participants who received the link were encouraged to
send the link to other college students, thus recruiting new participants. In addition, the link was posted to several websites
that college students could freely access. Participation was completely voluntary and anonymous and no personal data were
collected except age and gender. The researcher obtained informed consent from all participants through an online form at
the beginning of the survey. The participants received nancial compensation of 2 dollars (2500 Korean Won). This study
design was approved by the Institutional Ethical Review Board (IRB) of **** University.
In order to obtain data representative of national demographics, the researcher aimed to reach 50:50 compositions of
gender and geographical area (Seoul metropolitan area and non-metropolitan area) among participants. These compositions
reect the natural gender ratio and the current population density of South Korea. The plan was to stop accepting responses
via the web form when the gender and area ratios were close to 50:50 with 7001000 responses. The online survey was
terminated when 986 responses were collected in six days. Among 986 cases, 47 cases were excluded because they were
not college students (n = 13) or due to incomplete responses (n = 34). Thus, data for 939 cases were nally analyzed (95% of
completion rate, 50.2% male, 51.5% residing in the Seoul metropolitan area). The mean age of participants was 21.82 years
old. The oldest participants were 30 years old and the youngest were 19 years old.

2.2. Measures

2.2.1. Depression. Depressive symptoms of participants were measured with the Korean version of the Center for Epidemi-
ologic Studies Depression scale (CES-D-K) (Cho & Kim, 1998). The CES-D-K has been widely used to measure depressive
symptoms of the general population and for research purposes in Korea. The CES-D-K has 20 items and the score ranges
from 0 to 60. Higher scores indicate the individual has more depressive symptoms. The researcher classied participants
into three groups as suggested by Park and Kim (2011): scores ranging from 0 to 15 were classied as no depression (the
base group); scores from 16 to 24 as possible depression; and scores of 25 and higher as denite depression. The internal
consistency (Cronbachs alpha) of the CES-D-K in this study was 0.943.

2.2.2. Alcohol abuse. The present study employed the Korean version of Alcohol Use Disorder Identication Test (Audit-K)
(Kim, Oh, Park, Lee, & Kim, 1999), which was originally developed by WHO (World Health Organization, n.d.-b). The AUDIT-K
has 10 items and the score ranges from 0 to 40.The higher AUDIT-K scores indicate greater likelihood of harmful drinking.
The Korea Health Association proposes to use gender-specic cut-off scores of the AUDIT-K (The Korea Health Association,
n.d.). Men with AUDIT-K scores 09 are classied as normal drinkers; 1019 as problem drinkers; and scores of 20 and
higher as potential alcoholics. For women, the AUDIT-K score range 05 is for no drinking problem (the base group);
from 6 to 9, problem drinkers; and scores of 10 and higher are potential alcoholics. Based on these cut-off scores, the
researcher classied participants into three groups: normal drinkers, problem drinkers, and potential alcoholics. The internal
consistency of the 10 items in the AUDIT-K was 0.867.

2.2.3. Co-occurrence of depression and alcohol abuse. The researcher constructed another categorical outcome variable based
on comorbidity of depression and alcohol abuse. Participants were classied into no depression or alcohol abuse (the base
group), depression only (possible depression without alcohol abuse or denite depression without alcohol abuse), alcohol
abuse only (problem drinkers without depression or potential alcoholism without depression), and depression and alcohol
abuse (possible depression/denite depression and problem drinkers/potential alcoholism).

2.2.4. Adverse childhood experience. The present study employed the Korean version of Adverse Childhood Experience Inter-
national Questionnaire (K-ACE-IQ), a retrospective self-report measure of childhood trauma for people aged 18 years and
older. The original ACE-IQ measures 13 categories of ACEs using 29 items (World Health Organization. n.d. -a). The researcher
translated the ACE-IQ into Korean using the translation-back-translation method and examined the acceptability through a
pilot study. Two university professors in mental health areas reviewed the adequacy of the translated K-ACE-IQ items. The
Cohens Kappa test-retest reliabilities were obtained using survey results from 60 Korean college students. The reliability of
 Y.H. Kim / Child Abuse & Neglect 67 (2017) 338348 341

Fig. 1. Distribution of ACE scores.

the paper and pencil survey version of the K-ACE-IQ was 0.654 (three-week interval, N = 30), and.353 (three-week interval,
N = 30) for the online survey version, which was acceptable (Viera & Garrett, 2005).
The K-ACE-IQ makes two alterations to the ACE-IQ: it eliminates the category of collective violence and it modies the
scoring in the category of emotional neglect. First, the collective violence category of the original ACE-IQ, with four items
asking about violence caused by militia, gangs, or police, was excluded. As was done in the Saudi Arabian ACE study (Almuneef
et al., 2014), this category was excepted because collective violence is rare in South Korea. Second, the K-ACE-IQ adopted
altered scoring to measure exposure to emotional neglect. From a ve-category response scale (always, most of the
time, sometimes, rarely, and never), the original ACE-IQ scoring guide suggests coding either the responses rarely
or never as exposures of emotional neglect in response to two items (Did your parents/guardians know what you were
doing with your free time when you were not at school or work? or Did your parents/guardians understand your problems
and worries?). The researcher found that in the Korean context, over 50% of college students were emotionally neglected
according to the original scoring guide. Each culture has a different set of norms and modes of emotional expression and
recognition (Elfenbein & Ambady, 2002), and this should be taken into consideration when measuring emotional neglect.
Behaviors coded as neglectful in the two ACE-IQ questions can be considered normal in certain cultures, unless they are
extreme cases (Almuneef et al., 2014). Based on the cultural characteristics of Korean families, which are less sensitive and
responsive in emotional expressions and recognitions than are Western families, the K-ACE-IQ codes only the response
never as an exposure to emotional neglect. When the adjusted scoring is adopted, the rate of emotional neglect decreases
to around 10%, and the test-retest reliabilities increase.
Hence, the K-ACE-IQ measures 12 categories of ACE exposure with 25 items, adopting the altered scoring method in the
emotional neglect category. The 12 categories are emotional neglect; physical neglect; living with an alcohol or substance
abuser; living with a depressed, mentally ill, or suicidal person; living with a person who has been imprisoned; loss of
or separation from parents; domestic violence; emotional abuse; physical abuse; sexual abuse; bullying; and community
violence. Each exposure to a specic category of childhood adversity was coded as one ACE score. Participants sum ACE
scores indicate how many types of childhood adversity they were exposed to.

2.3. Analysis

To explore the links of specic ACEs to depression and alcohol abuse, a series of binary logistic regressions were conducted,
with each ACE exposure as an independent variable. The odd ratios of reporting depression (possible depression and denite
depression), alcohol abuse (problem drinking and possible alcoholics), and the comorbid condition (depression only, alcohol
abuse only, and both depression and alcohol abuse) were obtained when exposed to each ACE. To examine the graded
associations of cumulative ACEs with depression and alcohol abuse, three separate multiple logistic regression models were
performed on depression, alcohol abuse, and the comorbid condition. The independent variables were ACE scores 0 (referent),
1, 2, 3, and 4+. Participant demographics such as gender, geographical region, family income, and maternal and paternal
education were adjusted in the regressions.

3. Results

Fig. 1 presents the prevalence of ACE scores among Korean college students. Almost half of the sample (49.9%) had at
least one ACE, and 7.8% of the sample had ACE scores of 4+.
Table 1 presents characteristics of the sample and prevalence of ACEs. The associations between participant character-
istics and ACE exposures were tested using Chi-Squires (gender, region and parents education) and Analysis of variance
342 Y.H. Kim / Child Abuse & Neglect 67 (2017) 338348

Table 1
Participant demographics and prevalence of ACEs.

Socio-demographics ACE scores n (%)

0 n = 470 1 n = 241 2 n = 93 3 n = 62 4+ n = 73 Total N = 939

Gendera
Female 197 (41.9) 121 (50.2) 58 (62.4) 45 (72.6) 47 (64.4) 468 (49.8)
Male 273 (58.1) 120 (49.8) 35 (37.6) 17 (27.4) 26 (35.6) 471 (50.2)

Region
Seoul metropolitan area 252 (53.6) 115 (47.7) 45 (48.4) 37 (59.7) 35 (47.9) 484 (51.5)
Non-metropolitan area 218 (46.4) 126 (52.3) 48 (51.6) 25 (40.3) 38 (52.1) 455 (48.5)

Mothers education
High School 287 (61.1) 128 (53.1) 62 (66.7) 35 (56.5) 40 (54.8) 552 (58.8)
College 164 (34.9) 100 (41.5) 27 (29.0) 22 (35.5) 28 (38.4) 341 (36.3)
Graduate school + 19 (4.0) 13 (5.4) 4 (4.3) 5 (8.0) 5 (6.8) 46 (4.9)

Fathers education
High School 212 (45.1) 101 (41.9) 51 (54.8) 31 (50.0) 37 (50.7) 432 (46.0)
College 215 (45.8) 121 (50.2) 37 (39.8) 25 (40.3) 31 (42.5) 429 (45.7)
Graduate school + 43 (9.1) 19 (7.9) 5 (5.4) 6 (9.7) 5 (6.8) 78 (8.3)
Family incomeb 4577.21 (4599.54) 4576.43 (5433.92) 3600.35 (2305.06) 4308.33 (5153.99) 3623.28 (2670.79) 4387.10 (4585.16)
a
2 (4,N = 939) = 36.65, p = 0.000.
b
M (SD) of monthly income in U.S. dollars.

Table 2
Numbers of participants exposed to ACEs by categories and their ACE scores.

Categories of ACE ACE scores n (%)

1 2 3 4+

1. Emotional neglect 66 (41.5) 36 (22.6) 22 (13.8) 35 (22.0)

n = 159
2. Physical neglect 0 (0.0) 1 (7.7) 6 (46.2) 6 (46.2)
n = 13
3. Living with an alcohol or 18 (19.6) 18 (19.6) 12 (13.0) 44 (47.8)
substance abuser
n = 92
4. Living with depressed, 7 (11.5) 7 (11.5) 14 (23.0) 33 (54.1)
mentally ill, or suicidal person
n = 61
5. Living with a person who 0 1 4 22
had been imprisoned (0.0) (3.7) (14.8) (81.5)
n = 27
6. Loss of or separation from 51 32 15 44
parents (35.9) (22.5) (10.6) (31.0)
n = 142
7.Domestic violence 40 43 34 56
n = 173 (23.1) (24.9) (19.7) (32.4)
8. Emotional abuse 7 14 32 43
n = 96 (7.3) (14.6) (33.3) (44.8)
9. Physical abuse 1 6 19 29
n = 55 (1.8) (10.9) (34.5) (52.7)
10. Sexual abuse 42 25 20 32
n = 119 (35.3) (21.0) (16.8) (26.9)
11. Bullying 6 3 6 9
n = 24 (25.0) (12.5) (25.0) (37.5)
12.Community violence 3 0 2 7
n = 12 (25.0) (0.0) (16.7) (58.3)

(family income). A signicant association between gender and ACE scores was found. ACE scores differed by gender (2
(4,N = 939) = 36.65, p = 0.000). There were higher percentages of females than males with ACE scores of 2, 3, and 4+.
Table 2 shows numbers of participants exposed to each category of ACEs and their ACE scores. The ACE participants were
most frequently exposed to was domestic violence (173 cases); emotional neglect (159 cases) was the next-most common.
The least-reported ACE category was community violence (12 cases). Specic forms of ACEs are highly accompanied with
other types of ACEs. For example, among participants who lived with a person who had been imprisoned, 81.5% had an ACE
score of 4+. Likewise, 52.7% of participants who had been physically abused had an ACE score of 4+; 58.3% of participants who
had experienced community violence had an ACE score of 4+. In contrast, among participants who had been emotionally
abused, only 22.0% had an ACE score of 4+.
Table 3
Associations of individual ACEs with depression and alcohol abuse (N = 939).

Categories of ACE Depressiona Alcohol abuseb Co-occurrence of depression and alcohol abusec

Possible depression Denite depression Problem drinker Potential alcoholics Depression Alcohol abuse only Depression and
n = 181 n = 182 n = 281 n = 171 only n = 258 alcohol abuse
n = 169 n = 194
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)

1. Emotional 1.572 2.913*** 0.775 1.065 2.025** 0.735 1.824*

neglect (0.9962.480) (1.9214.417) (.5111.177) (0.6651.706) (1.2393.308) (0.4353.308) (1.1282.951)
2. Physical neglect 0.969 2.475 1.038 0.361 1.925 0.975 1.388
(0.1924.896) (0.7248.464) (0.3213.351) (0.0423.131) (0.4188.858) (0.1905.003) (0.2667.229)
3. Living with an 1.478 2.371** 1.452 2.110* 1.458 1.309 2.901**

Y.H. Kim / Child Abuse & Neglect 67 (2017) 338348

alcohol or (0.8372.608) (1.4133.976) (.8662.435) (1.1843.762) (0.7232.936) (0.6852.503) (1.5775.338)
substance abuser
4. Living with 2.552** 3.744*** 0.704 2.097* 3.254** 1.109 3.352**
depressed, (1.2975.023) (2.0076.983) (.3521.408) (1.0924.030) (1.4907.105) (0.4592.681) (1.5627.196)
mentally ill, or
suicidal person
5. Living with a 1.021 1.381 2.972* 1.100** 0.719 2.812 3.621*
person who had (0.3632.873) (0.5443.506) (1.1297.825) (0.9891.224) (0.1373.774) (0.9348.465) (1.18711.040)
been imprisoned
6. Loss of or 0.788 1.158 1.088 2.546*** 0.816 1.319 1.490
separation from (0.4761.304) (0.7351.822) (.6981.694) (1.5744.119) (.4551.463) (0.259.815) (0.8972.472)
parents
7.Domestic 1.365 3.415*** 0.877 1.465 2.678*** 1.228 2.334**
violence (0.8692.146) (2.2925.089) (.5871.310) (.9402.281) (1.6414.372) (0.7492.011) (1.4393.785)
8. Emotional abuse 1.893* 3.632*** 1.054 2.027* 4.819* 2.416* 4.421***
(1.0713.344) (2.1776.060) (.6151.808) (1.1873.462) (2.2810.154) (1.1545.059) (2.1439.121)
9. Physical abuse 1.203 2.225* 1.233 3.266** 2.009 2.228 3.359**
(0.5612.581) (1.1764.209) (.5852.598) (1.6416.498) (0.7525.369) (0.9315.335) (1.4237.927)
10. Sexual abuse 1.064 1.918** 1.574 3.003*** 1.667 2.314** 2.951***
(0.6271.805) (1.1983.071) (0.9632.572) (1.8355.014) (0.8483.276) (1.3014.114) (1.6405.307)
11. Bullying 2.193 3.288* 0.476 1.062 3.636* 0.867 1.899
(0.7636.302) (1.2508.649) (0.1541.470) (0.3743.015) (1.18311.175) (0.2223.381) (0.5566.480)
12.Community 1.562 4.260* 1.520 2.123 2.870 1.488 4.492
violence (0.2818.685) (1.16615.566) (0.4015.762) (0.44010.242) (0.46817.594) (0.20410.870) (0.83024.300)
a
No depression as the base group.
b
No drinking problem as the base group.
c
No depression or alcohol abuse as the base group.
*
p < 0.05.
**
p < 0.01.
***
p < 0.001.

343
344 Y.H. Kim / Child Abuse & Neglect 67 (2017) 338348

Table 4
Associations between ACEs and depression (N = 939).

Levels of depressiona ACE scores OR 95% CI

Possible depression 0 (Referent)

n = 181 1 1.375 0.915 2.066
2 1.116 0.592 2.103
3 3.129** 1.605 6.102
4+ 1.497 0.745 3.006

Denite depression 0 (Referent)

n = 182 1 2.500*** 1.610 3.882
2 3.783*** 2.171 6.592
3 5.296*** 2.633 10.651
4+ 5.648*** 3.090 10.325
a
No depression as the base group.
**
p < 0.01.
***
p < 0.001.

Table 5
Associations between ACEs and alcohol abuse (N = 939).

Levels of alcohol abusea ACE scores OR 95% CI

Problem drinkers 0 (Referent)

n = 281 1 0.918 0.641 1.315
2 0.867 0.512 1.470
3 1.035 0.529 2.025
4+ 1.291 0.680 2.451

Potential alcoholics 0 (Referent)

n = 171 1 1.290 0.804 2.069
2 1.456 0.776 2.730
3 2.434* 1.212 4.888
4+ 4.577*** 2.390 8.764
a
No drinking problem as the base group.
*
p < 0.05.
***
p < 0.001.

Table 3 displays correlations of specic ACE exposures with depression, alcohol abuse and the comorbid condition.
Except physical neglect, each category of ACE exposures showed signicant associations with depression, alcohol abuse or
the comorbid condition.
Table 4 shows associations between ACE scores and depression. Compared to the group with no ACEs, participants with
an ACE score of 3 were more likely to report depressive symptoms meeting the criteria for possible depression (OR = 3.129,
95% CI: 1.6056.102). Compared to the group with no ACEs, participants with any ACE exposure were more likely to report
depressive symptoms reaching the criteria for denite depression. The OR increases as ACE exposures increase, from OR = 2.5
(95% CI: 1.6103.882) of the ACE score of 1 to OR = 5.648 (95% CI: 3.09010.325) of the ACE score of 4+.
As presented in Table 5, participants with an ACE score of 3 (OR = 2.434, 95% CI: 1.2124.888) were more likely to report
alcohol use habits suggesting potential alcoholism than were participants with an ACE score of 0. If participants had an ACE
score of 4+, the likelihood of being in the potential alcoholic category increased to OR = 4.577 (95% CI: 2.3908.764).
As presented in Table 6, strong associations were found between ACE scores and the co-occurrence of depression and
alcohol abuse. Compared to participants without ACE exposures, participants with any ACE exposure were more likely to
exhibit the comorbid condition of depression and alcohol abuse. As the ACE scores increase, the probability of being in the
comorbid condition increases from OR = 1.790 (95% CI: 1.1372.818) of the ACE score of 1 to OR = 6.436 (95% CI: 2.92614.158)
of the ACE score of 4+.

4. Discussion

This is a cross-sectional online survey study exploring the prevalence of ACEs among 939 Korean college students and
testing how these childhood adversities may be associated with two health-related outcomes: depression and alcohol abuse.
About 50% of the participants reported experiencing at least one category of childhood adversity. Eight percent claimed to
have experienced four or more categories of adversity in childhood. The overall prevalence of ACEs reported by Korean
college students was lower than that in Saudi Arabia (Almuneef et al., 2014) or Philippines (Ramiro et al., 2010). It was
comparable to ACE prevalence in the United Kingdom study of college students, in which 56% of a university population
reported at least one ACE and 12.4% of participants reported four or more ACEs (McGavock & Spratt, 2014).
The prevalence of ACEs among participants differed by gender. Females were more likely than were males to report two
(62.4% vs. 37.6%), three (72.6% vs. 27.4%), and 4+ (64.4% vs. 35.6%) ACEs. Gender differences in ACEs have been reported in
previous studies, but the facets have differed in different cultural contexts. According to a survey of 29,212 adults in ve
 Y.H. Kim / Child Abuse & Neglect 67 (2017) 338348 345

Table 6
Associations between ACEs and co-occurrence of depression and alcohol abuse (N = 939).

Co-occurrence of depression or alcohol abuse a ACE scores OR 95% CI

Depression only 0 (Referent)

n = 169 1 1.671* 1.057 2.639
2 2.023* 1.060 3.860
3 6.273*** 2.471 15.926
4+ 3.617** 1.522 8.594

Alcohol abuse only 0 (Referent)

n = 258 1 0.920 0.609 1.389
2 0.940 0.504 1.751
3 2.231 0.874 5.695
4+ 2.420* 1.091 5.366

Depression and alcohol 0 (Referent)

abuse 1 1.790* 1.137 2.818
n = 194 2 2.084* 1.104 3.935
3 6.415*** 2.574 15.988
4+ 6.436*** 2.926 14.158
a
No depression or alcohol abuse as the base group.
*
p < 0.05.
**
p < 0.01.
***
p < 0.001.

states of the United States, men were less likely than women to report ve or more ACEs (Bynum et al., 2010), which is similar
to ndings of this study. Conversely, Almuneef et al. (2014) reported that males were more likely to claim exposures to ACEs
than were females in Saudi Arabia. There are two possible explanations for the gendered difference of reported ACEs among
Korean college students. First, the traditional son-preference culture of Korean families may be more likely to protect males
than females from childhood adversity by allocating more resources to boys than to girls in childhood (Choi & Hwang 2015),
such as giving sons priority access to high-quality childcare (Lim, Ahn, & Kim, 2014). Second, psycho-emotional differences
between females and males regarding interpreting and revealing childhood events may account for gendered differences in
ACEs. Females may be more susceptible than males to childhood traumatic events (Tolin & Foa, 2006). Females may also be
more willing than males to reveal or disclose their past adverse experiences and family dysfunctions in childhood (Bynum
et al., 2010).
Some categories of ACEs were highly concomitant with other types of ACEs. For example, 27 individuals reported living
with a person who had been imprisoned. All of the 27 cases had at least one additional ACE and 81.5% had an ACE score of 4+.
A similar pattern also appeared with physical abuse (55 cases, 98.2% with at least one additional ACE, and 52.7% with an ACE
score of 4+) and witnessing community violence (12 cases, 75% with at least one additional ACE, and 58.3% with an ACE score
of 4+). This is congruent with the previous claim that being subjected to different types of maltreatment is common among
people experiencing childhood adversity (Ramiro et al., 2010). Living with a person who had been imprisoned, physical
abuse, and witnessing community violence were found to be allied with multiple forms of abuse and neglect in the Korean
context, suggesting a need for special attention and proactive intervention for children experiencing these types of adversity.
As has been documented in previous studies (LaNoue, Graeber, de Hernandez, Warner, & Helitzer, 2012; Mersky et al.,
2013), signicant associations were found between ACEs among Korean college students and their mental health and health-
risk behaviors. Among the 12 categories of ACEs in this study, 11 types of ACE exposure increased the likelihood for reporting
depression, alcohol abuse, or the comorbid condition by up to four times. The graded associations of cumulated ACEs on the
outcome variables were also salient. As the ACE scores of participants increased, the probability of their reporting depression,
alcohol abuse or the comorbid condition increased up to six times, which is in line with the previous claim that cumulative
exposure assessed throughout a lifetime can better explain psychological dysfunctions of individuals than can particular
categories of ACE exposure (Richmond, Elliott, Pierce, Aspelmeier, & Alexander, 2009).
The associations between ACEs and depressive symptoms were more salient than those between ACEs and alcohol abuse.
This may be due to inated interpretations of past traumatic events by participants with mood difculties, a phenomenon
that has often been reported in previous studies (i.e., Wilson & Rapee, 2005). Regarding alcohol abuse, college students with
an ACE score of 3 were over two times, and college students with an ACE score of 4 + were over four times more likely to
be categorized as potential alcoholics. The group with an ACE score of 1 and the group with an ACE score of 2 showed no
statistical difference in alcohol abuse compared to the no ACE group. In previous literature, ACE scores of 3 or 4+ have been
considered markers of the likelihood of experiencing poor health-related outcomes (Almuneef et al., 2014; McGavock &
Spratt, 2014; Mersky et al., 2013). The current ndings also imply that it may be prudent to give intervention priority for
health-risk behaviors to Korean people exposed to more than three categories of ACEs.
The association of ACE scores with co-occurrence of depression and alcohol abuse was stronger than the associations
with depressive symptoms only or with alcohol abuse only. Even college students with only one ACE exposure had signif-
icantly more chance of developing the comorbid condition than did college students without ACEs. Compared to college
students without ACEs, college students exposed to four or more categories of ACEs were over six times more likely to report
346 Y.H. Kim / Child Abuse & Neglect 67 (2017) 338348

considerable depressive symptoms and alcohol abusive behaviors at the same time. Certainly, this nding corresponds to
the previous claim that cumulative disadvantage caused by victimization through multiple adversities predicts cumulative
dysfunctions (Mersky et al., 2013).
To sum up, this study makes a meaningful contribution by illuminating the links between ACEs and mental health issues
among Koreas young adult population. About half of the participants claimed to have been exposed to at least one adversity
in their childhood; eight percent claimed to have experienced four or more categories of ACEs. Exposure to certain types of
adversities (i.e., living with a person who had been imprisoned, physical abuse, and witnessing community violence) was
highly accompanied with multiple types of ACE exposures. Individual and cumulated associations of ACEs with respondents
depressive symptoms, alcohol abusive behaviors, and the comorbid condition of the two outcomes were evident when gender
and family backgrounds (parents education, regions, and family incomes) were adjusted. Indeed, these ndings strengthen
the link between adult public health issues carrying socioeconomic burdens and child maltreatment issues that have not
been extensively studied in Korean contexts.
The ndings of this study can be used to help Korean practitioners understand that appropriate intervention targeting
children exposed to adversities can be an effective way to promote public health and reduce social costs. It has recently been
proposed that neurobiological changes caused by toxic stress from maltreatment in childhood are the major mechanism
resulting in poor outcomes later in life (Shonkoff et al., 2012). Several factors, such as high-quality childcare, safe neighbor-
hoods, and appropriate schooling, have been known to protect children from adversity and help them develop resilience
to their disadvantages (Lim et al., 2014; Moore & Ramirez, 2016). In Korean contexts, there has been a long history of a
collective disregard for child abuse and neglect, considering these as private matters or means of disciplining children. In
2014, the Ministry of Justice of Korea specied procedures for handling child abuse crimes, punishing child abusers, and
protecting abused children with the Act on Special Cases concerning the Punishment, etc. of Child Abuse Crimes (Ministry of
Justice, 2014). Since then, a signicant change in social awareness has occurred, along with viewing child abuse as a crime.
However, Korean policies and interventions are still focused on the detection of victimized children and punishment of their
abusers. Interventions for abused children in dysfunctional families, such as providing high quality out-of-home support
systems or placing restrictions upon custody and parental rights of parents who commit child abuse crimes, have not yet
been embedded in Korean society (Lee, 2013). Based upon these previous research ndings, Korean practitioners need to
construct their own culturally-valid long term intervention programs against childhood abuse and neglect.
The results of this study should be interpreted in light of the following limitations. First, the sampling procedures of this
studyspreading the online questionnaire link to college students using SNS or messenger services and using participants as
recruitersmay lessen the representativeness of the data. Student council members and volunteer research assistants, pre-
sumably high-functioning young adults, initiated recruitment of other participants. There is a possibility that they recruited
young adults who were also better-functioning or more interested in research than are average college students.
Second, due to the retrospective nature of the K-ACE-IQ, there exist validity threats such as under-reporting or over-
reporting of ACEs. Considering that the participants in the current investigation were young adults, their recall problems
might not be as serious as those experienced by older people. However, young adults may have had less opportunity to reect
upon their experiences before age 18 and may be reluctant to interpret their experiences as adversity or maltreatment. Third,
the current study addressed self-reported depressive symptoms and alcohol use habits, not clinically-diagnosed depressive
disorders and alcohol-related disorders. Hence, in-depth investigations are needed employing standardized diagnostic pro-
grams in order to conrm the stable link between ACEs and depression and alcohol abuse. Fourth, this study is cross-sectional
with young adults. The current ndings did not provide information regarding the prevalence of ACEs and their impact on
health outcomes in different life stages such as middle- or advanced-age. As proposed by WHO (World Health Organization,
2011), large public health surveys including the ACE-IQ (in the Korean context, the K-ACE-IQ) need to be conducted. This
would allow researchers to collect comprehensive information regarding ACE prevalence and its links with public health
among the Korean population.

Funding

This research received no specic grant from any funding agency in the public, commercial, or not-for-prot sectors.

References

Almuneef, M., Qayad, M., Aleissa, M., & Albuhairan, F. (2014). Adverse childhood experiences, chronic diseases, and risky health behaviors in Saudi
Arabian adults: A pilot study. Child Abuse & Neglect, 38(11), 17871793.
Bae, M. H., & Cho, Y. A. (2014). The relationship between undergraduates childhood trauma and interpersonal problems: The mediating effects of
optimism. Korean Journal of Counseling, 15(5), 18491870.
Barratt, M. J. (2012). The efcacy of interviewing young drug users through online chat. Drug and Alcohol Review, 31(4), 566572.
Bellis, M. A., Hughes, K., Leckenby, N., Jones, L., Baban, A., Kachaeva, M., . . . & Raleva, M. (2014). Adverse childhood experiences and associations with
health-harming behaviours in young adults: Surveys in eight eastern European countries. Bulletin of the World Health Organization, 92(9), 641655.
Brire, F. N., Rohde, P., Seeley, J. R., Klein, D., & Lewinsohn, P. M. (2014). Comorbidity between major depression and alcohol use disorder from adolescence
to adulthood. Comprehensive Psychiatry, 55(3), 526533.
Bynum, L., Grifn, T., Riding, D. L., Wynkoop, K. S., Anda, R. F., Edwards, V. J., . . . & Croft, J. B. (2010). Adverse childhood experiences reported by adults-ve
states, 2009. Morbidity and Mortality Weekly Report, 59(49), 16091613.
Cho, M. J., & Kim, K. H. (1998). Use of the center for epidemiologic studies depression (CES-D) scale in Korea? The Journal of Nervous and Mental Disease,
186(5), 304310.
 Y.H. Kim / Child Abuse & Neglect 67 (2017) 338348 347

Cho, H. J., & Lee, S. Y. (2014). The relationship between childhood emotional maltreatment and early adulthood romantic relationship satisfaction: The
mediating effects of early maladaptive schemas and ambivalence over emotional expressiveness. The Korean Journal of Developmental Psychology,
27(1), 3353.
Choi, E. J., & Hwang, J. (2015). Child gender and parental inputs: No more son preference in Korea? The American Economic Review, 105(5), 638643.
Choi, Y. K. (2009). Childhood sexual abuse and impulsivity among subtypes of borderline personality. Korean Journal of Clinical Psychology, 28(2), 639650.
Dube, S. R., Felitti, V. J., Dong, M., Chapman, D. P., Giles, W. H., & Anda, R. F. (2003). Childhood abuse, neglect, and household dysfunction and the risk of
illicit drug use: The adverse childhood experiences study. Pediatrics, 111(3), 564572.
Elfenbein, H. A., & Ambady, N. (2002). On the universality and cultural specicity of emotion recognition: A meta-analysis. Psychological Bulletin, 128(2),
203.
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., . . . Edwards, V., . . . & Marks, J. S. (1998). Relationship of childhood abuse and
household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of
Preventive Medicine, 14(4), 245258.
Fox, B. H., Perez, N., Cass, E., Baglivio, M. T., & Epps, N. (2015). Trauma changes everything: Examining the relationship between adverse childhood
experiences and serious: Violent and chronic juvenile offenders. Child Abuse & Neglect, 46, 163173.
Hillis, S. D., Anda, R. F., Dube, S. R., Felitti, V. J., Marchbanks, P. A., & Marks, J. S. (2004). The association between adverse childhood experiences and
adolescent pregnancy, long-term psychosocial consequences, and fetal death. Pediatrics, 113(2), 320327.
Isumi, A., & Fujiwara, T. (2016). Association of adverse childhood experiences with shaking and smothering behaviors among Japanese caregivers. Child
Abuse & Neglect, 57, 1220.
Kessler, R. C., Amminger, G. P., Aguilar-Gaxiola, S., Alonso, J., Lee, S., & Ustun, T. B. (2007). Age of onset of mental disorders: A review of recent literature.
Current Opinion in Psychiatry, 20(4), 359.
Kim, H., & Han, S. (2015). The effect of early traumatic experience on empathetic ability? The Korean Journal of Counseling and Psychotherapy, 27(2),
251274.
Kim, J. S., Oh, M. K., Park, B. K., Lee, M. K., & Kim, G. J. (1999). Screening criteria of alcoholism by alcohol use disorders identication test (AUDIT) in Korea.
Journal of the Korean Academy of Family Medicine, 20(9), 11521159.
Kim, H. S., Kim, H. R., & Park, S. K. (2006). The impact of individual characteristics and social support on school maladjustment of adolescents: A
comparative study between maltreated adolescents and non-maltreated adolescents. Journal of the Korean Society of Child Welfare, 21(21), 207232.
Kim, W., Hwang, T. Y., Ham, B. J., Lee, J. S., Choi, B. H., Kim, S. J., . . . & Woo, J. M. (2007). The impact of major depressive disorder on productivity in workers:
A preliminary study using WHO-HPQ (Health and Work Performance Questionnaire). Journal of Korean Neuropsychiatric Association, 46(6), 587595.
Kim, J. Y., Chung, Y. K., & Lee, J. S. (2009). The moderating effect of social supportive relationship in the contribution of adolescents experience of domestic
child abuse to suicidal ideation. Korean Journal of Social Welfare Research, 21, 119144.
Kim, J. W., Lee, B. C., Kang, T. C., & Choi, I. G. (2013). The current situation of treatment systems for alcoholism in Korea? Journal of Korean Medical Science,
28(2), 181189.
Korea Health Association. (2017). The alcohol use disorders identication test: Guidelines for screening for risk drinker. (n.d.) Retrieved from.
http://www.kpha.or.kr/board/view.php?p pkid=1347&p mid=9&p mbs=01-05-01&p code=&p sdesc=&p stype=&nowpage=&movepage=&p soption1=
LaNoue, M., Graeber, D., de Hernandez, B. U., Warner, T. D., & Helitzer, D. L. (2012). Direct and indirect effects of childhood adversity on adult depression.
Community Mental Health Journal, 48(2), 187192.
Lee, E.-J. (2013). Flexibilization of the restrictions upon parental authority. Korean Journal of Family Law, 27(1), 217244.
Lim, J. J., Ahn, S. H., & Kim, Y. H. (2014). Quality of childcare and school readiness of children in poverty: A South Korean study. Child Indicators Research,
7(4), 881896.
McGavock, L., & Spratt, T. (2014). Prevalence of adverse childhood experiences in a university population: Associations with use of social services. British
Journal of Social Work, 44(3), 657674.
Mersky, J. P., Topitzes, J., & Reynolds, A. J. (2013). Impacts of adverse childhood experiences on health, mental health, and substance use in early
adulthood: A cohort study of an urban, minority sample in the US. Child Abuse & Neglect, 37(11), 917925.
Ministry of Justice. (2014). Act on special cases concerning the punishment, etc of child abuse crimes. Retrieved from.
http://elaw.klri.re.kr/kor service/lawView.do?hseq=34894&lang=ENG
Moore, K. A., & Ramirez, A. N. (2016). Adverse childhood experience and adolescent well-being: Do protective factors matter? Child Indicators Research,
9(2), 229316 [118].
Nurius, P. S., Green, S., Logan-Greene, P., & Borja, S. (2015). Life course pathways of adverse childhood experiences toward adult psychological well-being:
A stress process analysis. Child Abuse & Neglect, 45, 143153.
Park, J. H., & Kim, K. W. (2011). A review of the epidemiology of depression in Korea. Journal of the Korean Medical Association/Taehan Uisa Hyophoe Chi,
54(4), 362369.
Poushter, J. (2016). Smartphone ownership and internet usage continues to climb in emerging economies. Pew Research Center, Pewglobal.org. Retrieved
from. http://www.pewglobal.org/2016/02/22/smartphone-ownership-and-internet-usage-continues-to-climb-in-emerging-economies/
Ramiro, L. S., Madrid, B. J., & Brown, D. W. (2010). Adverse childhood experiences (ACE) and health-risk behaviors among adults in a developing country
setting. Child Abuse & Neglect, 34(11), 842855.
Richmond, J. M., Elliott, A. N., Pierce, T. W., Aspelmeier, J. E., & Alexander, A. A. (2009). Polyvictimization, childhood victimization, and psychological
distress in college women. Child MaltreRatment, 14(2), 127147.
Sareen, J., Henriksen, C. A., Bolton, S. L., A, T. O., Stein, M. B., & Asmundson, G. J. G. (2013). Adverse childhood experiences in relation to mood and
anxiety disorders in a population-based sample of active military personnel. Psychological Medicine, 43(01), 7384.
Shapka, J. D., Domene, J. F., Khan, S., & Yang, L. M. (2016). Online versus in-person interviews with adolescents: An exploration of data equivalence.
Computers in Human Behavior, 58, 361367.
Shonkoff, J. P., Garner, A. S., Siegel, B. S., Dobbins, M. I., Earls, M. F., . . . McGuinn, L., . . . & Wood, D. L. (2012). The lifelong effects of early childhood
adversity and toxic stress. Pediatrics, 129(1), 232246.
Sohn, I. K., Lee, J., Song, C. J., Sakong, J. K., & Lee, K. H. (2001). Childhood abuse and perceived parental dysfunction, and dissociative symptoms in anxiety
disorder. The Korean Society of Biological Therapies in Psychiatry, 7(1), 3844.
Tolin, D. F., & Foa, E. B. (2006). Sex differences in trauma and posttraumatic stress disorder: a quantitative review of 25 years of research. Psychological
Bulletin, 132(6), 959.
Viera, A. J., & Garrett, J. M. (2005). Understanding interobserver agreement: the kappa statistic? Family Medicine, 37(5), 360363.
Weigold, A., Weigold, I. K., & Russell, E. J. (2013). Examination of the equivalence of self-report survey-based paper-and-pencil and internet data collection
methods. Psychological Methods, 18(1), 53.
Wilson, J. K., & Rapee, R. M. (2005). The interpretation of negative social events in social phobia with versus without comorbid mood disorder? Journal of
Anxiety Disorders, 19(3), 245274.
World Health Organization. (2009). Addressing adverse childhood experiences to improve public health: expert consultation. , 45 May 2009. Retrieved from.
http://www.who.int/violence injury prevention/violence/activities/adverse childhood experiences/global research network may 2009.pdf?ua=1
World Health Organization. (2011). Adverse childhood experiences international questionnaire: pilot study review and nalization meeting. Retrieved from.
http://www.who.int/violence injury prevention/violence/activities/adverse childhood experiences/global research network may 2011.pdf?ua=1
World Health Organization. (2017a). Adverse childhood experiences international questionnaire (ACE-IQ): guidance for analyzing ACE-IQ. (n.d. -a) Retrieved
from. http://www.who.int/violence injury prevention/violence/activities/adverse childhood experiences/guidance for analysing.pdf?ua=1
348 Y.H. Kim / Child Abuse & Neglect 67 (2017) 338348

World Health Organization. (2017b). The alcohol use disorders identication test: guidelines for use in primary care. (n.d.-b) Retrieved from.
http://apps.who.int/iris/bitstream/10665/67205/1/WHO MSD MSB 01.6a.pdf
You, Y. D., & Heo, J. Y. (2012). Inuences of childhood emotional trauma on mental health and life satisfaction of university students: mediated by
self-esteem. Family and Culture, 24, 177211.