Effects of adverse childhood experiences on university students’ ability to lead healthy lives: an exploratory qualitative study in Lahore, Pakistan | BMC Public Health

After a thorough analysis of the data collected from the interviews of ten individuals who faced adverse childhood experiences, five core themes emerged. They were as follows (Fig. 2):

Chronic health struggles.
Mental health disorders.
Emotional and social difficulties.
Paranoia and distrust.
Academic and professional under-performance.

Sociodemographic profile and ACE scores of study participants.

The socio-demographics and ACE scores of the participants selected for the interviews, determined by the ACE-IQ and the guidelines provided by the World Health Organization, are as follows (Table 1):

Table 1 Socio-demographics of the study participants

Table of Contents

Chronic health struggles

Since childhood, most of the research participants have occasionally experienced psychosomatic symptoms. Physical illnesses or ailments that are brought on by or made worse by a mental element, like stress, are known as psychosomatic symptoms. These consist of migraines, stomach problems, obesity or low body weight, irregular sleep patterns, bad eating habits, and allergies. A small number of female participants reported having recurrent infections. In terms of physical well-being, P1 said, “There have always been health problems going on with me as far as I can remember. I eat a lot when I am stressed, which is most of the time. I always had stomach issues. I have always had migraines. I have allergy issues. I get seasonal infections, but sometimes they are difficult to treat. I get vaginal infections often, and some urinary tract infections keep recurring. There have always been some issues going on”. Another female participant, P2, said, “I experience psychosomatic symptoms quite a lot, like physical pain is very frequent. I get migraines a lot. There are very few days when I do not get any migraine”. All female participants experienced these psychosomatic headaches.

Another female participant, P3, who was very weak, said about her health, “I feel like I have taken so much stress that nothing (food) affects me now; that is why I am weak. I get headaches frequently, as well as stomach issues. My immunity is weak, and these issues have stayed with me for so long that I think even medication does not affect me or I have become careless as I know it will not get okay. This keeps happening, and I also have allergy issues”. Regarding eating habits one of the female participants who lived in a dysfunctional household; P5, said, “It is like that with my siblings and me that when we are stressed, we eat a lot. I have seen that my friends and other people eat less when stressed. They do not feel hungry. However, when stressed, we eat a lot, so we also have had obesity issues for a long time”. These symptoms were more prominent in female participants than male participants, who only had the headaches frequently. However, when asked about substance abuse, one of the male participants admitted to using smoking, alcohol, and recreational drugs.

Most female study participants with ACE scores of four or above were overweight from childhood, but a few male and female participants were also severely underweight.

Mental health disorders

All the participants revealed having symptoms of disturbed mental health, including stress, depression, and anxiety, from an early age, which were still persistent. Some were clinically diagnosed with various mental health disorders and had to get help through medication and sessions. In this regard, a female participant, P2, said, “I was diagnosed with MDD (Major Depressive Disorder), and I often get its episodes. I have been very disturbed regarding my mental health for a long time”. The relationship between ACEs and depression in women has also been reported in recent study reports. Another female participant, P1, who had faced multiple childhood adversities, also mentioned her mental health issues: “I was diagnosed with borderline personality disorder a couple of years ago, and my therapist told me that it was due to my traumatic childhood”. She added that she has also been facing other mental health issues: “I have always shown symptoms of depression. Like sadness so deeply rooted in my soul. In addition, emptiness and not wanting to talk to anybody. I would cry a lot, however, only in solitude. This was initially. Then, there were symptoms of anxiety, feeling restlessness and fears about the future life”. She also mentioned developing a mental state issue: “In fact, in college, I got a condition called trichotillomania which is hair-pulling mania. I used to pull my hair all the time. My forehead would get bare often, and people would tell me to stop doing that, but I could not help it”. Apart from depression and anxiety, fear of the future was also observed in many female study participants. Only two of the participants sought help from a professional. They were diagnosed with Major Depression, Borderline personality disorder and a condition known as trichotillomania, in which the patient pulls and plucks their hair.

Another female participant, P7, who lost her mother early, mentioned her mental health issues: “I still feel depression and anxiety. Often, I feel so empty that I do not want to talk to anybody. Everything feels bad and meaningless. It feels odd to say, but sometimes I do not feel like spending time with my children either”. Another female participant, P5, who witnessed domestic violence against her mother, mentioned her mental health issues as: “Depression and anger stay with me, I feel like staying all alone only and not interacting with anyone. I do not want to go out with my friends. I do not want to talk with anyone”.

Emotional and social difficulties

Most individuals reported abnormal emotional and social well-being. Compared to others, some participants said that their inability to socialize with others interfered with their capacity to lead a healthy social life. They also felt the extremity of some specific emotions, such as annoyance, impatience, and rage, which made it difficult for them to interact with people in a healthy way. A male participant, P4, who experienced domestic violence in childhood, described, “I cannot communicate with my teachers, I get terrified. Words do not even come out of my mouth at that time. My personality has become like that I feel difficulty when I have to talk to someone who is in a higher position or authority than me”. Another participant, P1, who experienced multiple adversities in her life, including sexual abuse, psychological abuse, witnessing domestic violence, and living a mentally ill family member, explained her social and emotional health as follows: “I was always slightly socially distant and interacted with the least people. I was not interested in social life until I started university. However, before that, I would prefer not to talk to people like my relatives. I would get nervous sometimes if I had to talk in front of people or if the teacher asked me a question. My mind goes blank sometimes”. In addition, she added that “I was mostly sad and upset in the start, then I used to be angry and anxious all the time. I have felt like I live in extremes. I laugh and have fun a lot, but I have never truly felt happy emotions until I married. There was guilt and shame and frustration too.” Lack of confidence and fear of being humiliated in front of everyone was dominant in many study participants. Another critical change the study participants felt was that they all preferred to be alone rather than being around people. They felt that socializing was meaningless for them and wanted to be left alone.

Some study participants talked about having abnormal emotional health, as they experienced a few emotions that were dominant in their personality, such as anger or sadness and feelings of emptiness or indifference. One of the study participants, P2, who experienced domestic violence at home, described her emotional health: “I used to stay depressed often. I felt sadness, hopelessness, anger, and irritable feelings mostly. This was common when I stayed home”. Another participant who experienced the loss of her father discussed her emotional health in these words: “Now it is like when someone talks to me in any strange way, I feel a surge of anger in me, and I just feel like shutting them up. I feel a lot of frustration that I cannot ignore things. I used to stay calm or silent in such matters, but now I cannot control my response. Anger has filled in me so much that it comes out violently, or I start crying. People usually talk oddly, and then I do not want to talk to anyone”. According to a few of the study participants, they were bottling up their emotions, such as anger and frustration, for many years. And even now they cannot control the expression of these emotions, and they often come out as rude statements or actions.

Another participant, P9, who lost her mentally disturbed father in her childhood, experienced physical abuse, described her emotional health as: “I got irritable, angry, and rude. I had so much aggression in me. I did not usually listen to anybody. It worsened after my father’s death. I got very irritable and frustrated. Whenever I saw a child with his father, I got angry that he had his father, and I did not. All these things got worsened after his death”.

Paranoia and distrust

Many of the study participants explained different personality changes after facing adverse childhood experiences. These included the Development of trust issues, insecurities, attachment issues, impulsivity, Inability to maintain healthy relationships, confusion, and Inability to decide confidently. In this regard, a female participant, P1, mentioned, “Once something clicks with my mind, I feel like I have to do it no matter what, and I would not feel okay without it. I have been living on my impulses. I still do. If I have a task on my mind, I cannot truly rest until I complete it”. She added, “I have always had deeply rooted trust issues because I initially used to trust blindly and got myself hurt. Then, I was just unable to trust anyone. I have had so many insecurities, which I still do. In addition, there is always the fear of abandonment, like everyone will leave me eventually, so only I can protect myself—like a defensive mechanism. I do not get attached to people; I always keep a safe distance first. And guilt, I used to feel guilt all the time, like issues with my life were all my mistakes. And like I am a bad person. Bad Muslim. And always felt embarrassed”. The development of severe trust issues, fears, paranoia, and insecurities were the reasons expressed by most of the study participants due to which they were unable to have healthy relationships.

Another female participant, P2, said, ” I could not develop a sense of trust in myself because of my parents. I never had a sense of security. I always felt like I was in a toxic relationship as I had at home. I could never trust anyone from the start. My relationships always deteriorated eventually”. She added, “I doubt myself a lot, and I cannot decide if something is good for me and whether I should do something. I feel unable to move forward with things, and I could never take the first step”. Additionally, I used to have so much aggression as far as I can recall”. She mentioned her aggravated emotions as: “I used to be so angry most of the time. Due to this anger once, I even left my home because nobody used to listen to me; I thought if I left, then I would struggle, and I would achieve something.” Most of the study participants from dysfunctional and abusive households observed a lack of self-confidence and poor strength to decide about important matters in their lives.

Another participant, P3, who lost her father and was bullied and neglected, discussed her behavior in relationships and that she was always full of insecurities and feared abandonment. She said, “I used to be very close with my friends, but now it is like people come into my life, and it is friendship, but I don’t truly feel anything.”

Another female participant, P5, who experienced domestic violence and physical abuse at home mentioned that she cannot even think that any relationship can be healthy and said in this regard that, “When any of my friends get married, I get this feeling that this marriage is also going to be like that of my parents. It never occurred to me that a relationship can be healthy”. She added, “I have observed that people take little things very normally, but we siblings overreact to everything, and I feel like this is the consequence of our adverse childhood experiences”.

Having trust issues, insecurities, and fear of abandonment were the major contributing factors towards becoming a paranoid personality, which was observed to different extents in all the study participants.

Academic and professional under-performance

Many of the study participants faced issues with their academic performance because they could not focus on their studies properly. Some participants revealed that they lost interest in their studies altogether. In this regard, P5 mentioned, “There were only a few tests that I prepared with proper attention because of tension at home due to my parent’s unstable relationship. Then, again in college life, I went through the same issues, and things got even more critical. And it was the same in my university life as well”.

In this regard, another female participant, P3, said, “I have always been an average student. I could never express what was going on in my mind. I never shared it. Therefore, I could also never focus on my studies. I always avoided discussing anything in class, and I never liked questioning by teachers. It made me uncomfortable”.

Some participants also mentioned that they could not normally interact, which caused a lag in their academic life. In this regard, P1 said, “I feel I could have done much better if my life wasn’t like this. Because I could not even ask questions in class, I lagged somehow. And in my profession, I am also susceptible to different attitudes like being dominated by male bosses; it makes me uncomfortable. And sometimes I also still feel a lack of confidence and focus. And we need these things to make a good career. I could have done much better if my life were normal”. In this regard, P2 said, “There was always a doubt cast by my parents on the personality that I can or can’t do things. In the classroom, when teachers used to ask me about stuff, even if I knew the answer, I could never reply. I was always doubtful if my answers were right or not” ” She added, “I was so afraid of interactions and what others would think about me if I gave a wrong answer. And my teachers might insult me over that (a wrong answer)”.

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