Adverse childhood experiences and mental health: the mediating role of perceived social support and coping strategies | BMC Psychiatry

The present study aimed to investigate the associations between ACEs and mental health problems among Bangladeshi adolescents and the mediating roles of social support and coping strategies between these relationships. The findings highlight the complex relationships between ACEs, coping strategies, social support, and mental health outcomes. ACEs were significantly associated with diminished social support across all dimensions (friend, family, and support from other significant persons), which in turn mediated their impact on depression, anxiety, and stress emphasizing the pivotal role of family support as a modifiable protective factor in adolescent psychopathology. Active coping emerged as a key mediator, linking ACEs to all mental health outcomes, while emotion-focused coping mediated anxiety and stress. Notably, maladaptive coping did not serve as a mediator. Among mental health outcomes, stress was the most robustly influenced, both directly and indirectly, by ACEs. Gender differences further revealed higher odds of depression, anxiety, and stress among females, with psychological and sexual abuse being significant factors of these outcomes. These findings contribute to the growing body of developmental psychopathology literature by identifying culturally relevant psychosocial pathways through which early adversity affects adolescent mental health in a low-resource context.

Consistent with some existing literature, the present study found that ACEs were significantly associated with greater stress among adolescents, but not with depression or anxiety. This aligns with research suggesting that early adversity often triggers heightened stress responses that may precede or exacerbate other forms of internalizing symptoms [14]. This pattern may reflect a developmental cascade, whereby chronic exposure to stress impairs regulatory systems before manifesting as clinical disorders. The consistency between our results and parts of the existing literature may be attributed to common mechanisms, such as heightened physiological reactivity, dysregulation of the hypothalamic–pituitary–adrenal (HPA) axis, and chronic activation of stress pathways following exposure to early adversity [36]. However, the lack of significant associations between ACEs and depression or anxiety in the present study may reflect differences in sample characteristics, cultural perceptions of emotional expression, measurement tools, or the developmental timing of symptom emergence. Previous study using data from the Canadian Health Survey reported significant association between childhood maltreatment and depression and anxiety, further reflecting the differences in sample characteristics (high school graduates vs. general population), sampling design (convenience vs. multistage stratified), measurement tools (PHQ-4 vs., WHO-CIDI) and cultural factors influencing symptom expression and reporting [37]. In particular, underreporting of emotional symptoms in settings with high mental health stigma, such as Bangladesh may account for weaker associations observed in our study.

In some sociocultural contexts, such as Bangladesh, adolescents may normalize emotional distress or underreport symptoms like depression and anxiety due to stigma and limited mental health literacy [38, 39]. Moreover, cultural coping norms that emphasize endurance and familial obligations might delay the expression or recognition of internalizing symptoms, potentially explaining the observed pattern of results.

The present study also found that ACEs were significantly associated with diminished perceived social support across all dimensions such as support from friends, family, and other significant individuals as well as with lower levels of active and emotional coping strategies. These findings are consistent with previous research demonstrating that exposure to early adversity can severely disrupt the development of interpersonal trust and relational skills, leading to lower levels of social support [17, 40, 41]. Similarly, research by Evans et al. (2013) found that cumulative childhood adversity predicts lower perceived social support in adolescence and adulthood, suggesting that early relational disruptions have lasting consequences [20].

Our findings regarding the association between ACEs and diminished active and emotional coping strategies align with studies suggesting that early adversities compromise the development of active emotional regulation and problem-solving skills [17, 25, 42]. Adolescents who grow up in chaotic, neglectful, or abusive environments often have fewer opportunities to learn and practice effective coping mechanisms, resulting in greater reliance on maladaptive or avoidant coping styles [43]. The similarities between our results and previous research may be explained by the shared underlying mechanisms, such as alterations in neurodevelopment (e.g., impaired prefrontal cortex functioning) and chronic stress exposure that undermines coping system development [36].

The present study also revealed important mediation effects, highlighting the mechanisms through which ACEs influence adolescent mental health. Specifically, family support significantly mediated the relationship between ACEs and depression, anxiety, and stress, while friend support mediated the relationship between ACEs and anxiety. These findings align with previous studies emphasizing the protective role of social support in mitigating the adverse psychological effects of early life stressors [20, 37, 44]. In particular, family support has been consistently identified as a critical buffer against the development of internalizing problems among adolescents exposed to adversity, likely due to the foundational role that familial relationships play in emotional security and resilience [17, 45]. This protective function may be particularly salient in the Bangladeshi context, where collectivist cultural norms and strong intergenerational family ties position the family as the primary source of emotional and instrumental support. Adolescents who perceive their families as understanding and supportive may be better equipped to regulate emotional responses to early adversity, thereby reducing vulnerability to internalizing symptoms such as depression.

Our results also mirror findings from a previous study indicating friend support becomes particularly salient in buffering anxiety symptoms during adolescence, a developmental period characterized by increased reliance on peer networks [45, 46]. Peer relationships are particularly important for navigating academic and social stressors and having trusted friends to share concerns may reduce anxiety and daily stress, even if it does not directly impact deeper emotional outcomes such as depression.

In addition, active coping strategies were found to mediate the relationship between ACEs and depression, anxiety, and stress, while emotional coping mediated the relationship between ACEs and anxiety and stress. These findings are in line with prior research suggesting that adolescents exposed to ACEs often experience disruptions in developing effective coping mechanisms [42, 43]. Similar findings have been reported in a study among Canadian general population, suggesting positive coping skills mediate the relationship between childhood abuse and depression and anxiety [37]. Adaptive coping strategies, such as active coping, have been shown to promote psychological resilience by enabling individuals to engage with stressors constructively, thereby reducing the likelihood of developing emotional problems [47]. The ability to actively address or reframe stressors, and process emotions, may help adolescents mitigate anxiety and stress. In contrast, depression may be more strongly linked to chronic feelings of helplessness or lack of perceived support, rather than specific coping styles. Emotional coping, while traditionally considered less effective than active coping, can still serve as a protective factor by facilitating emotional processing, particularly for anxiety and stress symptoms [42]. This suggests that emotion-focused strategies may have adaptive value in high-stress, low-control environments like those experienced by many adolescents in Bangladesh.

Notably, maladaptive coping did not mediate the relationship between ACEs and any mental health outcomes, nor was it significantly associated with ACE exposure. This finding is theoretically relevant, as it suggests that Bangladeshi adolescents exposed to childhood adversity may not necessarily adopt maladaptive coping styles such as avoidance or disengagement. It is possible that cultural or contextual factors, such as social expectations for emotional control or limited opportunities for behavioral disengagement, may attenuate the development or expression of these coping styles in this population. These findings emphasize the value of strengthening both familial and peer support networks and promoting active coping skills in school-based interventions to mitigate the psychological burden of ACEs among adolescents.

These findings are consistent with studies in high-income countries, where social support and coping behaviour have also been shown to buffer the effects of childhood adversity on mental health [37, 42, 43, 48]. This consistency underscores the universal relevance of these psychosocial resources across diverse sociocultural settings. However, the current study extends this literature by demonstrating these pathways in a South Asian context, where cultural norms, family structure, and mental health stigma may influence both the expression of adversity and the utilization of support systems.

The present study further revealed notable gender differences in mental health outcomes, with females exhibiting higher odds of experiencing depression, anxiety, and stress compared to males. Consistent with prior research, female adolescents appear more vulnerable to internalizing symptoms following exposure to adverse experiences [49, 50]. Several factors may contribute to this gender disparity. Biological differences, such as heightened hypothalamic-pituitary-adrenal (HPA) axis reactivity to stress in females may increase their vulnerability to emotional dysregulation [51]. Girls may experience unique psychosocial stressors, including greater exposure to emotional abuse, early caregiving responsibilities, and restricted autonomy, which can increase vulnerability to psychological distress. Additionally, societal norms in Bangladesh may encourage emotional expression more in females than males, potentially increasing the likelihood of symptom reporting among girls. These findings reinforce the need for gender-sensitive mental health strategies that consider the specific stressors, needs, and help-seeking patterns of adolescent girls.

In addition, psychological abuse was found to be significantly associated with higher odds of depression, anxiety, and stress, while sexual abuse was significantly associated with stress. These findings are aligned with previous studies demonstrating that psychological maltreatment often involving verbal aggression, emotional manipulation, and humiliation has profound and lasting impacts on adolescents’ emotional well-being [52, 53]. Psychological abuse, although less visible than physical forms of abuse, directly undermines self-esteem, trust, and emotional regulation capacities, increasing vulnerability to a wide range of psychiatric symptoms [54]. In Bangladesh, where discussions of mental health and emotional mistreatment are often stigmatized or minimized, psychological abuse may be both more prevalent and less likely to be recognized or reported, which may explain its particularly strong association with internalizing symptoms in this sample.

The significant association between sexual abuse and stress in our study is similarly supported by previous findings showing that experiences of sexual victimization are powerful predictors of chronic stress and trauma-related disorders [55, 56]. However, in contrast to some research that identified strong links between sexual abuse and depression or anxiety [57, 58], our findings showed a more specific association with stress. This variation could be attributed to cultural and contextual factors in Bangladesh, where stigma and silence surrounding sexual abuse may lead victims to internalize their experiences differently, manifesting more prominently psychological stress responses rather than clinically diagnosed depressive or anxiety disorders [59, 60]. It is also possible that the chronicity, severity, and timing of abuse, as well as available support systems, moderate these relationships. For instance, individuals who lack supportive environments may be more likely to experience ongoing stress symptoms following sexual abuse rather than develop overt depression or anxiety [61]. Overall, these findings advance conceptual understanding by delineating how modifiable psychosocial processes like social support and coping mediate the ACE-mental health link in a resource-constrained and culturally unique adolescent population.

Although our regression models identified significant associations between ACEs and mental health outcomes, they explained only a small proportion of variance in psychological distress (Nagelkerke R² = 4.9–6.8%). This indicates that additional factors, such as current life stressors, social context, or biological vulnerabilities likely contribute to adolescent mental health and were not captured in the present analysis. Moreover, while we adjusted for gender due to its strong association with mental health outcomes, we did not include other covariates such as age or residence status. Given the narrow age range and sampling context, their exclusion is unlikely to bias results substantially, though the potential influence of unmeasured confounders cannot be ruled out.