Pathways from Adverse Childhood Experiences to Depressive Symptoms and Substance Misuse Among Youths: The Intervening Role of Perceived Financial Stress

Background and Purpose: Adverse childhood experiences (ACEs), such as sexual abuse, physical abuse, neglect, and interpersonal violence, are common in resource-constrained environments and are linked to adverse mental health outcomes. Despite their prevalence, the pathways from ACEs to specific psychological effects such as depressive symptoms and substance misuse among youths remain underexplored, particularly in sub-Saharan Africa. This study aims to investigate the pathways from ACEs to depressive symptoms and substance misuse among youths in Uganda, focusing on the mediating role of perceived financial stress. By examining these relationships, the research will contribute to the understanding of how early adversities impact youth mental health and substance use behaviors in low-resource settings.

Methods: We employed a multi-stage probability sampling method to recruit 597 high school students from four Mukono district, Uganda secondary schools. All participants assented, and caregivers provided written consent for adolescents below 18 years to participate in the study. Path analysis was conducted using Structural Equation Modeling and weighted least squares (WLSMV) estimator to examine the pathways between ACEs, financial hardship, and depressive symptoms. Depressive symptoms were measured with the Patient Health Questionnaire (PHQ-9) (Cronbach’s α=0.91). Financial hardship was a continuous mediating variable with nine items (Cronbach’s α=0.91). Substance misuse was a binary outcome (use vs. no use). Several model fit criteria were assessed, including the root mean square error of approximation (RMSEA) ≤ .08, and the comparative fit index (CFI), and the Tucker-Lewis index (TLI) & SRMR ≤ .08. All models controlled for participant gender and age.

Results: The study sample comprised n=355 (59%) females and n=242 (41%) males, with an average age of 17.67 years (SD=1.74), and 27% (n= 163) had used one or more substances. The structural model yielded a good model: RMSEA =0.045 (90% CI: 0.00, 0.09); CFI=0.98; TLI=0.91; SRMR=0.031. ACEs had a direct positive effect on depressive symptoms (β =0.62; 95% CI: 0.43, 0.81, P<0.001) and perceived financial stress (β =0.58; 95% CI: 0.37, 0.79, P<0.001). Perceived financial stress (β =0.25; 95% CI: 0.17, 0.34, P<0.001) and substance misuse (β =0.16; 95% CI: 0.01, 0.30, P=0.04) were positively associated with depressive symptoms. The indirect effect of ACEs on depressive symptoms through perceived financial stress was: β =0.16; 95% CI: 0.09, 0.23, P<0.001. The model accounted for 35% of the variance in depressive symptoms

Conclusion and Implications: Findings that ACEs are a significant predictor of depressive symptoms in youths highlight the need for early screening and intervention strategies aimed at identifying and addressing ACEs and depressive symptoms. We also found an indirect pathway from ACEs to depressive symptoms through financial stress, further underscoring the role of socioeconomic factors in the mental health outcomes of youths and adolescents. Hence, there is a need for interventions that address the psychological impacts of ACEs and tackle the socioeconomic factors exacerbating mental health issues. As a result, programs aimed at enhancing financial literacy, providing financial assistance, and improving access to economic resources could be beneficial in mitigating one of the pathways through which ACEs impact mental health.