Adverse Childhood Experiences and Posttraumatic Stress Disorder among Ukrainian College Students: Mediating Role of Intimate Partner Violence and Lifetime Trauma Experience

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Structural Equation Modeling was used to assess direct and indirect (mediated by IPV and lifelong trauma experiences) effects of ACEs on participants’ PTSD symptoms. Results indicated that 24.97% of the participants have met the clinical cutoff for PTSD. Lower PTSD symptomatology was associated with fewer ACEs (b = .40, p < .001), fewer lifetime traumatic events (b = .17, p < .05), and male sex (b = − .15, p < .05). Participants with more ACEs were more likely to experience IPV (b = .35, p < .001) and lifetime traumatic events (b = .36, p < .001). ACEs had a significant standardized indirect association, mediated by lifetime traumatic events, with increased PTSD symptomatology (b = .06, p < .05). ACEs had a direct effect on PTSD. Early adversity also had an indirect association with PTSD mediated by lifelong victimization. Psychology Psychiatry posttraumatic stress disorder (PTSD) Ukraine war adverse childhood experiences (ACEs) lifetime trauma intimate partner violence (IPV) Figures Figure 1 Introduction Ukraine, the largest country within Europe with a population of 41.2 million [ 1 ]. Due to its strategic location and abundant natural resources, the country has a history marked by wars, persecutions, subjugation, and political upheaval [ 2 ]. Russia annexed Crimea in March 2014 following an invalid referendum [ 3 ]. The full-scale military invasion of Ukraine by the Russian Federation on February 24, 2022, caused unprecedented destruction, devastation, and a significant humanitarian crisis [ 4 ]. As millions of Ukrainians have been directly and indirectly affected by the war and its socioeconomic consequences, it is essential to comprehend the role of the underlying factors of Posttraumatic Stress Disorder (PTSD) symptoms among Ukrainians during the initial stage of the Russian-Ukrainian war. The present study uses a large sample of Ukrainian college students to examine the association between adverse childhood experiences and early adulthood PTSD, mediated by the intimate partner violence and traumatic life events after the annexation of Crimea in 2014 and prior to the start of the full-scale Russian military invasion of Ukraine in 2022. Post-traumatic stress disorder may develop in someone who experienced or witnessed a traumatic event and is typically characterized by intrusive memories of reliving traumatic experiences, avoiding reminders of the traumatic event, negative mood, and hyperarousal symptoms, such as being easily startled or irritability [ 5 ], leading to significant dysfunction or distress. The prevalence of PTSD varies widely depending on the population being studied and the type of trauma experienced. The lifetime prevalence of PTSD in the general U.S. population was reported at 8.3%, past 12-month at 4.7%, and past 6-months at 3.8% [ 6 ]. Among individuals who live in countries affected by war, the prevalence of PTSD can be as high as 26.51% [ 7 ]. It is essential to investigate the mental health consequences of the Russian war on Ukrainian people, particularly the interplay between childhood adversities, IPV and other traumas, and PTSD, to contribute to the broader knowledge base on the impact of war on wellbeing and functioning, tailor interventions, and inform preventive strategies to address the mental health needs of individuals and communities affected by armed conflict. Numerous studies have produced varying prevalence estimates of intimate partner violence (IPV) victimization in Ukraine. Burlaka et al. sampled 320 Ukrainian mothers of schoolchildren and found that 81% of respondents reported psychological violence and 58% reported physical assault by an intimate partner, with respondents enumerating an average of 66 IPV incidences in the past year [ 8 ]. Barrett et al. analyzed data gathered from ever-married or cohabitating Ukrainian women as part of the 2007 Ukraine Demographic Health Survey [ 9 ]. In this sample, a comparatively lower 21% of respondents reported experiencing emotional abuse in the context of a romantic relationship, 13% reported physical abuse, and 3% reported sexual abuse [ 9 ]. These differential findings suggest that different demographics of women may be at particularly elevated risk of IPV victimization, such as mothers of school-aged children as compared more generally to women who are or have been in long-term partnerships. Notably, however, Ismayilova and El-Bassel’s analysis of the same 2007 Ukraine Demographic Health Survey showed that among Ukrainian women with a history of IPV victimization, 70% experienced physical injury from IPV, such as bruises, aches, wounds, or broken bones or teeth [ 10 ], pointing to high severity of violence among those who are victimized. While data on intimate partner violence perpetrated against Ukrainian men is limited, O’Leary et al.’s analysis of Ukrainian married or cohabitating couples who completed the 2002 Ukraine World Mental Health Survey found that 20% of Ukrainian women reported at any time being the subject of physical aggression from their partner, as compared with 8.6% of Ukrainian men [ 11 ]. While these prevalence estimates vary significantly by study methodology, subpopulation, and survivor gender, all found an IPV prevalence of at least 20%, or 1 in 5, which points to a significant burden on Ukrainian women. Data in other countries throughout Eastern Europe and the post-Soviet region can also provide useful metrics for estimation of and comparison to IPV prevalence in Ukraine. The 2005 Moldova Demographic Survey, analogous to its Ukrainian counterpart, found twice the rate of physical partner violence (20%) and slightly higher sexual partner violence (5%) among Moldovan women compared to Ukrainian women [ 10 ]. The same survey conducted in 2006 in Azerbaijan captured rates of partner violence similar to those in Ukraine, with 10% of respondents reporting partner physical and 2% reporting partner sexual violence, respectively [ 10 ]. Potentially of note, rates of physical injury from victimization were lower in Moldova and Azerbaijan than in Ukraine, at 60% and 40%, respectively, supporting the need for attention to the high potential of severe harm for Ukrainian IPV survivors [ 10 ]. Theoretical framework Adverse Childhood Experiences, Intimate Partner Violence, and Post-Traumatic Stress Disorder To our knowledge, extant literature has not investigated the relationship between adverse childhood experiences and IPV in Ukraine specifically. However, this relationship has been well-studied in a variety of other global contexts. First defined by Felitti et al., adverse childhood experiences (ACEs) include measures of childhood exposure to physical, sexual, and psychological abuse; witnessed abuse against the mother; and having a caretaker with a mental illness, substance abuse condition, suicidality, and/or who was ever incarcerated [ 12 ]. Respondents to the ACE Questionnaire are given a cumulative ACE score that represents the sum total of ACEs they report [ 12 ]. Extensive literature has documented correlations between ACE scores and a variety of physical, mental, and behavioral health and socioeconomic outcomes, such as smoking, substance use disorders, depression, PTSD, anxiety and mood disorders, suicidality, sexually transmitted conditions, obesity, heart and respiratory disease, diabetes, cancer, houselessness, and having multiple classes of pharmaceutical prescriptions [ 12 – 14 ]. In an analysis of data from Brazilian women, Buffarini et al. found a graded association between respondents’ cumulative ACEs exposure and subsequent IPV victimization, with women reporting just 1 ACE at 1.5 the risk of IPV victimization relative to women reporting no ACEs, and those reporting 5 or more ACEs at 4.9 times the risk of IPV compared to women with no ACEs [ 15 ]. Interestingly, Nikulina et al.’s examination of a sample of United States college students found no relationship between total cumulative ACE scores and IPV, but rather reported that witnessed domestic violence specifically was predictive of IPV victimization and perpetration [ 16 ], suggesting that different ACEs differentially impact IPV and that an intergenerational cycle of violence may be at play in some cases. Mair et al. tested potential meditational pathways in the relationship of ACEs with IPV in a sample of couples residing in California and found that ACEs predicted depression, anxiety, and impulsivity among both male and female partners; and that male anxiety and impulsivity and female depression predicted male-to-female IPV, and male depression, impulsivity, and frequency of intoxication and female depression predicted female-to-male IPV [ 17 ]. A number of studies have also documented a positive relationship between ACEs and IPV perpetration, including among Sri Lankan, Norwegian, English, and Black U.S. men [ 18 – 21 ]. While to our knowledge, the extant literature has not examined the relationship between post-traumatic stress disorder (PTSD) and IPV in Ukraine, like the link between ACEs and IPV, it has been documented in a variety of other contexts. In their examination of the effects of various forms of interpersonal violence on mental health outcomes in a national U.S. sample, Iverson et al. found that physical IPV victimization predicted PTSD with an odds ratio (OR) of 2.29 [ 22 ]. Khadra et al. sampled Lebanese women and reported that 97% of those who experienced physical partner violence met criteria for some PTSD symptomatology [ 23 ]. De Vries’ 2008 dissertation investigated PTSD symptoms among individuals at a United States battered women’s shelter and found that 58% of respondents met current PTSD criteria, and 66% met one or more diagnostic criteria for complex PTSD (C-PTSD) [ 24 ]. In a sample of female U.S. community college students, IPV victimization was found to be predictive of PTSD, with more extensive IPV correlating with more PTSD symptoms [ 25 ]. Given evidence pointing to higher severity of physical violence experienced by IPV survivors in Ukraine compared with nearby countries, it is possible that this link may be comparable or even stronger in the Ukrainian context [ 10 ]. IPV as a Mediator Between ACEs and PTSD The impact of ACEs on adult mental health has been well-documented. A smaller subset of studies has attempted to elucidate the potential mediating influence of IPV victimization in the relationship between ACEs and numerous measures of adult mental health. Seon et al. investigated the link between ACEs and perceived poor mental health in adulthood with IPV as a mediator in a sample of U.S. college students and found that IPV victimization partially mediated the impact of ACEs on mental health [ 26 ]. Jiwani et al. studied the impact of ACEs mediated by IPV on maternal self-efficacy in a sample of mothers of young children in India and found that for low-caste but not high-caste mothers, ACEs exposure was associated with lower self-efficacy mediated by IPV exposure [ 27 ]. Furthermore, research has also documented a relationship between ACEs, IPV, and PTSD in a different causal combination. Swopes et al. found that in a group of U.S. male IPV offenders, the relationship of ACEs to IPV perpetration was mediated by PTSD [ 28 ]. Taken broadly, this research supports the existence of links among these three variables. While no research to date has examined PTSD as a specific outcome of ACEs mediated by IPV, existing evidence points to the connection between these variables as well as the mediating role of IPV in the impact of ACEs on adult mental health. Given that ACEs have been shown to predict IPV [ 15 – 17 ] and PTSD [ 29 , 30 ] and IPV has also been shown to predict PTSD [ 22 – 25 ], it is possible that IPV mediates some of the relationship between ACEs and PTSD. Additionally, Jiwani et al.’s [ 27 ] findings that caste affects this relationship indicates a potential influence of societal factors on this process. Adverse childhood experiences, lifetime traumatic events, and PTSD A history of ACEs is one of the most robust predictors of adversities and re-victimization later in life. One potential pathway appears to be associated with diminished self-capacities, which may be observed in individuals who have experienced childhood abuse, neglect, or maltreatment [ 31 ]. Diminished self-capacities may contribute to an increased susceptibility to repeated victimization due to such factors such as low self-esteem, impaired self-efficacy, limited assertiveness skills, or difficulties in recognizing and setting boundaries, which may render individuals more vulnerable to experiencing further instances of victimization. Additionally, ACEs can significantly impact the development of emotional intelligence [ 32 ], leading to difficulties in recognizing and understanding one's own emotions and the emotions of others, regulating emotions effectively, and forming healthy interpersonal relationships. Early adverse experienced were found to alter brain development of children leading to an increased risk for psychopathology and later-life adversity [ 33 , 34 ]. One prospective study utilized a sample of women who were survivors of sexual assault and found ACEs to be one of the key predictors of sexual assault revictimization [ 35 ]. Another study found that homeless individuals were at a higher risk for repeated victimization if they were exposed to ACEs [ 36 ]. Exposure to ACEs have significantly contributed to increased depression and substance use among Ukrainian young adults [ 37 ]. Burlaka et al. [ 38 ] also reported that Ukrainian students who experienced ACEs were more likely to be victims of bullying in college. Given that bullying is often associated with symptoms of PTSD [ 39 ], it is possible that other lifetime traumatic events can act as a mediator in the relationship between ACEs and the development of PTSD in adulthood. Frewen et al. [ 30 ] assessed the association between ACEs, lifetime traumatic stress and non-traumatic stressors with PTSD. These authors found that lifetime traumatic stressors and ACEs uniquely predicted PTSD. Additionally, ACEs were uniquely associated with PTSD after accounting for lifetime traumatic stress. Contributions of the Present Study The exposure to ACEs may increase the likelihood of encountering traumatic events later in life [ 40 ] due to factors such as disrupted attachment patterns [ 41 ], maladaptive coping strategies [ 42 ], or ongoing interpersonal difficulties stemming from the adverse experiences in childhood [ 43 ]. Importantly, ACEs are significantly associated with PTSD across studies that involved participants from different backgrounds [ 29 , 44 , 45 ]. However, no study has tested the association between ACEs, IPV, life traumas and PTSD among participants exposed to war. The present study aimed to investigate the associations between ACES, IPV, lifetime traumatic events, and PTSD among participants exposed to the Russian-Ukrainian war. This research aims to 1) examine the prevalence of PTSD in the period between initial invasion of Ukraine in 2014 and the full-scale Russian invasion of Ukraine in 2022, 2) expand the understanding of the relationship between ACEs and PTSD in the context of armed conflict, 3) explore the role of IPV and lifetime traumatic events as potential mediators in the ACEs-PTSD pathway, 4) enhance the understanding the mental health consequences of Russian war on Ukrainian people. Methods Participants The study used a cross-sectional sample of 999 students from all Ukrainian regions. Undergraduate and graduate students majored in social work, psychology, medicine, sociology, philosophy, cybersecurity, special education, law, and criminology. Two-third of participants were females (68.57%) with age ranging from 17 to 24 years (M = 19.1, SD = 1.59). Most participants (96%) were Ukrainians and other 4% were Armenians, Jews, Russians, Belarusians, Hungarians, Tatars, or Romanians. Most students were single (89%), some 10% were married or lived with their partner. Majority (91.66%) were debt-free and 19.40% were employed earning, on average, $ 32 per month. Procedure The study recruited participants by making announcements in classrooms. Researchers informed students that the study aimed to investigate the psychosocial well-being and success of Ukrainian students. Interested students who agreed to participate met with faculty members or research assistants individually or in small groups. They completed the survey using their own personal devices or were given access to school computers. All participants provided informed consent, and the study was approved by the Committee of Ethics and Deontology of the Ukrainian National Academy of Medical Sciences Institute of Neurology, Psychiatry, and Narcology (Protocol No 12-b from December 21, 2018). During the survey, participants spent about an hour answering questions related to their childhood, family experiences, mental health, and substance use. They were not offered any form of compensation or incentives, and their responses were collected via a secure online platform. Measures Participants answered sociodemographic questions measuring income (in UAH that we converted to USD to report in this study), sex (male or female), age (measured in years), program, ethnicity, and employment status. Adverse Childhood Experiences Questionnaire (ACEs) [ 46 ] has 10 questions such as “While you were growing up, during your first 18 years of life, did a parent or other adult in the household often swear at you, insult you, put you down, or humiliate you or act in a way that made you afraid that you might be physically hurt?” and “Did a parent or other adult in the household often push, grab, slap, or throw something at you or ever hit you so hard that you had marks or were injured?” measuring exposure to various childhood adversities. Participants also answered, “Did an adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way or try to or actually have oral, anal, or vaginal sex with you?” Response options were no (0) and yes (1). ACEs is a well-known measure that has been previously utilized in studies with Ukrainian college students [ 37 ]. In this study, the Kuder-Richardson coefficient of reliability was .78. The Composite Abuse Scale (Revised)—Short Form (CASR-SF) [ 47 ] was used to measure the students’ experiences of IPV. The CASR-SF is a valid and reliable measure of IPV. Example of 15 scale items include, “My partner shook, pushed, grabbed or threw me,” “Used or threatened to use a knife or gun or other weapon,” “Made me perform sex acts that I did not want to perform” reported dichotomously (yes, no) and and if “yes” then on a frequency scale ranging from “not in the past 12 months” (0) to “daily/almost daily” (5) measuring psychological, physical and sexual violence. The reported reliability for this measure is Cronbach’s α = .942. In our sample, the Cronbach α = .84 (psychological subscale α = .75, physical subscale α = .72 and sexual violence subscale α = .83). Life Events Questionnaire (LEC) [ 48 ] was developed by the National Center for PTSD to measure multiple types of exposure to various traumatic events on a 5-point nominal scale (1 = happened to me, 2 = witnessed it, 3 = learned about it, 4 = not sure, and 5 = does not apply). Examples of the LEC trauma domains include natural disaster, fire or explosion, transportation accedents and others that have happened to participants during their entire life. In our study, we recoded participants’ responses into weighted scores to estimate the lifetime exposure to trauma while taking into account the proximity of traumatic events to study participants [ 49 ]. Items that happened to participants were given a factor of 3, items witnessed by participants received a factor of 2, and items that participants learned about were given a factor of 1 for total maximum score of 102. Higher weighted scores mean participants have experienced more traumatic events that had a greater proximity to study participants. The Cronbach α was .95 for the weighted LEC scale in this study. Posttraumatic stress disorder symptoms have been measured using the Child PTSD Symptom Scale (CPSS) [ 50 ]. The CPSS has 17 items that map on DSM-IV symptoms. Participants were asked to how often they were bothered by such symptoms as “Having bad dreams or nightmares,” Not feeling close to people around you,” “Trying to avoid activities, people, or places that remind you of the traumatic event” in the last two weeks. The answers were on a Likert-type scale ranging from 0 (not at all) to 3 (5 or more times a week/almost always). Nixon et al. [ 51 ] recommended a clinical cutoff of 16 or greater for determining a risk for PTSD in participants. Previously reported reliability of CPSS total score was .83 − .90, for re-experiencing, .78 − .84, avoidance, .65 − .78, and arousal, .79 − .88) [ 51 ]. In our study, the total score Cronbach α was .90, re-experiencing, .79, avoidance, .78, and arousal, .79. Analytic Techniques We used structural equation modeling (SEM) to simultaneously assess direct and indirect effects of ACEs on participants’ PTSD symptoms. SEM allows separating the random measurement error from latent variables which increases the explanatory power. The SEM estimations of direct and indirect effects are “routinely included in structural models, assuming such specifications are theoretically justifiable” [ 52 ]. We followed Kline’s [2011] recommendations to evaluate SEM identification. We used the maximum likelihood estimation [ 53 ] to examine the model fit. Stata/ MP 16.1 software package [ 54 ] was used for all analyses. The goodness-of-fit comparative fit index (CFI), Tucker- Lewis index (TLI), and the root mean squared error of approximation (RMSEA) were employed in this study [ 55 ]. The recommended cutoff points are for TLI, .90 or above [ 56 ], CFI, 0.95 or above and RMSEA, 0.08 or below [ 57 ]. To estimate the indirect relationships in the model, we used the Stata’s delta method-based nlcom command [ 54 , 57 , 58 ]. Results Descriptive characteristics Our findings indicate that 24.97% of the participants have met the clinical cutoff of 16 (mild or more severe levels) for PTSD [ 51 ]. Adverse childhood experiences reported by the participants included being insulted and physically hurt (14.85%), feeling unloved (11.75%), growing in a single-parent household (29.05%), with the substance-abusing household member (14.87%). Eight percent of participants reported being pushed or grabbed by their intimate partner, 5.18% were made perform unwanted sexual acts, 10.89% were called crazy. The lifetime traumas included being sexually assaulted (5.83%), physically assaulted (14.26%) and getting in transportation accidents (14.98%). Table 1 includes additional information on study variables. Major study variables significantly correlated with each other and showed good reliability (see Table 2 ). Table 1 Means, Standard Deviations, Ranges and Percentages of the Study Variables (N = 999) Mean SD Range % Total ACEs .11 .16 0–1 Swored at, insulted, humiliated, was afraid to be physically hurt 14.85 Pushed, grabbed, slapped, or thrown at, had marks, injuries 9.17 Touched or fondled in a sexual way, an adult attempted oral, anal, or vaginal intercourse 5.71 Felt unloved by family, unimportant, family lacked mutual closeness, support 11.75 Lacked food, clean clothes, protection, parents were too drunk to provide care 2.92 Parents were separated or divorced 29.05 Parents/caregivers were pushed, grabbed, slapped, kicked, bitten, hit 7.97 Grew up with a problem drinker, alcoholic, or street drugs user 14.87 Grew up with a household member who was depressed, mentally ill, or attempted suicide 7.01 Household member went to prison 3.78 Total CASR-SF .07 .25 0–2.6 Physical abuse .04 .21 0–2.8 Partner shook, pushed, grabbed 8.04 Partner threatened to use a knife or gun or other weapon 3.39 Kicked me, bit me or hit me with a fist 5.00 Sexual abuse .04 .33 0–5 Made me perform unwanted sex acts 5.18 Forced or tried to force me to have sex 3.75 Psychological abuse .11 .34 0–3.7 Blamed for causing violence 5.36 Told family, friends I was crazy 4.11 Told me I that I was crazy 10.89 Total LEC Was sexually assaulted (rape, attempted rape, made to perform any type of sexual act through force or threat of harm) 5.83 Had other unwanted or uncomfortable sexual experience 7.49 Was in a transportation accident 14.98 Was physically assaulted 14.26 Total CPSS 10.13 8.59 0–44 Reexperiencing .64 .57 0–3 Avoidance .47 .51 0–2.57 Arousal .75 .68 0–3 Below threshold (0–10) 57.96 Subclinical – Mild (11–15) 17.07 Mild (16–20) 12.74 Moderate (21–25) 6.11 Moderately Severe (26–30) 3.95 Severe (31–40) 1.91 Extremely Severe (41–51) 0.25 Sex (female) 68.57 Age (years) 19.06 1.59 17–24 Note . SD = standard deviation. Table 2 Correlations between the Major Study Variables and Cronbach’s Alpha Coefficients (N = 999) 1 2 3 4 5 1. Total ACEs (KR = .78) 2. Total CASR-SF .29*** (α = .84) 3. Total LEC .13*** .03 (α = .95) 4. Total CPSS .36*** .23*** .05 (α = .90) 5. Age .18*** .03 − .01 .11** 6. Sex − .15*** − .03 .02 − .19*** − .23*** Note. ACEs = Adverse Childhood Experiences; CASR-SF = Composite Abuse Scale (Revised)—Short Form; LEC = Life Events Checklist; CPSS = Child PTSD Symptom Scale. * p < 0.05, ** p < 0.01, *** p < 0.001. α = Cronbach’s alpha coefficients indicating internal consistency reliability estimates of multi-item measures; KR = Kuder-Richardson coefficient of reliability. (Table 1 about here) (Table 2 about here) Measurement and Structural Models The measurement model allowed us to estimate whether the study variables were independently associated with the outcome variable of PTSD. We fit the measurement model with four latent factors corresponding to the study constructs. The model demonstrated good fit indices: χ 2 (48, N = 263) = 73.47, p < .05; RMSEA = .045, CFI = .972; TLI = .962. All factor loadings were significant for all latent variables in this model. The latent variables were significantly associated with the PTSD latent variable. In the next step, we tested the structural model (see Fig. 1 ). We modeled the path between ACEs and PTSD to examine whether Adverse Childhood Experiences had significant standardized direct effect as well as indirect effects, mediated by IPV and LEC, on student PTSD symptoms. The paths are represented as straight lines while the values along the lines indicate estimated strength of influences, standardized path coefficients (betas). Our model provided a satisfactory fit for the data: χ 2 (71, N = 263) = 116.91, p < .001, CFI = .951, TLI = .938, RMSEA = .050. (Fig. 1 about here) Results of the path model suggest that participants had lower PTSD symptomatology if they had fewer adverse childhood experiences ( b = .40, p < .001), fewer lifetime traumatic events ( b = .17, p < .05), and self-identified as males ( b = − .15, p < .05). Participants who recalled having more ACEs were significantly more likely to experience IPV ( b = .35, p < .001) and lifetime traumatic events ( b = .36, p < .001). Additionally, experiencing greater number of ACEs had a significant standardized indirect association, mediated by more lifetime traumatic events, with increased risk for developing PTSD during adolescent/early adulthood years ( b = .06, p < .05). Discussion This study has focused on expanding an understanding of unique associations and cumulative impact of ACEs, IPV, and lifetime traumatic events on the development of PTSD among war-affected populations. Our findings from a 2018 sample of Ukrainian college students demonstrated a significant positive relationship between ACEs and PTSD as well as between ACEs and IPV, but did not support the role of IPV as a mediator in this link. In this sample, adverse childhood events appeared to lead to subsequent traumatic stress symptoms as well as partner violence victimization, in line with extant literature [ 15 – 17 , 29 , 30 ]. Our study provided a high prevalence of PTSD among our sample, almost one in four screened positive for PTSD (compared with near 8% among U.S. population). Overall, this suggests trauma impact beyond what is usually seen in civilian populations and is in line with previous research on prevalence of PTSD in countries affected by wars [ 7 ]. This high prevalence could be due to the trauma and stress related to Russian invasion of Ukraine, political turmoil the prior to the war, family dynamics, or individual experiences [ 2 ]. The results of this study suggest that early life adversities may have a cumulative impact on the development and severity of PTSD symptoms during later stages of life. Our results highlight the enduring influence of ACEs on mental health outcomes and emphasize the importance of addressing and mitigating the impact of early life adversities to prevent or reduce the risk of PTSD. In contrast to expectations, IPV did not then predict subsequent PTSD when controlling for other lifetime traumas. This suggests that respondents’ PTSD symptoms were more closely tied to their adverse childhood experiences and other traumatic events than to intimate partner violence victimization, and/or that ACEs were associated with PTSD symptoms through mechanism(s) other than IPV victimization. A number of factors potentially account for these findings. Firstly, the ACEs portion of the survey asked respondents about their experiences throughout their first 18 years of life, while the IPV questions were limited to experiences in the last 12 months. The ACEs questions thus captured a much longer timespan than the IPV questions, and if respondents’ IPV experiences did not occur in the last 12 months, they were not captured in this survey. This may have led to a more thorough and accurate picture of respondents’ adverse childhood versus partner violence experiences, thus making it easier to accurately link ACEs to PTSD and more difficult to link IPV with PTSD. The lower prevalence of the IPV in our sample compared to another study of mothers of schoolchildren by our own group, suggests the possibility of a larger role of the IPV as people, especially women age through adulthood. Longer duration of exposure to an abusive relationship (or relationships) in older adults leading to cumulative number of IPV incidents, could also be another contributor to a possible stronger role of the IPV in older adults. Secondly, it is also possible that ACEs have more power to predict IPV than IPV has power to predict PTSD. For instance, it may be that ACEs predict a variety of IPV experiences, from one-time incidences of IPV to ongoing, severe abuse; while only a subset of IPV exposures - such as exposure to particularly severe, long-lasting, and/or variable IPV - go on to predict PTSD. In this case, because the time-limited nature of our questions prevented us from capturing respondents’ IPV experiences outside of a 12-month timeframe, we may not have captured respondents’ IPV experiences with sufficient accuracy to document the weaker relationship between IPV and PTSD. Thirdly, evidence shows that PTSD can develop as late as years following a traumatic experience, meaning that the full effects of past-year IPV may not have been evident at the time of the study [ 59 ]. Additionally, because ACEs definitionally occur in childhood and the IPV questions in this survey measured adulthood experiences, it is possible that respondents’ increased cognitive and emotional maturity and knowledge of and access to helpful resources were protective against PTSD resulting from the trauma of IPV, as compared with childhood trauma during less independent, more formative years. Fourthly, like all life events, ACEs and IPV occur in broader life and societal contexts that can also significantly impact individuals’ mental health. Of note for this sample is the fact that Ukraine has been at war with the Russian Federation since 2014, when Russia invaded the Crimean Peninsula and pro-Russian militants took control of portions of the Donbas region in Eastern Ukraine. The data for this study was collected in 2018, after the seizure of Crimea and amid ongoing armed conflict in Donbas. In December 2020, Amnesty International published a memorandum on the impact of this war on IPV in Eastern Ukraine, noting that increased IPV rates and lack of perpetrator accountability and survivor services since the start of the war have culminated in an increasingly dire situation for Ukrainian IPV survivors. If survivors are aware of this lack of response and resources, and/or if they are unable to prioritize IPV reporting given the more pressing realities of war, they may generally underreport their IPV experiences, potentially worsening the problem of undercounting IPV discussed above. It is also possible that war-related traumas - such as one’s own and/or loved ones’ participation in armed conflict, witnessed fighting, property destruction, conflict-related sexual violence, worsening economic circumstances, separation from loved ones, and/or concerns about safety and national stability - may be more predictive of PTSD symptoms for survivors in the context of war than recent IPV victimization. Future studies should seek to further elucidate these competing influences. Traumatic experiences can have varying impacts on the development of post-traumatic stress disorder (PTSD), with different trauma types potentially resulting in distinct manifestations and severity of symptoms. For example, Hinchey et al. [ 60 ] found that interpersonal traumas tended to be more predictive of the PTSD than non-interpersonal traumas. Understanding such differential impacts is crucial for tailoring interventions and providing appropriate support to individuals who have experienced specific types of trauma. A number of lifetime traumatic events was found to be positively associated with PTSD symptomatology, albeit with a smaller effect size compared to ACEs. This indicates that the accumulation of traumatic events throughout one's lifetime contributes to the manifestation and severity of PTSD symptoms. It is worth noting that while the effect size was smaller compared to ACEs, the cumulative impact of lifetime traumatic events should not be overlooked, as it represents an ongoing risk factor for PTSD development. Interestingly, gender differences emerged in our study, with self-identified males reporting lower levels of PTSD symptomatology. This finding aligns with previous research suggesting that males may exhibit different patterns of PTSD symptoms or may be less likely to seek help for their symptoms [ 61 ]. It underscores the need to consider gender-specific factors in understanding and addressing PTSD in clinical practice and future research endeavors. Importantly, our results revealed significant associations between ACEs and both IPV and lifetime traumatic events. Participants who reported higher numbers of ACEs were more likely to experience IPV and a greater number of lifetime traumatic events. These associations showed similar effect sizes. These findings align with the previous research that suggesting a greater risk of revictimization among individuals who have experienced ACEs [ 35 , 36 , 38 ]. The mediation analysis provided additional insights into the pathways through which ACEs may contribute to PTSD development. Consistent with previous research [ 30 ], our results demonstrated that the association between ACEs and PTSD symptomatology was partially mediated by the number of lifetime traumatic events. This indirect association suggests that ACEs may increase the risk for subsequent exposure to traumatic events, which in turn contributes to the development of PTSD symptoms. These findings highlight the importance of considering the cumulative impact of traumatic events as a mediator in the ACEs-PTSD pathway. Overall, the findings of this study contribute to the growing body of literature on the impact of ACEs, lifetime traumatic events, and IPV on the development of PTSD. The results underscore the significance of early life adversities as risk factors for subsequent traumatic experiences and highlight the cumulative and enduring effects of these experiences on mental health outcomes. The findings have important implications for clinical practice, emphasizing the need for early identification, prevention, and intervention efforts targeting both ACEs and subsequent traumatic events to mitigate the risk of PTSD. Limitations Despite the valuable contributions of this study, several limitations should be acknowledged. Firstly, the cross-sectional design restricts our ability to establish causal relationships between variables. Future longitudinal studies could provide more robust evidence regarding the temporal associations between ACEs, traumatic events (including IPV), and PTSD. Secondly, the reliance on self-report measures introduces the potential for recall bias or social desirability bias. Future studies could employ multiple assessment methods, including clinician-administered interviews or objective measures, to enhance the validity of findings. Lastly, the generalizability of the findings may be limited to the specific sample of participants who were affected by the Russian military aggression in Ukraine. Replication of these findings in diverse populations and across different developmental stages is warranted. Declarations Author Contributions: Conceptualization: V.B., O.S. and A.J.; methodology: V.B., O.S. and A.J.; formal analysis: V.B., Y.S. and O.S.; investigation: V.B., Y.S., Y.B., R.B., O.S., A.J.; data curation: V.B. and O.S.; writing - original draft preparation: V.B., Y.S., Y.B., R.B., O.S., A.J.; writing - review and editing: V.B., Y.S., Y.B., R.B., O.S., A.J.; visualization: V.B. and Y.S.; project administration: V.B., O.S. and A.J. All authors have read and agreed to the resubmitted version of the manuscript. Declarations of interest: The authors declare no conflict of interest. Institutional Review Board Statement: All procedures were approved by the Commission on Ethics and Deontology of the Institute of Neurology, Psychiatry and Narcology of the National Academy of Medical Sciences of Ukraine (Protocol No 12-b from December 21, 2018). Data Availability Statement: The data presented in this study are available on reasonable request from the corresponding author. 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Final structural equation model representing effects of adverce childhood experiences (ACEs) on risk for posttraumatic stress disorder among 999 Ukrainian college students 17-24 years of age. Ellipses represent latent constructs. The straight lines are paths and the values along the lines are standardized path coefficients significant at n.s. = “non-significant”, * \u003cem\u003ep\u003c/em\u003e \u0026lt; .05 and *** \u003cem\u003ep\u003c/em\u003e \u0026lt; .001.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4628445/v1/fb20ff33d8d395050a336761.png"},{"id":59032105,"identity":"52cf261f-20e1-4524-b271-9bb9a7706daa","added_by":"auto","created_at":"2024-06-25 14:18:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":735844,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4628445/v1/6c0ba0b6-409d-4c5d-bc8e-2fc498f03b81.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eAdverse Childhood Experiences and Posttraumatic Stress Disorder among Ukrainian College Students: Mediating Role of Intimate Partner Violence and Lifetime Trauma Experience\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUkraine, the largest country within Europe with a population of 41.2\u0026nbsp;million [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Due to its strategic location and abundant natural resources, the country has a history marked by wars, persecutions, subjugation, and political upheaval [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Russia annexed Crimea in March 2014 following an invalid referendum [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The full-scale military invasion of Ukraine by the Russian Federation on February 24, 2022, caused unprecedented destruction, devastation, and a significant humanitarian crisis [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. As millions of Ukrainians have been directly and indirectly affected by the war and its socioeconomic consequences, it is essential to comprehend the role of the underlying factors of Posttraumatic Stress Disorder (PTSD) symptoms among Ukrainians during the initial stage of the Russian-Ukrainian war. The present study uses a large sample of Ukrainian college students to examine the association between adverse childhood experiences and early adulthood PTSD, mediated by the intimate partner violence and traumatic life events after the annexation of Crimea in 2014 and prior to the start of the full-scale Russian military invasion of Ukraine in 2022.\u003c/p\u003e \u003cp\u003ePost-traumatic stress disorder may develop in someone who experienced or witnessed a traumatic event and is typically characterized by intrusive memories of reliving traumatic experiences, avoiding reminders of the traumatic event, negative mood, and hyperarousal symptoms, such as being easily startled or irritability [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], leading to significant dysfunction or distress. The prevalence of PTSD varies widely depending on the population being studied and the type of trauma experienced. The lifetime prevalence of PTSD in the general U.S. population was reported at 8.3%, past 12-month at 4.7%, and past 6-months at 3.8% [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Among individuals who live in countries affected by war, the prevalence of PTSD can be as high as 26.51% [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt is essential to investigate the mental health consequences of the Russian war on Ukrainian people, particularly the interplay between childhood adversities, IPV and other traumas, and PTSD, to contribute to the broader knowledge base on the impact of war on wellbeing and functioning, tailor interventions, and inform preventive strategies to address the mental health needs of individuals and communities affected by armed conflict.\u003c/p\u003e \u003cp\u003eNumerous studies have produced varying prevalence estimates of intimate partner violence (IPV) victimization in Ukraine. Burlaka et al. sampled 320 Ukrainian mothers of schoolchildren and found that 81% of respondents reported psychological violence and 58% reported physical assault by an intimate partner, with respondents enumerating an average of 66 IPV incidences in the past year [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Barrett et al. analyzed data gathered from ever-married or cohabitating Ukrainian women as part of the 2007 Ukraine Demographic Health Survey [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In this sample, a comparatively lower 21% of respondents reported experiencing emotional abuse in the context of a romantic relationship, 13% reported physical abuse, and 3% reported sexual abuse [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. These differential findings suggest that different demographics of women may be at particularly elevated risk of IPV victimization, such as mothers of school-aged children as compared more generally to women who are or have been in long-term partnerships. Notably, however, Ismayilova and El-Bassel\u0026rsquo;s analysis of the same 2007 Ukraine Demographic Health Survey showed that among Ukrainian women with a history of IPV victimization, 70% experienced physical injury from IPV, such as bruises, aches, wounds, or broken bones or teeth [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], pointing to high severity of violence among those who are victimized. While data on intimate partner violence perpetrated against Ukrainian men is limited, O\u0026rsquo;Leary et al.\u0026rsquo;s analysis of Ukrainian married or cohabitating couples who completed the 2002 Ukraine World Mental Health Survey found that 20% of Ukrainian women reported at any time being the subject of physical aggression from their partner, as compared with 8.6% of Ukrainian men [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. While these prevalence estimates vary significantly by study methodology, subpopulation, and survivor gender, all found an IPV prevalence of at least 20%, or 1 in 5, which points to a significant burden on Ukrainian women.\u003c/p\u003e \u003cp\u003eData in other countries throughout Eastern Europe and the post-Soviet region can also provide useful metrics for estimation of and comparison to IPV prevalence in Ukraine. The 2005 Moldova Demographic Survey, analogous to its Ukrainian counterpart, found twice the rate of physical partner violence (20%) and slightly higher sexual partner violence (5%) among Moldovan women compared to Ukrainian women [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The same survey conducted in 2006 in Azerbaijan captured rates of partner violence similar to those in Ukraine, with 10% of respondents reporting partner physical and 2% reporting partner sexual violence, respectively [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Potentially of note, rates of physical injury from victimization were lower in Moldova and Azerbaijan than in Ukraine, at 60% and 40%, respectively, supporting the need for attention to the high potential of severe harm for Ukrainian IPV survivors [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e"},{"header":"Theoretical framework","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eAdverse Childhood Experiences, Intimate Partner Violence, and Post-Traumatic Stress Disorder\u003c/h2\u003e \u003cp\u003eTo our knowledge, extant literature has not investigated the relationship between adverse childhood experiences and IPV in Ukraine specifically. However, this relationship has been well-studied in a variety of other global contexts.\u003c/p\u003e \u003cp\u003eFirst defined by Felitti et al., adverse childhood experiences (ACEs) include measures of childhood exposure to physical, sexual, and psychological abuse; witnessed abuse against the mother; and having a caretaker with a mental illness, substance abuse condition, suicidality, and/or who was ever incarcerated [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Respondents to the ACE Questionnaire are given a cumulative ACE score that represents the sum total of ACEs they report [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Extensive literature has documented correlations between ACE scores and a variety of physical, mental, and behavioral health and socioeconomic outcomes, such as smoking, substance use disorders, depression, PTSD, anxiety and mood disorders, suicidality, sexually transmitted conditions, obesity, heart and respiratory disease, diabetes, cancer, houselessness, and having multiple classes of pharmaceutical prescriptions [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn an analysis of data from Brazilian women, Buffarini et al. found a graded association between respondents\u0026rsquo; cumulative ACEs exposure and subsequent IPV victimization, with women reporting just 1 ACE at 1.5 the risk of IPV victimization relative to women reporting no ACEs, and those reporting 5 or more ACEs at 4.9 times the risk of IPV compared to women with no ACEs [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Interestingly, Nikulina et al.\u0026rsquo;s examination of a sample of United States college students found no relationship between total cumulative ACE scores and IPV, but rather reported that witnessed domestic violence specifically was predictive of IPV victimization and perpetration [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], suggesting that different ACEs differentially impact IPV and that an intergenerational cycle of violence may be at play in some cases. Mair et al. tested potential meditational pathways in the relationship of ACEs with IPV in a sample of couples residing in California and found that ACEs predicted depression, anxiety, and impulsivity among both male and female partners; and that male anxiety and impulsivity and female depression predicted male-to-female IPV, and male depression, impulsivity, and frequency of intoxication and female depression predicted female-to-male IPV [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. A number of studies have also documented a positive relationship between ACEs and IPV perpetration, including among Sri Lankan, Norwegian, English, and Black U.S. men [\u003cspan additionalcitationids=\"CR19 CR20\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile to our knowledge, the extant literature has not examined the relationship between post-traumatic stress disorder (PTSD) and IPV in Ukraine, like the link between ACEs and IPV, it has been documented in a variety of other contexts. In their examination of the effects of various forms of interpersonal violence on mental health outcomes in a national U.S. sample, Iverson et al. found that physical IPV victimization predicted PTSD with an odds ratio (OR) of 2.29 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Khadra et al. sampled Lebanese women and reported that 97% of those who experienced physical partner violence met criteria for some PTSD symptomatology [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. De Vries\u0026rsquo; 2008 dissertation investigated PTSD symptoms among individuals at a United States battered women\u0026rsquo;s shelter and found that 58% of respondents met current PTSD criteria, and 66% met one or more diagnostic criteria for complex PTSD (C-PTSD) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In a sample of female U.S. community college students, IPV victimization was found to be predictive of PTSD, with more extensive IPV correlating with more PTSD symptoms [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Given evidence pointing to higher severity of physical violence experienced by IPV survivors in Ukraine compared with nearby countries, it is possible that this link may be comparable or even stronger in the Ukrainian context [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eIPV as a Mediator Between ACEs and PTSD\u003c/h2\u003e \u003cp\u003eThe impact of ACEs on adult mental health has been well-documented. A smaller subset of studies has attempted to elucidate the potential mediating influence of IPV victimization in the relationship between ACEs and numerous measures of adult mental health. Seon et al. investigated the link between ACEs and perceived poor mental health in adulthood with IPV as a mediator in a sample of U.S. college students and found that IPV victimization partially mediated the impact of ACEs on mental health [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Jiwani et al. studied the impact of ACEs mediated by IPV on maternal self-efficacy in a sample of mothers of young children in India and found that for low-caste but not high-caste mothers, ACEs exposure was associated with lower self-efficacy mediated by IPV exposure [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurthermore, research has also documented a relationship between ACEs, IPV, and PTSD in a different causal combination. Swopes et al. found that in a group of U.S. male IPV offenders, the relationship of ACEs to IPV perpetration was mediated by PTSD [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Taken broadly, this research supports the existence of links among these three variables.\u003c/p\u003e \u003cp\u003eWhile no research to date has examined PTSD as a specific outcome of ACEs mediated by IPV, existing evidence points to the connection between these variables as well as the mediating role of IPV in the impact of ACEs on adult mental health. Given that ACEs have been shown to predict IPV [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and PTSD [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] and IPV has also been shown to predict PTSD [\u003cspan additionalcitationids=\"CR23 CR24\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], it is possible that IPV mediates some of the relationship between ACEs and PTSD. Additionally, Jiwani et al.\u0026rsquo;s [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] findings that caste affects this relationship indicates a potential influence of societal factors on this process.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAdverse childhood experiences, lifetime traumatic events, and PTSD\u003c/h3\u003e\n\u003cp\u003eA history of ACEs is one of the most robust predictors of adversities and re-victimization later in life. One potential pathway appears to be associated with diminished self-capacities, which may be observed in individuals who have experienced childhood abuse, neglect, or maltreatment [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Diminished self-capacities may contribute to an increased susceptibility to repeated victimization due to such factors such as low self-esteem, impaired self-efficacy, limited assertiveness skills, or difficulties in recognizing and setting boundaries, which may render individuals more vulnerable to experiencing further instances of victimization. Additionally, ACEs can significantly impact the development of emotional intelligence [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], leading to difficulties in recognizing and understanding one's own emotions and the emotions of others, regulating emotions effectively, and forming healthy interpersonal relationships. Early adverse experienced were found to alter brain development of children leading to an increased risk for psychopathology and later-life adversity [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOne prospective study utilized a sample of women who were survivors of sexual assault and found ACEs to be one of the key predictors of sexual assault revictimization [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Another study found that homeless individuals were at a higher risk for repeated victimization if they were exposed to ACEs [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Exposure to ACEs have significantly contributed to increased depression and substance use among Ukrainian young adults [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBurlaka et al. [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] also reported that Ukrainian students who experienced ACEs were more likely to be victims of bullying in college. Given that bullying is often associated with symptoms of PTSD [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], it is possible that other lifetime traumatic events can act as a mediator in the relationship between ACEs and the development of PTSD in adulthood. Frewen et al. [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] assessed the association between ACEs, lifetime traumatic stress and non-traumatic stressors with PTSD. These authors found that lifetime traumatic stressors and ACEs uniquely predicted PTSD. Additionally, ACEs were uniquely associated with PTSD after accounting for lifetime traumatic stress.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eContributions of the Present Study\u003c/h2\u003e \u003cp\u003eThe exposure to ACEs may increase the likelihood of encountering traumatic events later in life [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] due to factors such as disrupted attachment patterns [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], maladaptive coping strategies [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], or ongoing interpersonal difficulties stemming from the adverse experiences in childhood [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Importantly, ACEs are significantly associated with PTSD across studies that involved participants from different backgrounds [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. However, no study has tested the association between ACEs, IPV, life traumas and PTSD among participants exposed to war.\u003c/p\u003e \u003cp\u003eThe present study aimed to investigate the associations between ACES, IPV, lifetime traumatic events, and PTSD among participants exposed to the Russian-Ukrainian war. This research aims to 1) examine the prevalence of PTSD in the period between initial invasion of Ukraine in 2014 and the full-scale Russian invasion of Ukraine in 2022, 2) expand the understanding of the relationship between ACEs and PTSD in the context of armed conflict, 3) explore the role of IPV and lifetime traumatic events as potential mediators in the ACEs-PTSD pathway, 4) enhance the understanding the mental health consequences of Russian war on Ukrainian people.\u003c/p\u003e \u003c/div\u003e "},{"header":"Methods","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003e The study used a cross-sectional sample of 999 students from all Ukrainian regions. Undergraduate and graduate students majored in social work, psychology, medicine, sociology, philosophy, cybersecurity, special education, law, and criminology. Two-third of participants were females (68.57%) with age ranging from 17 to 24 years (M\u0026thinsp;=\u0026thinsp;19.1, SD\u0026thinsp;=\u0026thinsp;1.59). Most participants (96%) were Ukrainians and other 4% were Armenians, Jews, Russians, Belarusians, Hungarians, Tatars, or Romanians. Most students were single (89%), some 10% were married or lived with their partner. Majority (91.66%) were debt-free and 19.40% were employed earning, on average, \u003cspan\u003e$\u003c/span\u003e32 per month.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eProcedure\u003c/h2\u003e \u003cp\u003eThe study recruited participants by making announcements in classrooms. Researchers informed students that the study aimed to investigate the psychosocial well-being and success of Ukrainian students. Interested students who agreed to participate met with faculty members or research assistants individually or in small groups. They completed the survey using their own personal devices or were given access to school computers. All participants provided informed consent, and the study was approved by the Committee of Ethics and Deontology of the Ukrainian National Academy of Medical Sciences Institute of Neurology, Psychiatry, and Narcology (Protocol No 12-b from December 21, 2018). During the survey, participants spent about an hour answering questions related to their childhood, family experiences, mental health, and substance use. They were not offered any form of compensation or incentives, and their responses were collected via a secure online platform.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eMeasures\u003c/h2\u003e \u003cp\u003eParticipants answered sociodemographic questions measuring income (in UAH that we converted to USD to report in this study), sex (male or female), age (measured in years), program, ethnicity, and employment status.\u003c/p\u003e \u003cp\u003eAdverse Childhood Experiences Questionnaire (ACEs) [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] has 10 questions such as \u0026ldquo;While you were growing up, during your first 18 years of life, did a parent or other adult in the household often swear at you, insult you, put you down, or humiliate you or act in a way that made you afraid that you might be physically hurt?\u0026rdquo; and \u0026ldquo;Did a parent or other adult in the household often push, grab, slap, or throw something at you or ever hit you so hard that you had marks or were injured?\u0026rdquo; measuring exposure to various childhood adversities. Participants also answered, \u0026ldquo;Did an adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way or try to or actually have oral, anal, or vaginal sex with you?\u0026rdquo; Response options were no (0) and yes (1). ACEs is a well-known measure that has been previously utilized in studies with Ukrainian college students [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. In this study, the Kuder-Richardson coefficient of reliability was .78.\u003c/p\u003e \u003cp\u003eThe Composite Abuse Scale (Revised)\u0026mdash;Short Form (CASR-SF) [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] was used to measure the students\u0026rsquo; experiences of IPV. The CASR-SF is a valid and reliable measure of IPV. Example of 15 scale items include, \u0026ldquo;My partner shook, pushed, grabbed or threw me,\u0026rdquo; \u0026ldquo;Used or threatened to use a knife or gun or other weapon,\u0026rdquo; \u0026ldquo;Made me perform sex acts that I did not want to perform\u0026rdquo; reported dichotomously (yes, no) and and if \u0026ldquo;yes\u0026rdquo; then on a frequency scale ranging from \u0026ldquo;not in the past 12 months\u0026rdquo; (0) to \u0026ldquo;daily/almost daily\u0026rdquo; (5) measuring psychological, physical and sexual violence. The reported reliability for this measure is Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;.942. In our sample, the Cronbach α\u0026thinsp;=\u0026thinsp;.84 (psychological subscale α\u0026thinsp;=\u0026thinsp;.75, physical subscale α\u0026thinsp;=\u0026thinsp;.72 and sexual violence subscale α\u0026thinsp;=\u0026thinsp;.83).\u003c/p\u003e \u003cp\u003eLife Events Questionnaire (LEC) [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] was developed by the National Center for PTSD to measure multiple types of exposure to various traumatic events on a 5-point nominal scale (1\u0026thinsp;=\u0026thinsp;happened to me, 2\u0026thinsp;=\u0026thinsp;witnessed it, 3\u0026thinsp;=\u0026thinsp;learned about it, 4\u0026thinsp;=\u0026thinsp;not sure, and 5\u0026thinsp;=\u0026thinsp;does not apply). Examples of the LEC trauma domains include natural disaster, fire or explosion, transportation accedents and others that have happened to participants during their entire life. In our study, we recoded participants\u0026rsquo; responses into weighted scores to estimate the lifetime exposure to trauma while taking into account the proximity of traumatic events to study participants [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Items that happened to participants were given a factor of 3, items witnessed by participants received a factor of 2, and items that participants learned about were given a factor of 1 for total maximum score of 102. Higher weighted scores mean participants have experienced more traumatic events that had a greater proximity to study participants. The Cronbach α was .95 for the weighted LEC scale in this study.\u003c/p\u003e \u003cp\u003ePosttraumatic stress disorder symptoms have been measured using the Child PTSD Symptom Scale (CPSS) [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. The CPSS has 17 items that map on DSM-IV symptoms. Participants were asked to how often they were bothered by such symptoms as \u0026ldquo;Having bad dreams or nightmares,\u0026rdquo; Not feeling close to people around you,\u0026rdquo; \u0026ldquo;Trying to avoid activities, people, or places that remind you of the traumatic event\u0026rdquo; in the last two weeks. The answers were on a Likert-type scale ranging from 0 (not at all) to 3 (5 or more times a week/almost always). Nixon et al. [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e] recommended a clinical cutoff of 16 or greater for determining a risk for PTSD in participants. Previously reported reliability of CPSS total score was .83 \u0026minus;\u0026thinsp;.90, for re-experiencing, .78 \u0026minus;\u0026thinsp;.84, avoidance, .65 \u0026minus;\u0026thinsp;.78, and arousal, .79 \u0026minus;\u0026thinsp;.88) [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. In our study, the total score Cronbach α was .90, re-experiencing, .79, avoidance, .78, and arousal, .79.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eAnalytic Techniques\u003c/h2\u003e \u003cp\u003eWe used structural equation modeling (SEM) to simultaneously assess direct and indirect effects of ACEs on participants\u0026rsquo; PTSD symptoms. SEM allows separating the random measurement error from latent variables which increases the explanatory power. The SEM estimations of direct and indirect effects are \u0026ldquo;routinely included in structural models, assuming such specifications are theoretically justifiable\u0026rdquo; [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. We followed Kline\u0026rsquo;s [2011] recommendations to evaluate SEM identification. We used the maximum likelihood estimation [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e] to examine the model fit. Stata/ MP 16.1 software package [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e] was used for all analyses. The goodness-of-fit comparative fit index (CFI), Tucker- Lewis index (TLI), and the root mean squared error of approximation (RMSEA) were employed in this study [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. The recommended cutoff points are for TLI, .90 or above [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e], CFI, 0.95 or above and RMSEA, 0.08 or below [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. To estimate the indirect relationships in the model, we used the Stata\u0026rsquo;s delta method-based nlcom command [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eDescriptive characteristics\u003c/h2\u003e \u003cp\u003eOur findings indicate that 24.97% of the participants have met the clinical cutoff of 16 (mild or more severe levels) for PTSD [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Adverse childhood experiences reported by the participants included being insulted and physically hurt (14.85%), feeling unloved (11.75%), growing in a single-parent household (29.05%), with the substance-abusing household member (14.87%). Eight percent of participants reported being pushed or grabbed by their intimate partner, 5.18% were made perform unwanted sexual acts, 10.89% were called crazy. The lifetime traumas included being sexually assaulted (5.83%), physically assaulted (14.26%) and getting in transportation accidents (14.98%). Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e includes additional information on study variables. Major study variables significantly correlated with each other and showed good reliability (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eMeans, Standard Deviations, Ranges and Percentages of the Study Variables (N\u0026thinsp;=\u0026thinsp;999)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal ACEs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSwored at, insulted, humiliated, was afraid to be physically hurt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePushed, grabbed, slapped, or thrown at, had marks, injuries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTouched or fondled in a sexual way, an adult attempted oral, anal, or vaginal intercourse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFelt unloved by family, unimportant, family lacked mutual closeness, support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLacked food, clean clothes, protection, parents were too drunk to provide care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParents were separated or divorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParents/caregivers were pushed, grabbed, slapped, kicked, bitten, hit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrew up with a problem drinker, alcoholic, or street drugs user\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.87\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrew up with a household member who was depressed, mentally ill, or attempted suicide\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousehold member went to prison\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal CASR-SF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical abuse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartner shook, pushed, grabbed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartner threatened to use a knife or gun or other weapon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKicked me, bit me or hit me with a fist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSexual abuse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMade me perform unwanted sex acts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eForced or tried to force me to have sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychological abuse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlamed for causing violence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTold family, friends I was crazy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTold me I that I was crazy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal LEC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWas sexually assaulted (rape, attempted rape, made to perform any type of sexual act through force or threat of harm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHad other unwanted or uncomfortable sexual experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWas in a transportation accident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWas physically assaulted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal CPSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReexperiencing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAvoidance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;2.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArousal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBelow threshold (0\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e57.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubclinical \u0026ndash; Mild (11\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild (16\u0026ndash;20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate (21\u0026ndash;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerately Severe (26\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere (31\u0026ndash;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtremely Severe (41\u0026ndash;51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e68.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNote\u003c/em\u003e. SD\u0026thinsp;=\u0026thinsp;standard deviation.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eCorrelations between the Major Study Variables and Cronbach\u0026rsquo;s Alpha Coefficients (N\u0026thinsp;=\u0026thinsp;999)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Total ACEs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(KR\u0026thinsp;=\u0026thinsp;.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Total CASR-SF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.29***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(α\u0026thinsp;=\u0026thinsp;.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Total LEC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.13***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(α\u0026thinsp;=\u0026thinsp;.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Total CPSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.36***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.23***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(α\u0026thinsp;=\u0026thinsp;.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.18***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.11**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. Sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.15***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.19***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.23***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eNote. ACEs\u0026thinsp;=\u0026thinsp;Adverse Childhood Experiences; CASR-SF\u0026thinsp;=\u0026thinsp;Composite Abuse Scale (Revised)\u0026mdash;Short Form; LEC\u0026thinsp;=\u0026thinsp;Life Events Checklist; CPSS\u0026thinsp;=\u0026thinsp;Child PTSD Symptom Scale. * p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, ** p\u0026thinsp;\u0026lt;\u0026thinsp;0.01, *** p\u0026thinsp;\u0026lt;\u0026thinsp;0.001. α\u0026thinsp;=\u0026thinsp;Cronbach\u0026rsquo;s alpha coefficients indicating internal consistency reliability estimates of multi-item measures; KR\u0026thinsp;=\u0026thinsp;Kuder-Richardson coefficient of reliability.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e(Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e about here)\u003c/p\u003e \u003cp\u003e(Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e about here)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eMeasurement and Structural Models\u003c/h2\u003e \u003cp\u003eThe measurement model allowed us to estimate whether the study variables were independently associated with the outcome variable of PTSD. We fit the measurement model with four latent factors corresponding to the study constructs. The model demonstrated good fit indices: χ\u003csup\u003e2\u003c/sup\u003e (48, N\u0026thinsp;=\u0026thinsp;263)\u0026thinsp;=\u0026thinsp;73.47, p\u0026thinsp;\u0026lt;\u0026thinsp;.05; RMSEA\u0026thinsp;=\u0026thinsp;.045, CFI\u0026thinsp;=\u0026thinsp;.972; TLI\u0026thinsp;=\u0026thinsp;.962. All factor loadings were significant for all latent variables in this model. The latent variables were significantly associated with the PTSD latent variable.\u003c/p\u003e \u003cp\u003eIn the next step, we tested the structural model (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). We modeled the path between ACEs and PTSD to examine whether Adverse Childhood Experiences had significant standardized direct effect as well as indirect effects, mediated by IPV and LEC, on student PTSD symptoms. The paths are represented as straight lines while the values along the lines indicate estimated strength of influences, standardized path coefficients (betas). Our model provided a satisfactory fit for the data: χ\u003csup\u003e2\u003c/sup\u003e (71, N\u0026thinsp;=\u0026thinsp;263)\u0026thinsp;=\u0026thinsp;116.91, p\u0026thinsp;\u0026lt;\u0026thinsp;.001, CFI\u0026thinsp;=\u0026thinsp;.951, TLI\u0026thinsp;=\u0026thinsp;.938, RMSEA\u0026thinsp;=\u0026thinsp;.050.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e about here)\u003c/p\u003e \u003cp\u003eResults of the path model suggest that participants had lower PTSD symptomatology if they had fewer adverse childhood experiences (\u003cem\u003eb\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.40, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), fewer lifetime traumatic events (\u003cem\u003eb\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.17, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05), and self-identified as males (\u003cem\u003eb\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.15, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05). Participants who recalled having more ACEs were significantly more likely to experience IPV (\u003cem\u003eb\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.35, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) and lifetime traumatic events (\u003cem\u003eb\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.36, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Additionally, experiencing greater number of ACEs had a significant standardized indirect association, mediated by more lifetime traumatic events, with increased risk for developing PTSD during adolescent/early adulthood years (\u003cem\u003eb\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.06, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study has focused on expanding an understanding of unique associations and cumulative impact of ACEs, IPV, and lifetime traumatic events on the development of PTSD among war-affected populations. Our findings from a 2018 sample of Ukrainian college students demonstrated a significant positive relationship between ACEs and PTSD as well as between ACEs and IPV, but did not support the role of IPV as a mediator in this link. In this sample, adverse childhood events appeared to lead to subsequent traumatic stress symptoms as well as partner violence victimization, in line with extant literature [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study provided a high prevalence of PTSD among our sample, almost one in four screened positive for PTSD (compared with near 8% among U.S. population). Overall, this suggests trauma impact beyond what is usually seen in civilian populations and is in line with previous research on prevalence of PTSD in countries affected by wars [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This high prevalence could be due to the trauma and stress related to Russian invasion of Ukraine, political turmoil the prior to the war, family dynamics, or individual experiences [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The results of this study suggest that early life adversities may have a cumulative impact on the development and severity of PTSD symptoms during later stages of life. Our results highlight the enduring influence of ACEs on mental health outcomes and emphasize the importance of addressing and mitigating the impact of early life adversities to prevent or reduce the risk of PTSD.\u003c/p\u003e \u003cp\u003eIn contrast to expectations, IPV did not then predict subsequent PTSD when controlling for other lifetime traumas. This suggests that respondents\u0026rsquo; PTSD symptoms were more closely tied to their adverse childhood experiences and other traumatic events than to intimate partner violence victimization, and/or that ACEs were associated with PTSD symptoms through mechanism(s) other than IPV victimization.\u003c/p\u003e \u003cp\u003eA number of factors potentially account for these findings. Firstly, the ACEs portion of the survey asked respondents about their experiences throughout their first 18 years of life, while the IPV questions were limited to experiences in the last 12 months. The ACEs questions thus captured a much longer timespan than the IPV questions, and if respondents\u0026rsquo; IPV experiences did not occur in the last 12 months, they were not captured in this survey. This may have led to a more thorough and accurate picture of respondents\u0026rsquo; adverse childhood versus partner violence experiences, thus making it easier to accurately link ACEs to PTSD and more difficult to link IPV with PTSD. The lower prevalence of the IPV in our sample compared to another study of mothers of schoolchildren by our own group, suggests the possibility of a larger role of the IPV as people, especially women age through adulthood. Longer duration of exposure to an abusive relationship (or relationships) in older adults leading to cumulative number of IPV incidents, could also be another contributor to a possible stronger role of the IPV in older adults.\u003c/p\u003e \u003cp\u003eSecondly, it is also possible that ACEs have more power to predict IPV than IPV has power to predict PTSD. For instance, it may be that ACEs predict a variety of IPV experiences, from one-time incidences of IPV to ongoing, severe abuse; while only a subset of IPV exposures - such as exposure to particularly severe, long-lasting, and/or variable IPV - go on to predict PTSD. In this case, because the time-limited nature of our questions prevented us from capturing respondents\u0026rsquo; IPV experiences outside of a 12-month timeframe, we may not have captured respondents\u0026rsquo; IPV experiences with sufficient accuracy to document the weaker relationship between IPV and PTSD.\u003c/p\u003e \u003cp\u003eThirdly, evidence shows that PTSD can develop as late as years following a traumatic experience, meaning that the full effects of past-year IPV may not have been evident at the time of the study [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Additionally, because ACEs definitionally occur in childhood and the IPV questions in this survey measured adulthood experiences, it is possible that respondents\u0026rsquo; increased cognitive and emotional maturity and knowledge of and access to helpful resources were protective against PTSD resulting from the trauma of IPV, as compared with childhood trauma during less independent, more formative years.\u003c/p\u003e \u003cp\u003eFourthly, like all life events, ACEs and IPV occur in broader life and societal contexts that can also significantly impact individuals\u0026rsquo; mental health. Of note for this sample is the fact that Ukraine has been at war with the Russian Federation since 2014, when Russia invaded the Crimean Peninsula and pro-Russian militants took control of portions of the Donbas region in Eastern Ukraine. The data for this study was collected in 2018, after the seizure of Crimea and amid ongoing armed conflict in Donbas. In December 2020, Amnesty International published a memorandum on the impact of this war on IPV in Eastern Ukraine, noting that increased IPV rates and lack of perpetrator accountability and survivor services since the start of the war have culminated in an increasingly dire situation for Ukrainian IPV survivors. If survivors are aware of this lack of response and resources, and/or if they are unable to prioritize IPV reporting given the more pressing realities of war, they may generally underreport their IPV experiences, potentially worsening the problem of undercounting IPV discussed above. It is also possible that war-related traumas - such as one\u0026rsquo;s own and/or loved ones\u0026rsquo; participation in armed conflict, witnessed fighting, property destruction, conflict-related sexual violence, worsening economic circumstances, separation from loved ones, and/or concerns about safety and national stability - may be more predictive of PTSD symptoms for survivors in the context of war than recent IPV victimization. Future studies should seek to further elucidate these competing influences.\u003c/p\u003e \u003cp\u003eTraumatic experiences can have varying impacts on the development of post-traumatic stress disorder (PTSD), with different trauma types potentially resulting in distinct manifestations and severity of symptoms. For example, Hinchey et al. [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e] found that interpersonal traumas tended to be more predictive of the PTSD than non-interpersonal traumas. Understanding such differential impacts is crucial for tailoring interventions and providing appropriate support to individuals who have experienced specific types of trauma.\u003c/p\u003e \u003cp\u003eA number of lifetime traumatic events was found to be positively associated with PTSD symptomatology, albeit with a smaller effect size compared to ACEs. This indicates that the accumulation of traumatic events throughout one's lifetime contributes to the manifestation and severity of PTSD symptoms. It is worth noting that while the effect size was smaller compared to ACEs, the cumulative impact of lifetime traumatic events should not be overlooked, as it represents an ongoing risk factor for PTSD development.\u003c/p\u003e \u003cp\u003eInterestingly, gender differences emerged in our study, with self-identified males reporting lower levels of PTSD symptomatology. This finding aligns with previous research suggesting that males may exhibit different patterns of PTSD symptoms or may be less likely to seek help for their symptoms [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. It underscores the need to consider gender-specific factors in understanding and addressing PTSD in clinical practice and future research endeavors.\u003c/p\u003e \u003cp\u003eImportantly, our results revealed significant associations between ACEs and both IPV and lifetime traumatic events. Participants who reported higher numbers of ACEs were more likely to experience IPV and a greater number of lifetime traumatic events. These associations showed similar effect sizes. These findings align with the previous research that suggesting a greater risk of revictimization among individuals who have experienced ACEs [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe mediation analysis provided additional insights into the pathways through which ACEs may contribute to PTSD development. Consistent with previous research [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], our results demonstrated that the association between ACEs and PTSD symptomatology was partially mediated by the number of lifetime traumatic events. This indirect association suggests that ACEs may increase the risk for subsequent exposure to traumatic events, which in turn contributes to the development of PTSD symptoms. These findings highlight the importance of considering the cumulative impact of traumatic events as a mediator in the ACEs-PTSD pathway.\u003c/p\u003e \u003cp\u003eOverall, the findings of this study contribute to the growing body of literature on the impact of ACEs, lifetime traumatic events, and IPV on the development of PTSD. The results underscore the significance of early life adversities as risk factors for subsequent traumatic experiences and highlight the cumulative and enduring effects of these experiences on mental health outcomes. The findings have important implications for clinical practice, emphasizing the need for early identification, prevention, and intervention efforts targeting both ACEs and subsequent traumatic events to mitigate the risk of PTSD.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eDespite the valuable contributions of this study, several limitations should be acknowledged. Firstly, the cross-sectional design restricts our ability to establish causal relationships between variables. Future longitudinal studies could provide more robust evidence regarding the temporal associations between ACEs, traumatic events (including IPV), and PTSD. Secondly, the reliance on self-report measures introduces the potential for recall bias or social desirability bias. Future studies could employ multiple assessment methods, including clinician-administered interviews or objective measures, to enhance the validity of findings. Lastly, the generalizability of the findings may be limited to the specific sample of participants who were affected by the Russian military aggression in Ukraine. Replication of these findings in diverse populations and across different developmental stages is warranted.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e Conceptualization: V.B., O.S. and A.J.; methodology: V.B., O.S. and A.J.; formal analysis: V.B., Y.S. and O.S.; investigation: V.B., Y.S., Y.B., R.B., O.S., A.J.; data curation: V.B. and O.S.; writing - original draft preparation: V.B., Y.S., Y.B., R.B., O.S., A.J.; writing - review and editing: V.B., Y.S., Y.B., R.B., O.S., A.J.; visualization: V.B. and Y.S.; project administration: V.B., O.S. and A.J. All authors have read and agreed to the resubmitted version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclarations of interest:\u003c/strong\u003e The authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional Review Board Statement:\u003c/strong\u003e All procedures were approved by the Commission on Ethics and Deontology of the Institute of Neurology, Psychiatry and Narcology of the National Academy of Medical Sciences of Ukraine (Protocol No 12-b from December 21, 2018).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u003c/strong\u003e The data presented in this study are available on reasonable request from the corresponding author. The data are not publicly available due to privacy restrictions.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eUkrStat. State Statistics Committee of Ukraine (2022) [cited 2022 Feb 24]. 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J Immigr Minor Health 25(2):274\u0026ndash;281. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10903-022-01407-8\u003c/span\u003e\u003cspan address=\"10.1007/s10903-022-01407-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarhood L, Fares S, Hamady C (2018) PTSD and gender: Could gender differences in war trauma types, symptom clusters and risk factors predict gender differences in PTSD prevalence? Arch Womens Ment Health 21(6):725\u0026ndash;733. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00737-018-0849-7\u003c/span\u003e\u003cspan address=\"10.1007/s00737-018-0849-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"posttraumatic stress disorder (PTSD), Ukraine, war, adverse childhood experiences (ACEs), lifetime trauma, intimate partner violence (IPV)","lastPublishedDoi":"10.21203/rs.3.rs-4628445/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4628445/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis study assessed the prevalence of PTSD and its association with ACEs, IPV and lifetime trauma experiences in the context of Russian war on Ukraine. 999 college students from all Ukrainian regions (68.57% females, Mage\u0026thinsp;=\u0026thinsp;19.1 years), reported on PTSD, ACEs, IPV, and lifetime trauma experiences. Structural Equation Modeling was used to assess direct and indirect (mediated by IPV and lifelong trauma experiences) effects of ACEs on participants\u0026rsquo; PTSD symptoms. Results indicated that 24.97% of the participants have met the clinical cutoff for PTSD. Lower PTSD symptomatology was associated with fewer ACEs (b\u0026thinsp;=\u0026thinsp;.40, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), fewer lifetime traumatic events (b\u0026thinsp;=\u0026thinsp;.17, p\u0026thinsp;\u0026lt;\u0026thinsp;.05), and male sex (b\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.15, p\u0026thinsp;\u0026lt;\u0026thinsp;.05). Participants with more ACEs were more likely to experience IPV (b\u0026thinsp;=\u0026thinsp;.35, p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and lifetime traumatic events (b\u0026thinsp;=\u0026thinsp;.36, p\u0026thinsp;\u0026lt;\u0026thinsp;.001). ACEs had a significant standardized indirect association, mediated by lifetime traumatic events, with increased PTSD symptomatology (b\u0026thinsp;=\u0026thinsp;.06, p\u0026thinsp;\u0026lt;\u0026thinsp;.05). ACEs had a direct effect on PTSD. Early adversity also had an indirect association with PTSD mediated by lifelong victimization.\u003c/p\u003e","manuscriptTitle":"Adverse Childhood Experiences and Posttraumatic Stress Disorder among Ukrainian College Students: Mediating Role of Intimate Partner Violence and Lifetime Trauma Experience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-25 14:10:37","doi":"10.21203/rs.3.rs-4628445/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"55d4fbdb-183a-44d5-a1df-72902196a4cf","owner":[],"postedDate":"June 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":33637614,"name":"Psychology"},{"id":33637615,"name":"Psychiatry"}],"tags":[],"updatedAt":"2024-06-25T14:10:37+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-25 14:10:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4628445","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4628445","identity":"rs-4628445","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}