Factor Structure and Psychometric Properties of ACE-IQ-27: A Shorter Version of Adverse Childhood Experiences International Questionnaire (ACE-IQ) in Bhutan

Factor Structure and Psychometric Properties of ACE-IQ-27: A Shorter Version of Adverse Childhood Experiences International Questionnaire (ACE-IQ) in Bhutan | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Factor Structure and Psychometric Properties of ACE-IQ-27: A Shorter Version of Adverse Childhood Experiences International Questionnaire (ACE-IQ) in Bhutan Tshering Dorji, Pelden Nima This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6840865/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Adverse Childhood Experiences (ACEs) are potentially traumatic events that occur during childhood and have been consistently linked to poor school engagement, academic performance, and a range of negative health, developmental, and social outcomes throughout the lifespan. This survey study among Bhutanese students aged 13 to 21 years aimed to assess the factor structure and psychometric properties of ACE-IQ-27, a shorter version of Adverse Childhood Experiences International Questionnaire (ACE-IQ). The ACE-IQ-27 was created by excluding war and collective violence items, which are uncommon in Bhutan. The study employed two samples, selected based on convenience sampling. Through exploratory factor analysis with 250 students, a 4-factor solution emerged (violence exposure, parental neglect, family adversity, and sexual assault). Collectively, the four factors explained approximately 39% of the total variance. This structure was subsequently validated through confirmatory factor analysis (CFA) with a separate 300 students. The result produced acceptable model fit indices: χ² (265, N = 300) = 415.760, p = 0.000, χ ²/ df = 1.57, CFI = 0.947, TLI = 0.940, RMSEA = 0.038 (90% CI [0.029, 0.047], p = 0.907), and SRMR = 0.078). Following the CFA, a series of psychometric analyses were conducted to evaluate its convergent validity, discriminant validity, and internal consistency reliability of the four factors. The findings suggest that the adapted ACE-IQ-27 is sufficiently reliable and valid tool for measuring ACEs and their association with risk behaviours in later life among school-going Bhutanese children aged 13–21 years. The adapted ACE-IQ-27 is also particularly well-suited for assessing childhood adversities in schools, clinics, or community settings in regions where trauma related to war and collective violence is relatively uncommon. Adverse childhood experiences Bhutan psychometric properties of short adverse childhood experiences questionnaire exploratory factor analysis confirmatory factor analysis Figures Figure 1 Introduction ACEs and its Prevalence Adverse Childhood Experiences (ACEs) are potentially traumatic events that occur during childhood and have been consistently linked to poor school engagement (Bethell et al., 2014 ) academic performance (Qu et al., 2024 ) and a range of negative health, developmental, and social outcomes throughout the lifespan (Webster, 2022 ). These experiences include various forms of abuse (emotional, physical, or sexual), bullying, neglect (physical and emotional), witnessing domestic and community violence, household dysfunction (including family conflict, parental divorce, family members` incarceration, mental illness, alcohol and substance abuse), and peer violence, and have been shown to disrupt early brain development, compromise immune and nervous system functioning, and increase the risk of chronic diseases, mental health disorders, and risky behaviours in adulthood (Cook et al., 2005 ; Felitti et al., 1998 ; Shonkoff et al., 2012 ). A seminal study by Felitti et al. ( 1998 ) identified a strong dose-response relationship between the number of ACEs and the likelihood of adverse health outcomes, with individuals exposed to four or more ACEs facing substantially higher risks for conditions such as depression, alcoholism, drug use, and suicide attempts (Webster, 2022 ). A recent exhaustive review of extant literature on the neurobiological sequelae resulting from ACEs by Harden et al. (2022) has found that prolonged exposure to traumatic events during early childhood disrupt the brain`s normal development. This can particularly occur in areas associated with complex cognitive functioning such as emotion regulation, memory, decision-making, and social skills. The abnormal production of cortisol and oxytocin in the brain resulting from chronic stress is thought to be a primary contributory factor to these phenomena. Similarly, another comprehensive review of two decades of research on ACEs by Zarse et al. ( 2019 ) found numerous associations between ACEs and various health related issues (Zarse et al., 2019 ). These include physical disability, chronic diseases (pulmonary and cardiovascular diseases, diabetes, cancers, obesity, autoimmune and gastro-intestinal diseases), mental illnesses (depression, anxiety disorders, post-traumatic stress disorder, psychosis, substance use disorders such as alcohol and drug misuse, and tobacco use), suicide-related behaviours, maladaptive behaviors (aggression, violence perpetration, victimization), risk-taking sexual behaviors (unintended pregnancy, paternity in teen pregnancy, sexually transmitted diseases), poor coping mechanisms such as avoidance and emotional outbursts, insomnia, low quality of life in adulthood (homelessness and unemployment), and premature mortality brough on by foregoing deleterious conditions (Zarse et al., 2019 ). Therefore, understanding and measuring ACEs is critical for identifying at-risk populations and developing preventive strategies to mitigate these long-term effects. Recognizing the growing need to measure ACEs in all countries and the association between them and risk behaviours in later life (Gette et al., 2022; Kidman et al., 2019 ), as well as facilitate cross-cultural comparison, the WHO developed the Adverse Childhood Experiences International Questionnaire (ACE-IQ) (see WHO, 2020 ). This tool was adapted from the seminal ACE study conducted by Felitti et al. ( 1998 ) with the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente`s Adverse Childhood Experiences in the United States (Kidman et al., 2019 ). The original ACE questionnaire assesses the occurrence of 10 categories of ACEs, including emotional abuse, physical abuse, sexual abuse, household member with substance uses problems, household member with mental illness, mother treated violently, household criminal behaviour, parental separation or divorce, physical neglect, and emotional neglect (Afifi et al., 2020 ). However, to enhance the global applicability of the ACE framework and address a wider range of childhood adversities beyond those typically recognized in United States-based ACE studies, the WHO adapted it into the ACE-IQ (Pace et al., 2022 ). The ACE-IQ expands upon the original ACE categories, incorporating additional experiences such as war-related trauma, community violence, bullying, and exposure to collective violence, which are more prevalent in regions affected by conflict and instability (Gette et al., 2022). The ACE-IQ consists of 31 items to assess 13 categories of ACEs in individuals aged 18 years and older. These categories include physical abuse; emotional abuse; sexual abuse; violence against household members; living with household members who were substance abusers; living with household members who were mentally ill or suicidal, incarcerated household members; one or no parents, parental separation or divorce; emotional neglect; physical neglect; bullying; community violence; and exposure to war and collective violence (Gette et al., 2022; Kidman et al., 2019 ). With both binary and frequency scoring options, the ACE-IQ provides a flexible framework for studying childhood adversity across different populations. Its applicability has been demonstrated in several countries, including Germany, Netherlands, China, Lebanon, Kenya, Brazil, Saudi Arabia, Iraq, South Africa, Nigeria, Korea, Tunisia, Vietnam, Philipines, the former Yugoslav Republic of Macedonia, and Serbia (Gettee et al., 2022; Kidman et al., 2019 ; Kostić et al., 2019 ). Recent studies have examined the factor structure of the ACE-IQ to understand how its items cluster into meaningful and cohesive categories, by implementing it in diverse populations and settings. To analyze the data, they have used both reflective modelling approaches, such as CFA and EFA, as well as formative modelling techniques, like Principal Component Analysis (PCA) (Gette et al., 2022). For instance, Kidman et al. ( 2019 ) conducted a PCA on a data collected form Malawian adolescents aged 10–16 years and identified a three-factor structure. The three components included: (1) Household dysfunction, with nine items related to household member drug use and incarceration, parental divorce or death, mental health, and collective or community violence; (2) Abuse, which comprised 11 items related to physical and emotional abuse and domestic violence; (3) Neglect, with seven items related to physical and emotional neglect, and bullying. Their study excluded sexual abuse, familial mental illness, and community violence in the final model due to the low (6% and 7%) and high (99%) endorsement of the sample. Furthermore, Kidman and colleagues expanded the original ACE-IQ by adding HIV-specific questions to address adversities related to the HIV/AID epidemic. They also included the timing of adverse experiences to better understand how the developmental stage of experiencing trauma influences adolescent health outcomes. Similarly, a study in Serbia with Serbian adults aged 18–65 years found three factors for ACE-IQ (Kostić et al., 2019 ). The three factors included: (1) Violence, with items related to factors such as physical fight involvement, bullying, community violence, physical abuse, and collective violence; (2) Neglect, with items related to factors such as depression and suicide in the family, psychological neglect, sexual abuse, and parental separation; (3) Abuse, with items related to factors such as family alcoholism, parental partner abuse, family member incarceration, household member drug abuse, and physical neglect. Likewise, a study by Gette et al. (2022) among U.S. college students (mean age = 19.10 years, SD = 2.56) identified a six-component solution through PCA for the 30-item ACE-IQ, excluding item 23 on bullying, which had a “Check all that apply” response option. The six components included: (1) Emotional and Physical Abuse, which comprised seven items related to being the victim or witness of physical and/or emotional abuse; (2) Sexual Abuse, which included four items specific to experiencing sexual abuse; (3) Community and Collective violence, with seven items related to peer violence, exposure to community violence, and other adverse experiences related to community violence; (4) Impaired or Absent Parenting, with five items about dysfunctional caregiving, such as substance abuse or incarceration; (5) Resource Disruption, which captured experiences like displacement or physical neglect; and (6) Emotional Neglect, which included two items related to parental understanding and awareness. In their analysis, items 10 (parental death), 22 and 23 (Bullying) were excluded. Additionally, items 29 (destruction of home) and 30 (victim of collective violence) appeared in both the Community and Collective Violence and Resource Disruption components. For further details, refer Gette et al. (2022). Additionally, Santelices et al. ( 2025 ) evaluated the structural validity, concurrent validity with the Marshall Trauma Scale (MTS), and internal consistency reliability of the ACE-IQ in a Chilean cohort. Structural validity analyses showed best fit for three-factor (household dysfunction, childhood abuse, and external violence) and four-factor models (household dysfunction, childhood abuse, external violence, and childhood negligence) for both the binary and frequency scoring. The overall internal consistency of the scale was adequate (α > 0.7), with the exception of factors such as childhood neglect and violence outside the home with lower internal consistency. Christoforou and Ferreira ( 2020 ) also investigated the psychometric properties of the ACE-IQ with two hundred eighty-four adult individuals engaging in non-suicidal self-injury. The findings of this study supported ACE-IQ’s reliability (Cronbach’s alpha = 0.854), convergent validity (r = 0.85, p < 0.001 with the Childhood Trauma Questionnaire – Short Form (CTQ-SF)), predictive validity ( R 2 = 0.12, p = 0.001 of the Self-harm Inventory (SHI) total score) and discriminant validity ( F -value = 13.90, p < 0.001). An exploration of the factor structure demonstrated a 5-factor solution (physical abuse, sexual abuse, emotional abuse, exposure to violence, family environment). Several other studies have also examined the factor structure and evaluated the psychometric properties of the ACE questionnaire (Afifi et al., 2020 ; Brown et al., 2013 ; Choi et al., 2020 ; Ford et al., 2014 ; Ho et al., 2019 ; van der Feltz-Cornelis & de Beurs, 2023 ). However, these investigations have focused on either shorter or longer version of the 11-item Behavioural Risk Factor Surveillance System ACE questionnaire or adaptions of the original CDC-Kaiser Permanente ACE study questionnaire developed by Felitti et al. ( 1998 ). These adapted versions often differ in content and structure from the ACE-IQ, which forms the basis of our present study. The findings from the foregoing studies reveal that the factor structure of the ACE-IQ is not fixed; it often varies depending on the socio-cultural, economic, and political environment of the population being studied. This variability emphasizes the necessity of tailoring the ACE-IQ to align with the unique characteristics and needs of specific populations to ensure its effectiveness and relevance. ACEs, as originally conceived, were based on Western conceptualizations of trauma, and as such, may not fully capture the breath of adverse experiences in non-Western societies. In Bhutan, for example, the rarity of war and collective violence due to the country’s stable sociopolitical environment and absence of recent armed conflict renders certain ACE-IQ items contextually irrelevant. Including such items may introduce measurement error, reduce the reliability of the instrument, and potentially distort the factor structure of the questionnaire. This highlights the need to adapt the ACE-IQ to better align with the unique socio-cultural realities of Bhutanese youth. Refining the ACE-IQ questionnaire not only enhances its accuracy but also allows for a deeper understanding of how childhood adversities manifest in a unique cultural setting like Bhutan. Therefore, the present study aimed to refine and validate the factor structure of ACE-IQ, originally developed for individuals aged 18 years and older (WHO, 2020 ), to make it more suitable for Bhutanese school-going children aged 13 to 21 years. Specifically, the current study develops a shortened version of the ACE-IQ, referred to as ACE-IQ-27. This version excluded items related to war and collective violence, which are less applicable in Bhutan due to the country`s peaceful environment. The revised questionnaire includes 27 items (see Table 3 ) covering 12 categories of ACEs (see Table 4 ), ensuring that it remains comprehensive while contextually relevant. Then, it examines the factor structure and psychometric properties of the ACE-IQ-27 questionnaire by employing Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA). Specifically, EFA is conducted to explore the underlying factor structure and determine which items are most central to the ACE construct, thereby identifying a subset of items that effectively represent the core dimensions of childhood adversity. Following this, CFA is conducted to test the factor structure identified in EFA, confirming the construct validity and assessing the reliability of the shortened ACE-IQ-27 questionnaire. Through this approach, we present a reliable and contextually appropriate tool to assess the prevalence of ACEs among populations where war and collective violence are not prevalent, thereby enhancing the accuracy and utility of ACE measurement for cross-cultural studies and public health interventions. Following questions are addressed: What is the underlying factor structure of the ACE-IQ-27, a shorter version of ACE-IQ? Is ACE-IQ-27 a valid and reliable instrument to measure ACEs among adolescents in politically stable regions where war and collective violence are less prevalent? Addressing this research question is noteworthy, especially considering the WHO`s recommendation to establish a global ACEs surveillance framework (Ho et al., 2019 ). Such a framework would facilitate cross-country and cross-cultural comparisons, ultimately contributing to the development of universal prevention programs and policies worldwide (Camille et al., 2023 ). Methods Participants This study employed two samples to examine the factor structure and evaluate the psychometric properties of the ACE-IQ-27. Both samples were selected using convenience sampling method. For EFA, 250 grade 9–12 high school students aged 13 to 21 years was involved. For CFA, another 300 grade 9–12 high school students from the same age range were used. The first sample was drawn from the school where the first author is working, while the second sample came from the school where the second author is working. Instrument Data for this study was collected using the ACE-IQ-27, which was administered through a Google Form. The ACE-IQ-27 questionnaire consists of 27 items, each corresponding to 12 distinct categories of ACEs, as outlined in Table 3 and Table 4 . Items about relationships with parents or guardians had a five-point Likert scale measuring frequency of experience ( Never, Rarely, sometimes, Most of the time, and Always ), family environment (except items 6–10 with dichotomous Yes/No response options ), peer violence (except item 23 with Check All That Apply response options). Witnessing community violence used a four-point Likert scale ( Never, Once, a few times, and Many times ). Students` responses were coded as 1 if they experienced a particular ACE (i.e., for Rarely, Sometimes, a few times, Many times, Most of the time, or Always responses) and 0 otherwise (for Never responses). Additionally, for the “Check all that apply” questions, we coded selected options as 1 and not selected options as 0. Survey Administration The link to the Google Form was sent to students via email and messaging platforms (Facebook Messenger, Telegram, WhatsApp, and WeChat), with measures in place to allow only one response per student. The survey was carried out from September 1 to 30, 2023. Ethical Clearance This study strictly adhered to ethical guidelines, as permission to conduct the study was sought from the Director of School Education (DSE) under the Ministry of Education and Skills Development. Additionally, formal communication, in the form of an official letter (No. DSE/SLCD/(2.1)/2023/961), was forwarded by the DSE to the district education office and school principals, apprising them of the study and soliciting their cooperation in facilitating the data collection process for this study. Moreover, student participants were explicitly notified on the first page of the online survey created using Google Form that their participation is entirely voluntary. By responding to the survey, participants were considered to have provided informed consent, acknowledging their voluntary participation in the study. Furthermore, participants were informed that the study's findings would not identify specific informants and that the collected data would be used exclusively for the stated research purpose. No personally identifiable information was recorded. The survey was carried out from September 1 to 30, 2023. Data Analysis Data from a Google spreadsheet was imported, cleaned, and analysed using the statistical software R, version 4.3.2. Statistical analyses were considered significant at the p < .05 level. EFA EFA is typically used in initial item selection and reduction, helping researchers identify the underlying factor structure and determine which items are most representative of the ACE construct. To explore the factor structure of the ACE-IQ-27, an EFA was conducted using the fa () function from the psych package (Revelle, 2023 ). We used a common factor analysis with an iterated principal axis (PA, also known as the principal factor) extraction method (Fabriger et al., 1999) with promax rotation. A promax (oblique) factor rotation was chosen to allow substantial correlations among the factors (Fabriger et al., 1999). Since the data did not meet the normality assumption, as confirmed by Mardia`s (1970) test using the mardia () function from the mvnormalTest package (Zhou & Shao, 2013 ), we used iterated PA estimates, a least squares extraction method for EFA when multivariate normality is violated (Fabriger et al., 1999). Given the binary nature of the variables, EFA was conducted on a Revelle polychoric correlation matrix created using the POLYCHORIC_R () function within the EFA.dimensions package (Gorosuch, 1983; O`Connor, 2023 ). Prior to performing EFA analysis, the factorability of the data was checked with the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy and Bartlett`s test of sphericity (Shrestha, 2021 ). Then, acknowledging the dearth of universally agreed upon methods for factor extraction (Gorosuch, 1983; Watkins, 2021 ), several factor extraction methods were employed using the EFA.dimensions package (O`connor, 2023 ). These included parallel analysis (PA) with both reduced and unreduced correlation matrixes, Parallel Analysis Scree plot test (Horn, 1965 ), Velicer's Minimum Average Partial (MAP) test (Velicer, 1976 ), the Scree test (Cattell, 1966 ), the Sequential Chi-square Model test (SMT), and the Empirical Kaiser Criterion test (EMPKC) (Braeken & van Assen, 2017 ). Gorosuch (1983) stated “factor the data by several different analytic procedures and hold sacred only those factors that appear across all the procedures used” (p. 330). This approach was adopted to avoid both over-factoring and under-factoring (Fabriger et al., 1999). The details of the functions or commands executed in RStudio for factor extraction and the suggested number of factors are depicted in Table 2 . We discarded the EFA model with five to seven factors due to its inability to conform to the criteria outlined by (Gorsuch, 1983 ), which necessitates a minimum of three observed variables (items) for each identified factor. Likewise, we discarded the two-and three-factor model due to certain items exhibiting loadings less than 0.30 and loading on more than one factor, thereby violating the hallmark feature of simple structure. Watkins ( 2021 ) emphasied that, in a simple structure, “several variables will saliently load onto each factor and each variable will saliently load onto only one factor.” The items were assigned to the factors where the highest loadings were found, setting a salience threshold of 0.30 (Tavakol & Wetzel, 2020 ). Therefore, we report a four-factor solution for the ACE-IQ-27 (Table 3 ). CFA CFA is subsequently used to confirm the factor structure identified in EFA, validating model`s fit and reliability. In this study, CFA is crucial for ensuring that the shortened tool maintains construct validity and accurately measures the intended constructs across diverse populations. Subsequently, the EFA suggested four-factor ACE-IQ-27 with items with factor loadings of 0.30 and above was further vetted with CFA on data from another 300 students using the cfa () function in the lavaan package. Since Mardia`s test revealed the absence of multivariate normality in the data, we used Diagonally Weighted Least Square (DWLS) as the model estimator (Roos & Bauldry, 2022 ). To assess the fit of the model, various goodness-of-fit indices, including chi-square test ( χ ²) and χ ²/ df , Root Mean Square Error of Approximation (RMSEA) with 95% confidence interval (CI), Comparative fit Index (CFI), Tucker-Lewis Index (TLI), and Standardized Root Mean Square Residual (SRMR) were used. The CFA model was deemed to be a good fit for the data when the χ ² result was non-significant (Roos & Bauldry, 2022 ) and the χ ²/ df < 2 (Hu & Bentler, 1999 ). The adequacy of the other fit indices was assessed by comparing them to the threshold values recommended in prior studies (Hu & Bentler, 1999 ; Roos & Bauldry, 2022 ); RMSEA ≤ 0.05, CFI ≥ 0.95, and SRMR < 0.08 indicate the model`s good fit to the observed data. Finally, we used the semPlot () function from the semPlot package to visualise the ultimate CFA model of ACE-IQ-27 (Fig. 1 ). Following CFA, various psychometric analyses were conducted, including assessments of convergent and discriminant validity, and internal consistency reliability of the four constructs. Convergent validity was assessed by calculating the Average Variance Extracted (AVE), with a cut-off value of 0.5 or above indicating satisfactory convergent validity (Cheung et al., 2023 ). Discriminant validity was assessed by examining the correlation coefficients among the factors, where a coefficient value of 0.85 or less was considered an acceptable threshold for discriminant validity (Cheung et al., 2023 ). The internal consistency reliability of the four constructs was determined using Cronbach`s alpha. Results Sample Description Table 1 summarises the demographic characteristics of the student participants for EFA and CFA. Table 1 Demographic information EFA Participants ( N = 250) Sex Total Male Female n % n % n % Age groups (Years) 13-15 34 30.4 47 34.1 81 32.4 16-18 60 53.5 77 55.8 137 54.8 19-21 18 16.1 14 10.1 32 12.8 Total 112 100 138 100 250 100 CFA Participants ( N = 300) Age groups (Years) 13-15 13 7.3 26 21.1 39 13.0 16-18 137 77.4 67 54.5 204 68.0 19-21 27 15.3 30 24.4 57 19.0 Total 177 100 123 100 300 100 EFA The Bartlett`s test of sphericity ( χ ² =10339.4, df = 325, p .50) verified the factorability of the data. Table 2 portrays the details of the factor extraction methods, commands executed in RStudio, and suggested number of factors. Table 2 Details of the factor extractions Factor Extraction Method Factors suggested Command Executed* Parallel Analysis With unreduced correlation matrix With reduced correlation matrix Parallel Analysis Scree plot 5 8 6 RAWPAR (data, factormodel = “PCA”, Ndatasets = 1000, percentile = 95) RAWPAR (data, factormodel = “PAF”, Ndatasets = 1000, percentile = 95) fa.parallel(data) MAP test 5 MAP(data) Cattell`s Scree test 7 SCREE_PLOT(data, “polychoric”) SMT test 8 SMT(data) EMPKC test 4 EMPKC(data, corkind = “polychoric”) * Refer to the attached R script for further details. Following the 0.30 salience threshold criteria (Tavakol & Wetzel, 2020 ), 25 items out of 27 revealed a four-factor structure. Items 21 was excluded from the factor analysis because it exhibited zero variance, with all students responding “NO.” Similarly, item 23, being a “Check all that apply” type question, was also excluded from the analysis. Table 3 reports the factor loadings of each item of ACE-IQ-27 that are assigned to the factors where the highest loadings were found. Factors 1, 2, 3, and 4 explained 12%, 11%, 9%, and 7% of the total variance (39%), respectively. Table 3 EFA factor loadings Items Factor Loadings 1 2 3 4 1. Did your parents/guardians understand your problems and worries? 0.73 2. Did your parents/guardians really know what you were doing with your free time when you were not at school or home? 0.54 3. How often did your parents/guardians not give you enough food even when they could easily have done so? 0.87 4. Were your parents/guardians too drunk or intoxicated by drugs to take care of you? 0.71 5. How often did your parents/guardians not give send you to school even when it was available? 0.82 6. Did you live with a household member who was a problem drinker or alcoholic, or misused street or prescription drugs? 0.53 7. Did you live with a household member who was depressed, mentally ill or suicidal? 0.65 8. Did you live with a household member who was ever sent to jail or prison? 0.81 9. Were your parents ever separated or divorced? 0.61 10. Did your mother, father or guardian die? 0.46 11. Did you see or hear a parent or household member in your home being yelled at, screamed at, sworn at, insulted or humiliated? 0.49 12. Did you see or hear a parent or household member in your home being slapped, kicked, punched or beaten up? 0.41 13. Did you see or hear a parent or household member in your home being hit or cut with an object, such as a stick (or cane), bottle, club, knife, whip etc.? 0.45 14. Did a parent, guardian or other household member yell, scream or swear at you, insult or humiliate you? 0.50 15. Did a parent, guardian or other household member threaten to, or actually, abandon you or throw you out of the house? 0.36 16. Did a parent, guardian or other household member spank, slap, kick, punch or beat you up? 0.62 17. Did a parent, guardian or other household member hit or cut you with an object, such as a stick (or cane), bottle, club, knife, whip etc? 0.36 18. Did someone touch or fondle you in a sexual way when you did not want them to? 0.67 19. Did someone make you touch their body in a sexual way when you did not want them to? 0.69 20. Did someone attempt oral, anal, or vaginal intercourse with you when you did not want them to? 0.78 21. Did someone actually have oral, anal, or vaginal intercourse with you when you did not want them to? 22. How often were you bullied? 0.34 23. How were you bullied most often? - - - - 24. How often were you in a physical fight? 0.44 25. Did you see or hear someone being beaten up in real life? 0.43 26. Did you see or hear someone being stabbed or shot in real life? 0.75 27. Did you see or hear someone being threatened with a knife or gun in real life? 0.70 Note : 1 = Violence Exposure, 2 = Parental Neglect, 3 = Family Adversity, and 4 = Sexual Assault. CFA The initial CFA of a four-structure ACE-IQ-27 suggested by EFA yielded an inadequate fit with the data; χ² (269, N = 300) = 558.407, p = .00, χ ²/ df = 2.08, CFI = .861, TLI = .845, RMSEA = .062 (90% CI [0.055, 0.069], p = .010), and SRMR = .095. However, allowing the error terms to be correlated for items 26 and 27, items 25 and 27, and items 25 and 26 under factor 1 and items 4 and 5 under factor 2, following modification indices, improved the model fit: χ² (265, N = 300) = 415.760, p = 0.000, χ ²/ df = 1.57, CFI = 0.947, TLI = 0.940, RMSEA = 0.038 (90% CI [0.029, 0.047], p = 0.907), and SRMR = 0.078. Due to the χ ² statistic`s sensitivity to the sample size and departures from multivariate normality in the data (Roos & Bauldry, 2022 ), more importance was placed on these fit indices. The χ ² statistic tends to reject the null hypothesis in samples larger than 100 (Roos & Bauldry, 2022 ). Except χ² , all the goodness-of-fit indices, including χ ²/ df , passed the threshold recommended in prior papers (Hu & Bentler, 1999 ; Roos & Bauldry, 2022 ). Therefore, we retained a four-factor solution for ACE-IQ-27. All the standardised factor loadings of 25 items depicted in the CFA model (Fig. 1 ) exhibited moderate to strong values (Tavakol & Wetzel, 2020 ; Afifi et al., 2020 ). Figure 1 shows the four-factor CFA model of ACE-IQ-27 with item factor loadings and correlations between the factors. We named Factor 1 as Violence Exposure, Factor 2 as Parental Neglect, Factor 3 as Family Adversity, and Factor 4 as Sexual Assault. Table 4 depicts the four factors with their corresponding ACE types and the associated items, excluding exposure to war and collective violence categories and items. Figure 1 Four-factor CFA model of ACE-IQ-27 In Fig. 1 , a single-headed arrow represents the causal relationship from the latent variables to the observed variables, while a double-headed straight arrow shows covariance between the factors (Tavakol & Wetzel, 2020 ). The small double-headed arrows outside the boxes of the observed variables represent error variances. These indicate portion of variability in the observed data that is not explained by the model. Essentially, they capture factors like measurement errors or any other accounted variability within the 25 items being analysed. Discriminant Validity and Convergent Validity From Fig. 1 , it is evident that the inter-factor correlation values for all factor pairs are below the recommended threshold of 0.85. This result indicates that the factors are sufficiently distinct from one another, thereby providing evidence of discriminant validity. The AVE values for Violence Exposure, Parental Neglect, Family Adversity, and Sexual Assault are 0.24, 0.24, 0.35, and 0.7, respectively. These results suggest that while Sexual Assault demonstrates satisfactory convergent validity with an AVE above the cut-off value, the other constructs fall below the recommended threshold, indicating the need for further refinement of measurement items or the constructs themselves. Table 4 Factors, ACE types, and corresponding items Factors ACE types Items Violence Exposure Household member treated violently 11, 12, 13 Emotional abuse 14, 15 Physical abuse 16, 17 Bullying 22, 23 Community violence 24, 25, 26, 27 Parental Neglect Emotional neglect 1, 2 Physical neglect 3, 4, 5 Family Adversity Alcohol/drug abuser in household 6 Someone chronically depressed, mentally ill, institutionalized or suicidal household member 7 Incarcerated household member 8 One or no parents, parental separation or divorce 9, 10 Sexual Assault Sexual abuse 18, 19, 20, 21 Note : Items 21 and 23 are not included in the factor analyses Internal Consistency Reliability The instrument was reliable, as evidenced by the overall Cronbach`s alpha coefficient of 0.81 (95% CI = 0.77–0.84). The Cronbach`s alpha coefficient was 0.80 (95% CI = 0.77–0.84) for factor 1, 0.64 (95% CI = 0.57– 0.70) for factor 2, and 0.72 (95% CI = 0.67–0.77) for factor 3, 0.85 (95% CI = 0.81–0.87) for factor 4 of ACE-IQ-27. These values indicate acceptable to good internal consistency reliability (George & Mallery, 2019 ). Discussion This study is the first of its kind in Bhutan to examine the underlying factor structure of a shortened version of the ACE-IQ, referred to as ACE-IQ-27, focusing on school-going Bhutanese children aged 13 to 21 years, identified as a priority group for research and intervention on ACEs (Kidman et al., 2019 ). The original ACE-IQ, developed by WHO, consists of 31 items designed to assess 13 categories of ACEs that includes constructs such as war and collective violence, which may not be universally applicable. The ACE-IQ-27 is a shorter version with 27 items (see Table 3 ) related to 12 ACE categories (see Table 4 ). This version involved dropping four items from war and collective violence domain, as such adversities are not common in Bhutan`s peaceful and politically stable context and may not meaningfully contribute to the measurement of childhood adversity. However, factor analyses were performed with 25 items as depicted in Table 3 and Fig. 1 . Since there wasn`t much variation in the responses for item 21, this was left out of the factor analysis. Furthermore, item 23, being a “Check all that apply” type question, was also excluded from the analysis. The EFA revealed a four-factor structure as the most appropriate and accurate representation of the ACE-IQ-27. This structure was supported by strong item loadings on their respective constructs, indicating the instrument`s structural validity. This EFA findings was further confirmed by the CFA, which produced acceptable model fit indices: χ² (265, N = 300) = 415.760, p = 0.000, χ ²/ df = 1.57, CFI = 0.947, TLI = 0.940, RMSEA = 0.038 (90% CI [0.029, 0.047], p = 0.907), and SRMR = 0.078). The four factors are Violence Exposure, Parental Neglect, Family Adversity, and Sexual Assault as depicted in Table 4 . Collectively, the four factors explained approximately 39% of the total variance. After CFA, various psychometric analyses were conducted, including assessments of convergent and discriminant validity, and internal consistency reliability of the four constructs. The reliability of the four constructs was determined using Cronbach`s alpha. The overall internal consistency of ACE-IQ-27 was good, with a Cronbach`s alpha coefficient of 0.81. At the factor level, reliability ranged from acceptable to good. For instance, Violence Exposure and Sexual Assault exhibited good reliability, reflecting the cohesiveness of the items within these factors. However, Parental Neglect had slightly lower reliability coefficient, suggesting that these factors might benefit from further refinement or the inclusion of the additional items to enhance their internal consistency. The inter-factor correlation values for all factor pairs are below the recommended threshold of 0.85, confirming that the factors are sufficiently distinct from one another and thus providing strong evidence of discriminant validity. While the factor Sexual Assault demonstrates satisfactory convergent validity with an AVE exceeding the recommended cut-off, the other factors fall short of this threshold, suggesting a need for further refinement of measurement items or the factors themselves. Overall, based on the results of both the EFA and CFA, the ACE-IQ-27, as adapted for school-going Bhutanese children aged 13–21 years, excluding items addressing rare adversities such as exposure to war and collective violence is psychometrically reliable and valid instrument for measuring ACEs and their association with risk behaviours in later life. While the findings of this study align with prior studies (e.g., Gette et al., 2022; Kidman et al., 2019 ; Kostić et al., 2019 ) in identifying distinct factors of adversity, the specific factor structure identified here differs from those reported in these studies. This discrepancy in factor structure reinforces the idea that the ACE-IQ`s factor structure is not universal, but rather context-dependent. The way items group into meaningful categories depends on the lived realities of population in different regions. For example, in regions with ongoing or recent history of war, violence, and political instability, adversities related to war or collective violence are often more pronounced. In contrast, in regions characterized by high political stability – where war and collective violence are absent or rare – the adversities children face tend to stem from different sources. In these settings, the factor structure may shift to emphasize familial and interpersonal adversities, as was observed in this study. Our modified ACE-IQ-27 is suited for assessing childhood adversities in schools, clinics, or communities in regions with a low prevalence of trauma related to war and collective violence. Implications Bhutan is currently undergoing rapid industrialization, economic growth, and urbanization, processes that have reshaped many aspects of daily life, particularly for families and children. Traditional support systems within communities and families are being eroded due to factors such as separation, divorce, economic stress, and interpersonal violence. Additionally, harmful practices such as corporal punishment remain prevalent as a means of disciplining children (NCWC & UNICEF, 2016). The COVID-19 pandemic has further intensified these stressors, with disruptions to family dynamics, education, and community structures. As a result of these shifts, it is highly plausible that many Bhutanese students are living with multiple ACEs. Researchers and educators can administer ACE-IQ-27 questionnaire among school-going Bhutanese children aged 13 to 21 years. The outcomes derived from this assessment can provide valuable insights for policymakers to design evidence-based policies and targeted intervention programs tailored to Bhutanese children, with the aim of preventing and mitigating the long-term effects of childhood adversity on mental health, education, and overall well-being. Limitation and Future Research This study relied on a self-report questionnaire. As a result, the study`s ability to establish causation for the identified relationships is limited. We don’t have any observations or confirmation of the self-reported results (Kidman et al., 2019 ). Additionally, our result may be subject to social desirability bias, such as in self-reports of sensitive issues like sexual abuse (Fisher, 1993 ). Also, the response obtained is vulnerable to various issues such as social desirability bias, response bias (both acquiescent and non-acquiescent bias), the inherent subjectivity of participants when responding to open-ended questions, potential recall bias, and the limited flexibility associated with fixed-choice questions (Demetriou et al., 2015 ). Consequently, further research with a larger sample size, incorporating observations and interviews, is necessary to ascertain whether the findings it yields align with the present study`s findings. Moreover, although the scale demonstrates sufficient psychometric properties, it has yet to be validated using other standard methods. Future research should consider assessing other forms of validation, such as concurrent validity, predictive validity, and test-retest reliability. Declarations I affirm that the information provided below is accurate and complete to the best of my knowledge. Funding Statement No funding was received for this study. Conflict of Interest The authors declare that there is no conflict of interests regarding the publication of this paper. Ethical Approval This study was approved by the Director of School Education (DSE) under the Ministry of Education and Skills Development. An official letter (No.: DSE/SLCD/(2.1)/2023/961) was forwarded by the DSE to the district education office and school principals, apprising them of the study and soliciting their cooperation in facilitating the data collection process for this study. Informed Consent Student participants were explicitly notified on the first page of the online survey created using Google Form that their participation is entirely voluntary. By responding to the survey, participants were considered to have provided informed consent, acknowledging their voluntary participation in the study. Furthermore, participants were informed that the study's findings would not identify specific informants and that the collected data would be used exclusively for the stated research purpose. Consent to publish By submitting this manuscript, we give our consent for its publication in Journal of Child & Adolescent Trauma . Author`s Contribution First author played a key role in conceptualisation, data collection, analyses, interpretation, and writing the entire manuscript. Second author contributed to data collection, discussion of the results, and manuscript revision. Both authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on request. References Afifi, T. O., Salmon, S., Garcés, I., Struck, S., Fortier, J., Taillieu, T., Stewart-Tufescu, A., Asmundson, G. J. G., Sareen, J., & MacMillan, H. L. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6840865","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":495416824,"identity":"73086ce2-edfc-4786-b5b6-d47d563f7579","order_by":0,"name":"Tshering Dorji","email":"data:image/png;base64,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","orcid":"","institution":"Shari Higher Secondary School","correspondingAuthor":true,"prefix":"","firstName":"Tshering","middleName":"","lastName":"Dorji","suffix":""},{"id":495416825,"identity":"12a03936-0c6d-4568-8f72-073c23b6e2b2","order_by":1,"name":"Pelden Nima","email":"","orcid":"","institution":"Wangbama Central School","correspondingAuthor":false,"prefix":"","firstName":"Pelden","middleName":"","lastName":"Nima","suffix":""}],"badges":[],"createdAt":"2025-06-07 06:23:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6840865/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6840865/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88412160,"identity":"c837dd36-cc94-44eb-95cb-5cae912b4abc","added_by":"auto","created_at":"2025-08-06 08:32:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":637985,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eFour-factor CFA model of ACE-IQ-27\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6840865/v1/f1d4c9b04c8236c83cfb8631.png"},{"id":88413299,"identity":"320acd1f-fd7b-4ac7-b1e4-8208c5e653e7","added_by":"auto","created_at":"2025-08-06 08:40:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1383766,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6840865/v1/41f48a2b-4590-42a4-ba9b-ce8ae536ac03.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Factor Structure and Psychometric Properties of ACE-IQ-27: A Shorter Version of Adverse Childhood Experiences International Questionnaire (ACE-IQ) in Bhutan","fulltext":[{"header":"Introduction","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003eACEs and its Prevalence\u003c/h2\u003e\u003cp\u003eAdverse Childhood Experiences (ACEs) are potentially traumatic events that occur during childhood and have been consistently linked to poor school engagement (Bethell et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) academic performance (Qu et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) and a range of negative health, developmental, and social outcomes throughout the lifespan (Webster, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). These experiences include various forms of abuse (emotional, physical, or sexual), bullying, neglect (physical and emotional), witnessing domestic and community violence, household dysfunction (including family conflict, parental divorce, family members` incarceration, mental illness, alcohol and substance abuse), and peer violence, and have been shown to disrupt early brain development, compromise immune and nervous system functioning, and increase the risk of chronic diseases, mental health disorders, and risky behaviours in adulthood (Cook et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; Felitti et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e1998\u003c/span\u003e; Shonkoff et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). A seminal study by Felitti et al. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e1998\u003c/span\u003e) identified a strong dose-response relationship between the number of ACEs and the likelihood of adverse health outcomes, with individuals exposed to four or more ACEs facing substantially higher risks for conditions such as depression, alcoholism, drug use, and suicide attempts (Webster, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA recent exhaustive review of extant literature on the neurobiological sequelae resulting from ACEs by Harden et al. (2022) has found that prolonged exposure to traumatic events during early childhood disrupt the brain`s normal development. This can particularly occur in areas associated with complex cognitive functioning such as emotion regulation, memory, decision-making, and social skills. The abnormal production of cortisol and oxytocin in the brain resulting from chronic stress is thought to be a primary contributory factor to these phenomena. Similarly, another comprehensive review of two decades of research on ACEs by Zarse et al. (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) found numerous associations between ACEs and various health related issues (Zarse et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). These include physical disability, chronic diseases (pulmonary and cardiovascular diseases, diabetes, cancers, obesity, autoimmune and gastro-intestinal diseases), mental illnesses (depression, anxiety disorders, post-traumatic stress disorder, psychosis, substance use disorders such as alcohol and drug misuse, and tobacco use), suicide-related behaviours, maladaptive behaviors (aggression, violence perpetration, victimization), risk-taking sexual behaviors (unintended pregnancy, paternity in teen pregnancy, sexually transmitted diseases), poor coping mechanisms such as avoidance and emotional outbursts, insomnia, low quality of life in adulthood (homelessness and unemployment), and premature mortality brough on by foregoing deleterious conditions (Zarse et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Therefore, understanding and measuring ACEs is critical for identifying at-risk populations and developing preventive strategies to mitigate these long-term effects.\u003c/p\u003e\u003cp\u003eRecognizing the growing need to measure ACEs in all countries and the association between them and risk behaviours in later life (Gette et al., 2022; Kidman et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), as well as facilitate cross-cultural comparison, the WHO developed the Adverse Childhood Experiences International Questionnaire (ACE-IQ) (see WHO, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). This tool was adapted from the seminal ACE study conducted by Felitti et al. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e1998\u003c/span\u003e) with the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente`s Adverse Childhood Experiences in the United States (Kidman et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). The original ACE questionnaire assesses the occurrence of 10 categories of ACEs, including emotional abuse, physical abuse, sexual abuse, household member with substance uses problems, household member with mental illness, mother treated violently, household criminal behaviour, parental separation or divorce, physical neglect, and emotional neglect (Afifi et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). However, to enhance the global applicability of the ACE framework and address a wider range of childhood adversities beyond those typically recognized in United States-based ACE studies, the WHO adapted it into the ACE-IQ (Pace et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The ACE-IQ expands upon the original ACE categories, incorporating additional experiences such as war-related trauma, community violence, bullying, and exposure to collective violence, which are more prevalent in regions affected by conflict and instability (Gette et al., 2022). The ACE-IQ consists of 31 items to assess 13 categories of ACEs in individuals aged 18 years and older. These categories include physical abuse; emotional abuse; sexual abuse; violence against household members; living with household members who were substance abusers; living with household members who were mentally ill or suicidal, incarcerated household members; one or no parents, parental separation or divorce; emotional neglect; physical neglect; bullying; community violence; and exposure to war and collective violence (Gette et al., 2022; Kidman et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). With both binary and frequency scoring options, the ACE-IQ provides a flexible framework for studying childhood adversity across different populations. Its applicability has been demonstrated in several countries, including Germany, Netherlands, China, Lebanon, Kenya, Brazil, Saudi Arabia, Iraq, South Africa, Nigeria, Korea, Tunisia, Vietnam, Philipines, the former Yugoslav Republic of Macedonia, and Serbia (Gettee et al., 2022; Kidman et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Kostić et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eRecent studies have examined the factor structure of the ACE-IQ to understand how its items cluster into meaningful and cohesive categories, by implementing it in diverse populations and settings. To analyze the data, they have used both reflective modelling approaches, such as CFA and EFA, as well as formative modelling techniques, like Principal Component Analysis (PCA) (Gette et al., 2022). For instance, Kidman et al. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) conducted a PCA on a data collected form Malawian adolescents aged 10\u0026ndash;16 years and identified a three-factor structure. The three components included: (1) Household dysfunction, with nine items related to household member drug use and incarceration, parental divorce or death, mental health, and collective or community violence; (2) Abuse, which comprised 11 items related to physical and emotional abuse and domestic violence; (3) Neglect, with seven items related to physical and emotional neglect, and bullying. Their study excluded sexual abuse, familial mental illness, and community violence in the final model due to the low (6% and 7%) and high (99%) endorsement of the sample.\u003c/p\u003e\u003cp\u003eFurthermore, Kidman and colleagues expanded the original ACE-IQ by adding HIV-specific questions to address adversities related to the HIV/AID epidemic. They also included the timing of adverse experiences to better understand how the developmental stage of experiencing trauma influences adolescent health outcomes. Similarly, a study in Serbia with Serbian adults aged 18\u0026ndash;65 years found three factors for ACE-IQ (Kostić et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). The three factors included: (1) Violence, with items related to factors such as physical fight involvement, bullying, community violence, physical abuse, and collective violence; (2) Neglect, with items related to factors such as depression and suicide in the family, psychological neglect, sexual abuse, and parental separation; (3) Abuse, with items related to factors such as family alcoholism, parental partner abuse, family member incarceration, household member drug abuse, and physical neglect. Likewise, a study by Gette et al. (2022) among U.S. college students (mean age\u0026thinsp;=\u0026thinsp;19.10 years, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.56) identified a six-component solution through PCA for the 30-item ACE-IQ, excluding item 23 on bullying, which had a \u0026ldquo;Check all that apply\u0026rdquo; response option. The six components included: (1) Emotional and Physical Abuse, which comprised seven items related to being the victim or witness of physical and/or emotional abuse; (2) Sexual Abuse, which included four items specific to experiencing sexual abuse; (3) Community and Collective violence, with seven items related to peer violence, exposure to community violence, and other adverse experiences related to community violence; (4) Impaired or Absent Parenting, with five items about dysfunctional caregiving, such as substance abuse or incarceration; (5) Resource Disruption, which captured experiences like displacement or physical neglect; and (6) Emotional Neglect, which included two items related to parental understanding and awareness. In their analysis, items 10 (parental death), 22 and 23 (Bullying) were excluded. Additionally, items 29 (destruction of home) and 30 (victim of collective violence) appeared in both the Community and Collective Violence and Resource Disruption components. For further details, refer Gette et al. (2022).\u003c/p\u003e\u003cp\u003eAdditionally, Santelices et al. (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) evaluated the structural validity, concurrent validity with the Marshall Trauma Scale (MTS), and internal consistency reliability of the ACE-IQ in a Chilean cohort. Structural validity analyses showed best fit for three-factor (household dysfunction, childhood abuse, and external violence) and four-factor models (household dysfunction, childhood abuse, external violence, and childhood negligence) for both the binary and frequency scoring. The overall internal consistency of the scale was adequate (α\u0026thinsp;\u0026gt;\u0026thinsp;0.7), with the exception of factors such as childhood neglect and violence outside the home with lower internal consistency. Christoforou and Ferreira (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) also investigated the psychometric properties of the ACE-IQ with two hundred eighty-four adult individuals engaging in non-suicidal self-injury. The findings of this study supported ACE-IQ\u0026rsquo;s reliability (Cronbach\u0026rsquo;s alpha\u0026thinsp;=\u0026thinsp;0.854), convergent validity (r\u0026thinsp;=\u0026thinsp;0.85, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001 with the Childhood Trauma Questionnaire \u0026ndash; Short Form (CTQ-SF)), predictive validity (\u003cem\u003eR\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.12, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001 of the Self-harm Inventory (SHI) total score) and discriminant validity (\u003cem\u003eF\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;13.90, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). An exploration of the factor structure demonstrated a 5-factor solution (physical abuse, sexual abuse, emotional abuse, exposure to violence, family environment).\u003c/p\u003e\u003cp\u003eSeveral other studies have also examined the factor structure and evaluated the psychometric properties of the ACE questionnaire (Afifi et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Brown et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Choi et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Ford et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Ho et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; van der Feltz-Cornelis \u0026amp; de Beurs, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). However, these investigations have focused on either shorter or longer version of the 11-item Behavioural Risk Factor Surveillance System ACE questionnaire or adaptions of the original CDC-Kaiser Permanente ACE study questionnaire developed by Felitti et al. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e1998\u003c/span\u003e). These adapted versions often differ in content and structure from the ACE-IQ, which forms the basis of our present study.\u003c/p\u003e\u003cp\u003eThe findings from the foregoing studies reveal that the factor structure of the ACE-IQ is not fixed; it often varies depending on the socio-cultural, economic, and political environment of the population being studied. This variability emphasizes the necessity of tailoring the ACE-IQ to align with the unique characteristics and needs of specific populations to ensure its effectiveness and relevance. ACEs, as originally conceived, were based on Western conceptualizations of trauma, and as such, may not fully capture the breath of adverse experiences in non-Western societies. In Bhutan, for example, the rarity of war and collective violence due to the country\u0026rsquo;s stable sociopolitical environment and absence of recent armed conflict renders certain ACE-IQ items contextually irrelevant. Including such items may introduce measurement error, reduce the reliability of the instrument, and potentially distort the factor structure of the questionnaire. This highlights the need to adapt the ACE-IQ to better align with the unique socio-cultural realities of Bhutanese youth. Refining the ACE-IQ questionnaire not only enhances its accuracy but also allows for a deeper understanding of how childhood adversities manifest in a unique cultural setting like Bhutan. Therefore, the present study aimed to refine and validate the factor structure of ACE-IQ, originally developed for individuals aged 18 years and older (WHO, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), to make it more suitable for Bhutanese school-going children aged 13 to 21 years.\u003c/p\u003e\u003cp\u003eSpecifically, the current study develops a shortened version of the ACE-IQ, referred to as ACE-IQ-27. This version excluded items related to war and collective violence, which are less applicable in Bhutan due to the country`s peaceful environment. The revised questionnaire includes 27 items (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) covering 12 categories of ACEs (see Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), ensuring that it remains comprehensive while contextually relevant. Then, it examines the factor structure and psychometric properties of the ACE-IQ-27 questionnaire by employing Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA). Specifically, EFA is conducted to explore the underlying factor structure and determine which items are most central to the ACE construct, thereby identifying a subset of items that effectively represent the core dimensions of childhood adversity. Following this, CFA is conducted to test the factor structure identified in EFA, confirming the construct validity and assessing the reliability of the shortened ACE-IQ-27 questionnaire. Through this approach, we present a reliable and contextually appropriate tool to assess the prevalence of ACEs among populations where war and collective violence are not prevalent, thereby enhancing the accuracy and utility of ACE measurement for cross-cultural studies and public health interventions. Following questions are addressed:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWhat is the underlying factor structure of the ACE-IQ-27, a shorter version of ACE-IQ?\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eIs ACE-IQ-27 a valid and reliable instrument to measure ACEs among adolescents in politically stable regions where war and collective violence are less prevalent?\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eAddressing this research question is noteworthy, especially considering the WHO`s recommendation to establish a global ACEs surveillance framework (Ho et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Such a framework would facilitate cross-country and cross-cultural comparisons, ultimately contributing to the development of universal prevention programs and policies worldwide (Camille et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003cdiv id=\"Sec4\" class=\"Section3\"\u003e\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eThis study employed two samples to examine the factor structure and evaluate the psychometric properties of the ACE-IQ-27. Both samples were selected using convenience sampling method. For EFA, 250 grade 9\u0026ndash;12 high school students aged 13 to 21 years was involved. For CFA, another 300 grade 9\u0026ndash;12 high school students from the same age range were used. The first sample was drawn from the school where the first author is working, while the second sample came from the school where the second author is working.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\n\u003ch3\u003eInstrument\u003c/h3\u003e\n\u003cp\u003eData for this study was collected using the ACE-IQ-27, which was administered through a Google Form. The ACE-IQ-27 questionnaire consists of 27 items, each corresponding to 12 distinct categories of ACEs, as outlined in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Items about relationships with parents or guardians had a five-point Likert scale measuring frequency of experience (\u003cem\u003eNever, Rarely, sometimes, Most of the time, and Always\u003c/em\u003e), family environment (except items 6\u0026ndash;10 with dichotomous \u003cem\u003eYes/No response options\u003c/em\u003e), peer violence (except item 23 with \u003cem\u003eCheck All That Apply\u003c/em\u003e response options). Witnessing community violence used a four-point Likert scale (\u003cem\u003eNever, Once, a few times, and Many times\u003c/em\u003e). Students` responses were coded as 1 if they experienced a particular ACE (i.e., for \u003cem\u003eRarely, Sometimes, a few times, Many times, Most of the time, or Always\u003c/em\u003e responses) and 0 otherwise (for \u003cem\u003eNever\u003c/em\u003e responses). Additionally, for the \u0026ldquo;Check all that apply\u0026rdquo; questions, we coded selected options as 1 and not selected options as 0.\u003c/p\u003e\n\u003ch3\u003eSurvey Administration\u003c/h3\u003e\n\u003cp\u003eThe link to the Google Form was sent to students via email and messaging platforms (Facebook Messenger, Telegram, WhatsApp, and WeChat), with measures in place to allow only one response per student. The survey was carried out from September 1 to 30, 2023.\u003c/p\u003e\n\u003ch3\u003eEthical Clearance\u003c/h3\u003e\n\u003cp\u003e This study strictly adhered to ethical guidelines, as permission to conduct the study was sought from the Director of School Education (DSE) under the Ministry of Education and Skills Development. Additionally, formal communication, in the form of an official letter (No. DSE/SLCD/(2.1)/2023/961), was forwarded by the DSE to the district education office and school principals, apprising them of the study and soliciting their cooperation in facilitating the data collection process for this study. Moreover, student participants were explicitly notified on the first page of the online survey created using Google Form that their participation is entirely voluntary. By responding to the survey, participants were considered to have provided informed consent, acknowledging their voluntary participation in the study. Furthermore, participants were informed that the study's findings would not identify specific informants and that the collected data would be used exclusively for the stated research purpose. No personally identifiable information was recorded. The survey was carried out from September 1 to 30, 2023.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eData from a Google spreadsheet was imported, cleaned, and analysed using the statistical software R, version 4.3.2. Statistical analyses were considered significant at the \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05 level.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEFA\u003c/h3\u003e\n\u003cp\u003eEFA is typically used in initial item selection and reduction, helping researchers identify the underlying factor structure and determine which items are most representative of the ACE construct. To explore the factor structure of the ACE-IQ-27, an EFA was conducted using the fa () function from the \u003cem\u003epsych\u003c/em\u003e package (Revelle, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). We used a common factor analysis with an iterated principal axis (PA, also known as the principal factor) extraction method (Fabriger et al., 1999) with promax rotation. A promax (oblique) factor rotation was chosen to allow substantial correlations among the factors (Fabriger et al., 1999). Since the data did not meet the normality assumption, as confirmed by Mardia`s (1970) test using the mardia () function from the \u003cem\u003emvnormalTest\u003c/em\u003e package (Zhou \u0026amp; Shao, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2013\u003c/span\u003e), we used iterated PA estimates, a least squares extraction method for EFA when multivariate normality is violated (Fabriger et al., 1999). Given the binary nature of the variables, EFA was conducted on a Revelle polychoric correlation matrix created using the POLYCHORIC_R () function within the \u003cem\u003eEFA.dimensions\u003c/em\u003e package (Gorosuch, 1983; O`Connor, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Prior to performing EFA analysis, the factorability of the data was checked with the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy and Bartlett`s test of sphericity (Shrestha, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Then, acknowledging the dearth of universally agreed upon methods for factor extraction (Gorosuch, 1983; Watkins, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), several factor extraction methods were employed using the \u003cem\u003eEFA.dimensions\u003c/em\u003e package (O`connor, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). These included parallel analysis (PA) with both reduced and unreduced correlation matrixes, Parallel Analysis Scree plot test (Horn, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1965\u003c/span\u003e), Velicer's Minimum Average Partial (MAP) test (Velicer, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e1976\u003c/span\u003e), the Scree test (Cattell, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e1966\u003c/span\u003e), the Sequential Chi-square Model test (SMT), and the Empirical Kaiser Criterion test (EMPKC) (Braeken \u0026amp; van Assen, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Gorosuch (1983) stated \u0026ldquo;factor the data by several different analytic procedures and hold sacred only those factors that appear across all the procedures used\u0026rdquo; (p. 330). This approach was adopted to avoid both over-factoring and under-factoring (Fabriger et al., 1999). The details of the functions or commands executed in RStudio for factor extraction and the suggested number of factors are depicted in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. We discarded the EFA model with five to seven factors due to its inability to conform to the criteria outlined by (Gorsuch, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e1983\u003c/span\u003e), which necessitates a minimum of three observed variables (items) for each identified factor. Likewise, we discarded the two-and three-factor model due to certain items exhibiting loadings less than 0.30 and loading on more than one factor, thereby violating the hallmark feature of simple structure. Watkins (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) emphasied that, in a simple structure, \u0026ldquo;several variables will saliently load onto each factor and each variable will saliently load onto only one factor.\u0026rdquo; The items were assigned to the factors where the highest loadings were found, setting a salience threshold of 0.30 (Tavakol \u0026amp; Wetzel, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Therefore, we report a four-factor solution for the ACE-IQ-27 (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eCFA\u003c/h3\u003e\n\u003cp\u003eCFA is subsequently used to confirm the factor structure identified in EFA, validating model`s fit and reliability. In this study, CFA is crucial for ensuring that the shortened tool maintains construct validity and accurately measures the intended constructs across diverse populations. Subsequently, the EFA suggested four-factor ACE-IQ-27 with items with factor loadings of 0.30 and above was further vetted with CFA on data from another 300 students using the cfa () function in the lavaan package. Since Mardia`s test revealed the absence of multivariate normality in the data, we used Diagonally Weighted Least Square (DWLS) as the model estimator (Roos \u0026amp; Bauldry, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). To assess the fit of the model, various goodness-of-fit indices, including chi-square test (\u003cem\u003eχ\u003c/em\u003e\u0026sup2;) and \u003cem\u003eχ\u003c/em\u003e\u0026sup2;/\u003cem\u003edf\u003c/em\u003e, Root Mean Square Error of Approximation (RMSEA) with 95% confidence interval (CI), Comparative fit Index (CFI), Tucker-Lewis Index (TLI), and Standardized Root Mean Square Residual (SRMR) were used. The CFA model was deemed to be a good fit for the data when the \u003cem\u003eχ\u003c/em\u003e\u0026sup2; result was non-significant (Roos \u0026amp; Bauldry, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and the \u003cem\u003eχ\u003c/em\u003e\u0026sup2;/\u003cem\u003edf\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;2 (Hu \u0026amp; Bentler, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e1999\u003c/span\u003e). The adequacy of the other fit indices was assessed by comparing them to the threshold values recommended in prior studies (Hu \u0026amp; Bentler, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e1999\u003c/span\u003e; Roos \u0026amp; Bauldry, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2022\u003c/span\u003e); RMSEA\u0026thinsp;\u0026le;\u0026thinsp;0.05, CFI\u0026thinsp;\u0026ge;\u0026thinsp;0.95, and SRMR\u0026thinsp;\u0026lt;\u0026thinsp;0.08 indicate the model`s good fit to the observed data. Finally, we used the semPlot () function from the \u003cem\u003esemPlot\u003c/em\u003e package to visualise the ultimate CFA model of ACE-IQ-27 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Following CFA, various psychometric analyses were conducted, including assessments of convergent and discriminant validity, and internal consistency reliability of the four constructs. Convergent validity was assessed by calculating the Average Variance Extracted (AVE), with a cut-off value of 0.5 or above indicating satisfactory convergent validity (Cheung et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Discriminant validity was assessed by examining the correlation coefficients among the factors, where a coefficient value of 0.85 or less was considered an acceptable threshold for discriminant validity (Cheung et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The internal consistency reliability of the four constructs was determined using Cronbach`s alpha.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eSample Description\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarises the demographic characteristics of the student participants for EFA and CFA.\u003c/p\u003e\u003cp\u003eTable 1 \u003cem\u003eDemographic information\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"605\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" rowspan=\"3\" valign=\"top\" style=\"width: 21.1363%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eEFA Participants (\u003cem\u003eN\u0026nbsp;\u003c/em\u003e= 250)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 13.5772%;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 7.6326%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 6.3849%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 7.2656%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2.7888%;\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.5961%;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.6695%;\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.5961%;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.5961%;\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.0365%;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 9.7609%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAge groups (Years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 11.3755%;\"\u003e\n \u003cp\u003e13-15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.7888%;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.5961%;\"\u003e\n \u003cp\u003e30.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.6695%;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.5961%;\"\u003e\n \u003cp\u003e34.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.5961%;\"\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.0365%;\"\u003e\n \u003cp\u003e32.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 11.3755%;\"\u003e\n \u003cp\u003e16-18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.7888%;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.5961%;\"\u003e\n \u003cp\u003e53.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.6695%;\"\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.5961%;\"\u003e\n \u003cp\u003e55.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.5961%;\"\u003e\n \u003cp\u003e137\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.0365%;\"\u003e\n \u003cp\u003e54.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 11.3755%;\"\u003e\n \u003cp\u003e19-21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.7888%;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.5961%;\"\u003e\n \u003cp\u003e16.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.6695%;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.5961%;\"\u003e\n \u003cp\u003e10.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.5961%;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.0365%;\"\u003e\n \u003cp\u003e12.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 21.1363%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Total\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.7888%;\"\u003e\n \u003cp\u003e112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.5961%;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.6695%;\"\u003e\n \u003cp\u003e138\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.5961%;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.5961%;\"\u003e\n \u003cp\u003e250\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.0365%;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" valign=\"top\" style=\"width: 42.7864%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCFA Participants (\u003cem\u003eN\u0026nbsp;\u003c/em\u003e= 300)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"3\" valign=\"top\" style=\"width: 10.2012%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAge groups (Years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.3755%;\"\u003e\n \u003cp\u003e13-15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.7888%;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.5961%;\"\u003e\n \u003cp\u003e7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.6695%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.5961%;\"\u003e\n \u003cp\u003e21.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.5961%;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.0365%;\"\u003e\n \u003cp\u003e13.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.3755%;\"\u003e\n \u003cp\u003e16-18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.7888%;\"\u003e\n \u003cp\u003e137\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.5961%;\"\u003e\n \u003cp\u003e77.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.6695%;\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.5961%;\"\u003e\n \u003cp\u003e54.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.5961%;\"\u003e\n \u003cp\u003e204\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.0365%;\"\u003e\n \u003cp\u003e68.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.3755%;\"\u003e\n \u003cp\u003e19-21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.7888%;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.5961%;\"\u003e\n \u003cp\u003e15.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.6695%;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.5961%;\"\u003e\n \u003cp\u003e24.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.5961%;\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.0365%;\"\u003e\n \u003cp\u003e19.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 21.5767%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Total\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.7888%;\"\u003e\n \u003cp\u003e177\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.5961%;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.6695%;\"\u003e\n \u003cp\u003e123\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.5961%;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.5961%;\"\u003e\n \u003cp\u003e300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.0365%;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u003c/br\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eEFA\u003c/h2\u003e\u003cp\u003eThe Bartlett`s test of sphericity (\u003cem\u003eχ\u003c/em\u003e\u0026sup2; =10339.4, \u003cem\u003edf\u003c/em\u003e\u0026thinsp;=\u0026thinsp;325, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) and the result of the Kaiser-Meyer-Olkin (KMO) measure (KMO\u0026thinsp;=\u0026thinsp;.76; all items KMOs\u0026thinsp;\u0026gt;\u0026thinsp;.50) verified the factorability of the data. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e portrays the details of the factor extraction methods, commands executed in RStudio, and suggested number of factors.\u003c/p\u003e\u003cp\u003eTable 2 \u003cem\u003eDetails of the factor extractions\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"604\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eFactor Extraction Method\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eFactors suggested\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eCommand Executed*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eParallel Analysis\u0026nbsp;\u003c/p\u003e\n \u003col\u003e\n \u003cli\u003eWith unreduced correlation matrix\u003c/li\u003e\n \u003c/ol\u003e\n \u003col start=\"2\"\u003e\n \u003cli\u003eWith reduced correlation matrix\u003c/li\u003e\n \u003c/ol\u003e\n \u003col start=\"3\"\u003e\n \u003cli\u003eParallel Analysis Scree plot\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eRAWPAR (data, factormodel = \u0026ldquo;PCA\u0026rdquo;, Ndatasets = 1000, percentile = 95)\u003c/p\u003e\n \u003cp\u003eRAWPAR (data, factormodel = \u0026ldquo;PAF\u0026rdquo;, Ndatasets = 1000, percentile = 95)\u003c/p\u003e\n \u003cp\u003efa.parallel(data)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eMAP test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eMAP(data)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eCattell`s Scree test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eSCREE_PLOT(data, \u0026ldquo;polychoric\u0026rdquo;)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eSMT test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eSMT(data)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eEMPKC test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eEMPKC(data, corkind = \u0026ldquo;polychoric\u0026rdquo;)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e* Refer to the attached R script for further details.\u0026nbsp;\u003c/p\u003e\u003cp\u003eFollowing the 0.30 salience threshold criteria (Tavakol \u0026amp; Wetzel, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), 25 items out of 27 revealed a four-factor structure. Items 21 was excluded from the factor analysis because it exhibited zero variance, with all students responding \u0026ldquo;NO.\u0026rdquo; Similarly, item 23, being a \u0026ldquo;Check all that apply\u0026rdquo; type question, was also excluded from the analysis. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e reports the factor loadings of each item of ACE-IQ-27 that are assigned to the factors where the highest loadings were found. Factors 1, 2, 3, and 4 explained 12%, 11%, 9%, and 7% of the total variance (39%), respectively.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eEFA factor loadings\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\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eItems\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u003cp\u003eFactor Loadings\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\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\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1. Did your parents/guardians understand your problems and worries?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.73\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2. Did your parents/guardians really know what you were doing with your free time when you were not at school or home?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.54\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3. How often did your parents/guardians not give you enough food even when they could easily have done so?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.87\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4. Were your parents/guardians too drunk or intoxicated by drugs to take care of you?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.71\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5. How often did your parents/guardians not give send you to school even when it was available?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.82\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6. Did you live with a household member who was a problem drinker or alcoholic, or misused street or prescription drugs?\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\u003cp\u003e0.53\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\u003e7. Did you live with a household member who was depressed, mentally ill or suicidal?\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\u003cp\u003e0.65\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\u003e8. Did you live with a household member who was ever sent to jail or 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\u003cp\u003e0.81\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\u003e9. Were your parents ever 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\u003cp\u003e0.61\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\u003e10. Did your mother, father or guardian die?\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\u003cp\u003e0.46\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\u003e11. Did you see or hear a parent or household member in your home being yelled at, screamed at, sworn at, insulted or humiliated?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.49\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12. Did you see or hear a parent or household member in your home being slapped, kicked, punched or beaten up?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.41\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13. Did you see or hear a parent or household member in your home being hit or cut with an object, such as a stick (or cane), bottle, club, knife, whip etc.?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.45\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14. Did a parent, guardian or other household member yell, scream or swear at you, insult or humiliate you?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.50\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15. Did a parent, guardian or other household member threaten to, or actually, abandon you or throw you out of the house?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.36\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16. Did a parent, guardian or other household member spank, slap, kick, punch or beat you up?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.62\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e17. Did a parent, guardian or other household member hit or cut you with an object, such as a stick (or cane), bottle, club, knife, whip etc?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.36\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18. Did someone touch or fondle you in a sexual way when you did not want them to?\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\u003e0.67\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e19. Did someone make you touch their body in a sexual way when you did not want them to?\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\u003e0.69\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20. Did someone attempt oral, anal, or vaginal intercourse with you when you did not want them to?\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\u003e0.78\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e21. Did someone actually have oral, anal, or vaginal intercourse with you when you did not want them to?\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\u003e22. How often were you bullied?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.34\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e23. How were you bullied most often?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e24. How often were you in a physical fight?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.44\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e25. Did you see or hear someone being beaten up in real life?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.43\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e26. Did you see or hear someone being stabbed or shot in real life?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.75\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e27. Did you see or hear someone being threatened with a knife or gun in real life?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.70\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\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eNote\u003c/em\u003e: 1\u0026thinsp;=\u0026thinsp;Violence Exposure, 2\u0026thinsp;=\u0026thinsp;Parental Neglect, 3\u0026thinsp;=\u0026thinsp;Family Adversity, and 4\u0026thinsp;=\u0026thinsp;Sexual Assault.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eCFA\u003c/h2\u003e\u003cp\u003eThe initial CFA of a four-structure ACE-IQ-27 suggested by EFA yielded an inadequate fit with the data; χ\u0026sup2; (269, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;300)\u0026thinsp;=\u0026thinsp;558.407, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.00, \u003cem\u003eχ\u003c/em\u003e\u0026sup2;/\u003cem\u003edf\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.08, CFI\u0026thinsp;=\u0026thinsp;.861, TLI\u0026thinsp;=\u0026thinsp;.845, RMSEA\u0026thinsp;=\u0026thinsp;.062 (90% CI [0.055, 0.069], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.010), and SRMR\u0026thinsp;=\u0026thinsp;.095. However, allowing the error terms to be correlated for items 26 and 27, items 25 and 27, and items 25 and 26 under factor 1 and items 4 and 5 under factor 2, following modification indices, improved the model fit: \u003cem\u003eχ\u0026sup2;\u003c/em\u003e (265, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;300)\u0026thinsp;=\u0026thinsp;415.760, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000, \u003cem\u003eχ\u003c/em\u003e\u0026sup2;/\u003cem\u003edf\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.57, CFI\u0026thinsp;=\u0026thinsp;0.947, TLI\u0026thinsp;=\u0026thinsp;0.940, RMSEA\u0026thinsp;=\u0026thinsp;0.038 (90% CI [0.029, 0.047], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.907), and SRMR\u0026thinsp;=\u0026thinsp;0.078. Due to the \u003cem\u003eχ\u003c/em\u003e\u0026sup2; statistic`s sensitivity to the sample size and departures from multivariate normality in the data (Roos \u0026amp; Bauldry, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), more importance was placed on these fit indices. The \u003cem\u003eχ\u003c/em\u003e\u0026sup2; statistic tends to reject the null hypothesis in samples larger than 100 (Roos \u0026amp; Bauldry, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Except \u003cem\u003eχ\u0026sup2;\u003c/em\u003e, all the goodness-of-fit indices, including \u003cem\u003eχ\u003c/em\u003e\u0026sup2;/\u003cem\u003edf\u003c/em\u003e, passed the threshold recommended in prior papers (Hu \u0026amp; Bentler, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e1999\u003c/span\u003e; Roos \u0026amp; Bauldry, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Therefore, we retained a four-factor solution for ACE-IQ-27. All the standardised factor loadings of 25 items depicted in the CFA model (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) exhibited moderate to strong values (Tavakol \u0026amp; Wetzel, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Afifi et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the four-factor CFA model of ACE-IQ-27 with item factor loadings and correlations between the factors. We named Factor 1 as Violence Exposure, Factor 2 as Parental Neglect, Factor 3 as Family Adversity, and Factor 4 as Sexual Assault. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e depicts the four factors with their corresponding ACE types and the associated items, excluding exposure to war and collective violence categories and items.\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eFour-factor CFA model of ACE-IQ-27\u003c/h2\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIn Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, a single-headed arrow represents the causal relationship from the latent variables to the observed variables, while a double-headed straight arrow shows covariance between the factors (Tavakol \u0026amp; Wetzel, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The small double-headed arrows outside the boxes of the observed variables represent error variances. These indicate portion of variability in the observed data that is not explained by the model. Essentially, they capture factors like measurement errors or any other accounted variability within the 25 items being analysed.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eDiscriminant Validity and Convergent Validity\u003c/h2\u003e\u003cp\u003eFrom Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, it is evident that the inter-factor correlation values for all factor pairs are below the recommended threshold of 0.85. This result indicates that the factors are sufficiently distinct from one another, thereby providing evidence of discriminant validity. The AVE values for Violence Exposure, Parental Neglect, Family Adversity, and Sexual Assault are 0.24, 0.24, 0.35, and 0.7, respectively. These results suggest that while Sexual Assault demonstrates satisfactory convergent validity with an AVE above the cut-off value, the other constructs fall below the recommended threshold, indicating the need for further refinement of measurement items or the constructs themselves.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eFactors, ACE types, and corresponding items\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFactors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eACE types\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eItems\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eViolence Exposure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHousehold member treated violently\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11, 12, 13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmotional abuse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14, 15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePhysical abuse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16, 17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBullying\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22, 23\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCommunity violence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24, 25, 26, 27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eParental Neglect\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmotional neglect\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1, 2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePhysical neglect\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3, 4, 5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eFamily Adversity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAlcohol/drug abuser in household\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSomeone chronically depressed, mentally ill, institutionalized or suicidal household member\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIncarcerated household member\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOne or no parents, parental separation or divorce\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9, 10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSexual Assault\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSexual abuse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18, 19, 20, 21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003eNote\u003c/em\u003e: Items 21 and 23 are not included in the factor analyses\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eInternal Consistency Reliability\u003c/h2\u003e\u003cp\u003eThe instrument was reliable, as evidenced by the overall Cronbach`s alpha coefficient of 0.81 (95% CI\u0026thinsp;=\u0026thinsp;0.77\u0026ndash;0.84). The Cronbach`s alpha coefficient was 0.80 (95% CI\u0026thinsp;=\u0026thinsp;0.77\u0026ndash;0.84) for factor 1, 0.64 (95% CI\u0026thinsp;=\u0026thinsp;0.57\u0026ndash; 0.70) for factor 2, and 0.72 (95% CI\u0026thinsp;=\u0026thinsp;0.67\u0026ndash;0.77) for factor 3, 0.85 (95% CI\u0026thinsp;=\u0026thinsp;0.81\u0026ndash;0.87) for factor 4 of ACE-IQ-27. These values indicate acceptable to good internal consistency reliability (George \u0026amp; Mallery, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study is the first of its kind in Bhutan to examine the underlying factor structure of a shortened version of the ACE-IQ, referred to as ACE-IQ-27, focusing on school-going Bhutanese children aged 13 to 21 years, identified as a priority group for research and intervention on ACEs (Kidman et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). The original ACE-IQ, developed by WHO, consists of 31 items designed to assess 13 categories of ACEs that includes constructs such as war and collective violence, which may not be universally applicable. The ACE-IQ-27 is a shorter version with 27 items (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) related to 12 ACE categories (see Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). This version involved dropping four items from war and collective violence domain, as such adversities are not common in Bhutan`s peaceful and politically stable context and may not meaningfully contribute to the measurement of childhood adversity. However, factor analyses were performed with 25 items as depicted in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Since there wasn`t much variation in the responses for item 21, this was left out of the factor analysis. Furthermore, item 23, being a \u0026ldquo;Check all that apply\u0026rdquo; type question, was also excluded from the analysis. The EFA revealed a four-factor structure as the most appropriate and accurate representation of the ACE-IQ-27. This structure was supported by strong item loadings on their respective constructs, indicating the instrument`s structural validity. This EFA findings was further confirmed by the CFA, which produced acceptable model fit indices: \u003cem\u003eχ\u0026sup2;\u003c/em\u003e (265, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;300)\u0026thinsp;=\u0026thinsp;415.760, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000, \u003cem\u003eχ\u003c/em\u003e\u0026sup2;/\u003cem\u003edf\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.57, CFI\u0026thinsp;=\u0026thinsp;0.947, TLI\u0026thinsp;=\u0026thinsp;0.940, RMSEA\u0026thinsp;=\u0026thinsp;0.038 (90% CI [0.029, 0.047], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.907), and SRMR\u0026thinsp;=\u0026thinsp;0.078). The four factors are Violence Exposure, Parental Neglect, Family Adversity, and Sexual Assault as depicted in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Collectively, the four factors explained approximately 39% of the total variance.\u003c/p\u003e\u003cp\u003eAfter CFA, various psychometric analyses were conducted, including assessments of convergent and discriminant validity, and internal consistency reliability of the four constructs. The reliability of the four constructs was determined using Cronbach`s alpha. The overall internal consistency of ACE-IQ-27 was good, with a Cronbach`s alpha coefficient of 0.81. At the factor level, reliability ranged from acceptable to good. For instance, Violence Exposure and Sexual Assault exhibited good reliability, reflecting the cohesiveness of the items within these factors. However, Parental Neglect had slightly lower reliability coefficient, suggesting that these factors might benefit from further refinement or the inclusion of the additional items to enhance their internal consistency. The inter-factor correlation values for all factor pairs are below the recommended threshold of 0.85, confirming that the factors are sufficiently distinct from one another and thus providing strong evidence of discriminant validity. While the factor Sexual Assault demonstrates satisfactory convergent validity with an AVE exceeding the recommended cut-off, the other factors fall short of this threshold, suggesting a need for further refinement of measurement items or the factors themselves. Overall, based on the results of both the EFA and CFA, the ACE-IQ-27, as adapted for school-going Bhutanese children aged 13\u0026ndash;21 years, excluding items addressing rare adversities such as exposure to war and collective violence is psychometrically reliable and valid instrument for measuring ACEs and their association with risk behaviours in later life.\u003c/p\u003e\u003cp\u003eWhile the findings of this study align with prior studies (e.g., Gette et al., 2022; Kidman et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Kostić et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) in identifying distinct factors of adversity, the specific factor structure identified here differs from those reported in these studies. This discrepancy in factor structure reinforces the idea that the ACE-IQ`s factor structure is not universal, but rather context-dependent. The way items group into meaningful categories depends on the lived realities of population in different regions. For example, in regions with ongoing or recent history of war, violence, and political instability, adversities related to war or collective violence are often more pronounced. In contrast, in regions characterized by high political stability \u0026ndash; where war and collective violence are absent or rare \u0026ndash; the adversities children face tend to stem from different sources. In these settings, the factor structure may shift to emphasize familial and interpersonal adversities, as was observed in this study. Our modified ACE-IQ-27 is suited for assessing childhood adversities in schools, clinics, or communities in regions with a low prevalence of trauma related to war and collective violence.\u003c/p\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eImplications\u003c/h2\u003e\u003cp\u003eBhutan is currently undergoing rapid industrialization, economic growth, and urbanization, processes that have reshaped many aspects of daily life, particularly for families and children. Traditional support systems within communities and families are being eroded due to factors such as separation, divorce, economic stress, and interpersonal violence. Additionally, harmful practices such as corporal punishment remain prevalent as a means of disciplining children (NCWC \u0026amp; UNICEF, 2016). The COVID-19 pandemic has further intensified these stressors, with disruptions to family dynamics, education, and community structures. As a result of these shifts, it is highly plausible that many Bhutanese students are living with multiple ACEs. Researchers and educators can administer ACE-IQ-27 questionnaire among school-going Bhutanese children aged 13 to 21 years. The outcomes derived from this assessment can provide valuable insights for policymakers to design evidence-based policies and targeted intervention programs tailored to Bhutanese children, with the aim of preventing and mitigating the long-term effects of childhood adversity on mental health, education, and overall well-being.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eLimitation and Future Research\u003c/h2\u003e\u003cp\u003eThis study relied on a self-report questionnaire. As a result, the study`s ability to establish causation for the identified relationships is limited. We don\u0026rsquo;t have any observations or confirmation of the self-reported results (Kidman et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Additionally, our result may be subject to social desirability bias, such as in self-reports of sensitive issues like sexual abuse (Fisher, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e1993\u003c/span\u003e). Also, the response obtained is vulnerable to various issues such as social desirability bias, response bias (both acquiescent and non-acquiescent bias), the inherent subjectivity of participants when responding to open-ended questions, potential recall bias, and the limited flexibility associated with fixed-choice questions (Demetriou et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Consequently, further research with a larger sample size, incorporating observations and interviews, is necessary to ascertain whether the findings it yields align with the present study`s findings. Moreover, although the scale demonstrates sufficient psychometric properties, it has yet to be validated using other standard methods. Future research should consider assessing other forms of validation, such as concurrent validity, predictive validity, and test-retest reliability.\u003c/p\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eI affirm that the information provided below is accurate and complete to the best of my knowledge.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there is no conflict of interests regarding the publication of this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Director of School Education (DSE) under the Ministry of Education and Skills Development.\u0026nbsp;An official letter (No.: DSE/SLCD/(2.1)/2023/961) was forwarded by the DSE to the district education office and school principals, apprising them of the study and soliciting their cooperation in facilitating the data collection process for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudent participants were explicitly notified on the first page of the online survey created using Google Form that their participation is entirely voluntary. By responding to the survey, participants were considered to have provided informed consent, acknowledging their voluntary participation in the study. Furthermore, participants were informed that the study\u0026apos;s findings would not identify specific informants and that the collected data would be used exclusively for the stated research purpose.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBy submitting this manuscript, we give our consent for its publication in \u003cem\u003eJournal of Child \u0026amp; Adolescent Trauma\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor`s Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFirst author played a key role in conceptualisation, data collection, analyses, interpretation, and writing the entire manuscript. Second author contributed to data collection, discussion of the results, and manuscript revision. Both authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAfifi, T. O., Salmon, S., Garc\u0026eacute;s, I., Struck, S., Fortier, J., Taillieu, T., Stewart-Tufescu, A., Asmundson, G. J. G., Sareen, J., \u0026amp; MacMillan, H. L. (2020). Confirmatory factor analysis of adverse childhood experiences (ACEs) among a community-based sample of parents and adolescents. \u003cem\u003eBMC Pediatrics\u003c/em\u003e, \u003cem\u003e20\u003c/em\u003e(1). https://doi.org/10.1186/s12887-020-02063-3 \u003c/li\u003e\n\u003cli\u003eBethell, C. D., Newacheck, P., Hawes, E., \u0026amp; Halfon, N. (2014). 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A powerful test for multivariate normality. \u003cem\u003eJournal of Applied Statistics\u003c/em\u003e, \u003cem\u003e41\u003c/em\u003e(2): 351\u0026ndash;63. https://doi.org/10.1080/02664763.2013.839637\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"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":"Adverse childhood experiences, Bhutan, psychometric properties of short adverse childhood experiences questionnaire, exploratory factor analysis, confirmatory factor analysis","lastPublishedDoi":"10.21203/rs.3.rs-6840865/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6840865/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAdverse Childhood Experiences (ACEs) are potentially traumatic events that occur during childhood and have been consistently linked to poor school engagement, academic performance, and a range of negative health, developmental, and social outcomes throughout the lifespan. This survey study among Bhutanese students aged 13 to 21 years aimed to assess the factor structure and psychometric properties of ACE-IQ-27, a shorter version of Adverse Childhood Experiences International Questionnaire (ACE-IQ). The ACE-IQ-27 was created by excluding war and collective violence items, which are uncommon in Bhutan. The study employed two samples, selected based on convenience sampling. Through exploratory factor analysis with 250 students, a 4-factor solution emerged (violence exposure, parental neglect, family adversity, and sexual assault). Collectively, the four factors explained approximately 39% of the total variance. This structure was subsequently validated through confirmatory factor analysis (CFA) with a separate 300 students. The result produced acceptable model fit indices: \u003cem\u003eχ\u0026sup2;\u003c/em\u003e (265, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;300)\u0026thinsp;=\u0026thinsp;415.760, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000, \u003cem\u003eχ\u003c/em\u003e\u0026sup2;/\u003cem\u003edf\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.57, CFI\u0026thinsp;=\u0026thinsp;0.947, TLI\u0026thinsp;=\u0026thinsp;0.940, RMSEA\u0026thinsp;=\u0026thinsp;0.038 (90% CI [0.029, 0.047], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.907), and SRMR\u0026thinsp;=\u0026thinsp;0.078). Following the CFA, a series of psychometric analyses were conducted to evaluate its convergent validity, discriminant validity, and internal consistency reliability of the four factors. The findings suggest that the adapted ACE-IQ-27 is sufficiently reliable and valid tool for measuring ACEs and their association with risk behaviours in later life among school-going Bhutanese children aged 13\u0026ndash;21 years. The adapted ACE-IQ-27 is also particularly well-suited for assessing childhood adversities in schools, clinics, or community settings in regions where trauma related to war and collective violence is relatively uncommon.\u003c/p\u003e","manuscriptTitle":"Factor Structure and Psychometric Properties of ACE-IQ-27: A Shorter Version of Adverse Childhood Experiences International Questionnaire (ACE-IQ) in Bhutan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-06 08:16:09","doi":"10.21203/rs.3.rs-6840865/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":"961a2741-ddad-4fce-8517-987e8b2a778d","owner":[],"postedDate":"August 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-30T15:57:03+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-06 08:16:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6840865","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6840865","identity":"rs-6840865","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}