City University of New York (CUNY)
CUNY Academic Works
Dissertations and Theses
City College of New York
2022
Being Black & Blue: Sex as a Moderator Between Adverse
Childhood Experiences and Depressive Symptoms Among Black
Emerging Adults
Wynta C. Alexander
CUNY City College
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Running head: SEX AS A MODERATOR BETWEEN ACES AND DEPRESSIVE SYMPTOMS
Being Black & Blue:
Sex as a Moderator Between Adverse Childhood Experiences and Depressive Symptoms
Among Black Emerging Adults
Wynta Alexander
June, 2022
Submitted to the Department of Psychology of The City College of New York in partial
fulfillment of the requirements for the degree of Master of Arts in General Psychology
SEX AS A MODERATOR BETWEEN ACES AND DEPRESSIVE SYMPTOMS
Acknowledgments
I would like to express my deepest gratitude to Dr. Adriana Espinosa for your consistent
guidance, support, and valuable feedback throughout my graduate studies. This endeavor of
researching and writing my thesis, would not be possible without your mentorship.
Additionally, I would like to thank my committee members, Dr. Sarah O’ Neill and Dr.
Adeyinka Akinsulure – Smith, for their valuable remarks on this thesis.
Lastly, I would like to thank my mother, Tahela for her unwavering love, wisdom, and
emotional support. I would not be the woman I am today, without you.
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SEX AS A MODERATOR BETWEEN ACES AND DEPRESSIVE SYMPTOMS
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Table of Contents
Acknowledgements……………………………………………………………………….….......ii
Table of Contents………………………………………………………………...………..….…iii
List of Tables…………..……………………………………….…………………….….…...….iv
List of Figures……………………………………………….……………………………..….....v
Abstract……………………………………………………………….……………………..…..vi
Introduction…………………………………………………………….………………….….….1
Methods……………………………………………………………………...………….…… .…7
a. Participants/Procedure………………………………………..……………….…..………… ..7
b. Measures……………………………………………………………………….…..………. …8
c. Data Analysis………………………………………………………………………................ 10
Results………………………………………………………………………………….………..10
Discussion…………………………………………………………………..……………………12
References………………...……………………………………………………………………...19
Appendix A; Adverse Childhood Experiences (ACEs) Questionnaire (Felitti et al., 1998)
…………………………………………………………………………………………………....35
Appendix B; Centre for Epidemiological Studies Depression Scale (CES-D-R 10) (Andresen et
al. 1994)………………………………………………………………………………………….36
SEX AS A MODERATOR BETWEEN ACES AND DEPRESSIVE SYMPTOMS
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List of Tables
Table 1. Participants’ Characteristics by Ethnicity …………………………………………….31
Table 2. Distribution of Adverse Childhood Experiences by Sex……………………………......32
Table 3. Hierarchical Regressions for Total ACEs and Sex Predicting Depressive Symptoms....33
SEX AS A MODERATOR BETWEEN ACES AND DEPRESSIVE SYMPTOMS
List of Figures
Figure 1. ACEs pyramid………………………………………………………………….…….4
Figure 2. Moderation Model Including Depressive Symptoms, ACEs and Sex……………...34
v
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Abstract
Adverse Childhood Experiences (ACEs) have been linked to adult mental health
consequences (e.g., depressive symptoms). Black people are disproportionately affected by
ACEs, and factors related to ethnic subgroups and/or sex may produce differential depressive
outcomes. The current study examined the moderating role of sex in the association between
adverse childhood experiences and depression symptoms using a life course of health approach
among a sample of Black emerging adults. Participants (n = 159) of the current study were Black
(e.g., African – American) and Black Caribbean (e.g., Jamaican) undergraduate students (18 – 59
years old; 72.3% female) attending a large, public northeastern college in the United States, who
took part of a broader study aiming to understand factors influencing mental health outcomes in
adulthood. Participants self – reported their sociodemographic information, their early childhood
adversity (Adverse Childhood Experiences (ACEs) Questionnaire), and their depressive
symptoms within the past week (Centre for Epidemiological Studies Depression Scale (CES-D-R
10). Significant sex differences in type of ACEs were found such that females were more likely
to report sexual abuse and emotional neglect compared to males. ACEs were moderately
positively correlated with depressive symptoms. Significant differences were not observed
between Black and Caribbean Black students’ depressive scores. No sex x total number of ACEs
interaction was found. Clinical implications for college based and culturally – sensitive
interventions are discussed.
SEX AS A MODERATOR BETWEEN ACES AND DEPRESSIVE SYMPTOMS
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Sex as a Moderator Between Adverse Childhood Experiences and Depressive Symptoms Among
Black Emerging Adults
Black individuals constitute the third largest racial/ethnic group in the United States
(U.S.) (Cunningham et al. 2017), accounting for 12.4% of the US population (Census, 2020). At
the same time research within the last two decades, indicates that 10.4% of African-American
and 12.9% of Afro-Caribbean people met criteria for major depressive disorder (MDD) and have
a higher rate of chronicity than White adults (Williams et al., 2007). It is estimated that by age
18, twenty percent of American youth will have had at minimum one depressive episode with
majority of these adolescents being African-American or Black (Freeny et al. 2021). Black
people are disproportionately exposed to multiple psychosocial stressors over the life course,
which are salient risk factors for severe depression or MDD in the long run (Lincoln et al. 2011).
In particular, Black people are disproportionately affected by differing forms of
adverse events, such as physical and sexual abuse, before the age of 18. National studies have
indicated that one in three Black youth are exposed to multiple adverse events before the age of
18 years compared to one in five White youth (Sacks & Murphey, 2018; Woods-Jaeger et al.
2021). Other research indicates that the rate of adverse experiences during childhood among
Black youth is approximately 33% higher than that among White counterparts (Slopen et al.,
2016). These early forms of childhood trauma occur during a formative period in which the brain
has increased sensitivity to external stimuli (D'Orazio, 2016, Williams, 2020), and they have
been linked to the development of severe depression in adulthood (Freeny et al., 2021). As the
incidence of major depressive disorder significantly increases during adolescence and peaks in
emerging adulthood (Mondi, Reynolds, & Ou, 2017), the latter period constitutes a focal point
for investigation.
SEX AS A MODERATOR BETWEEN ACES AND DEPRESSIVE SYMPTOMS
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Depression is a leading cause for disease and death among Black people in the United
States (Adams et al. 2021). Namely, suicide is currently the third leading cause of death for
Black American adolescent and young adult males (Goodwill, Taylor, Watkins, 2021). Further,
from 1991 – 2017, depression related actions such as suicide attempts among Black people have
increased at a faster rate than any other racial/ethnic group (Rabinowitz et al. 2021). Previous
studies show a higher persistence rate and impairment associated with depression for Black
people in contrast to White people (Lincoln & Chae., 2012).
Furthermore, while prior studies targeting the Black population, typically combine
African Americans and Black Caribbeans together, lumping these ethnic subgroups together is
not helpful as there are differences between them related to protective factors for depressive
symptoms (Molina & James, 2016). In contrast with African – Americans, Black Caribbeans
customarily belong to a higher socioeconomic status and are more likely to be immigrants to the
United States which are protective factors against mental disorders (Molina & James, 2016,
Robinson et al. 2022).
Moreover, there are distinctions between these two ethnic subgroups related to
depressive outcomes (Robinson et al. 2022). For example, Taylor et al. (2015) found for African
– Americans, sense of attachment and belonging (subjective closeness) among family and non –
kin associates were negatively associated with depressive symptoms and psychological distress,
whereas for Black Caribbeans, in addition to subjective closeness; prevalence of family contact
is more consequential for this subgroup in relation to depressive symptomology. This finding
may be due to Black Caribbeans having more transnational family arrangements (Basch, 2001;
Foner, 2005) compared to African – Americans.
SEX AS A MODERATOR BETWEEN ACES AND DEPRESSIVE SYMPTOMS
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Historically, and contemporary, Black Americans face institutionalized discrimination
which subjects them to disadvantages such as poor living conditions and greater stress and
adversity due to marginalized social rank which may put Black people at higher risk for
depression compared to other racial groups (Keyes, Barnes, & Bates, 2011). Additionally, while
studies have shown sex differences in the types of childhood trauma experienced (Melton-Fant,
2019), no study to date has investigated the differential impact of these experiences on
depressive symptoms between Black male and female individuals. This information is critical for
enhancing our comprehension of the differential consequences of adverse experiences in
childhood on depressive symptomology among Black people.
This study employs a life course approach to health perspective which highlights the
significance of examining the impact of a multitude of risk factors within one’s sociocultural
context at the differing stages of development (Halley Grigsby et al. 2014; Jones et al. 2019;
Espinosa et al. 2021) to investigate the impact of childhood adversity on depressive symptoms at
the intersection of sex among Black emerging adults.
Life Course Approach to Health
A life course approach to health perspective (Elder, 1985) provides a multilevel
developmental approach that considers the factors that impact an individual’s health, beginning
with experiences in early childhood. A life course approach to health perspective explains that
experiences that occur early in life significantly affect future life outcomes (Elder et al. 2003,
Umberson et al. 2014, Fothergill et al. 2016) and provides a theoretical framework for
understanding the influence of adverse experiences in childhood (ACEs) on depression
symptoms and risk of MDD in the long run. According to this framework, adverse experiences in
SEX AS A MODERATOR BETWEEN ACES AND DEPRESSIVE SYMPTOMS
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childhood can have a more extensive impact on the brain than later experiences because they
induce toxic stress, which becomes chronic and can disrupt the development of the child’s brain
(Jones & Pierce, 2021; Sciaraffa et al. 2018; Tottenham, 2018; Tsehay, Necho, & Mekonnen,
2020; Williams, 2020). These disruptions in brain development are exacerbated by the
accumulation of these adverse experiences, thus leading to cognitive (Evan-Chase, 2014;
Williams,2020) and emotional impairments over time which may predispose the individual to
depression symptoms in emerging adulthood and MDD in late adulthood (Schalinski et al. 2016).
Figure 1 depicts the described pathways linking adverse experiences to depression from early
childhood to late adulthood.
MDD
Depressive
Middle/Late Adulthood
Emerging Adulthood
Symptoms
Social, Emotional
and Cognitive
Impairment
Disrupted
Neurodevelopment
Adverse Childhood Experiences
(ACE)
Figure 1. ACEs pyramid. Figure adapted from Felitti, et al., 1998.
Adolescence
Childhood
SEX AS A MODERATOR BETWEEN ACES AND DEPRESSIVE SYMPTOMS
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Adverse Childhood Experiences (ACEs) among Black youth
Adverse experiences in childhood (ACE) are recognized as a salient public health
concern in the U.S. as national studies indicate that 66% of adults reported experiencing at least
one ACE and 25% of adults reported experiencing three or more ACEs (Hampton – Anderson et
al., 2021). Studies also have demonstrated that ACEs are particularly prevalent in low-income
minority populations (Goldstein et al.2019). Beginning with the seminal study of ACEs, racial
differences were found, with 62% of Black children experiencing at minimum one ACE
compared to 51.3% of White children and 57.1% of Hispanic children (Felitti et al. 1998).
Maguire – Jack, Lanier, & Lombardi (2020) found that compared to White children, Black
children were more likely to have higher exposure to specific types of ACEs such as parental
incarceration, and were more likely to experience all types of ACEs except for parental drug use
and mental illness. Additionally, while examining individual ACEs, Freeny (2021) observed that
physical abuse was the most prevalent ACE in a sample of African-American adolescents.
Further, findings indicate that Black youth presented with a higher frequency of ACEs with 34%
of Black children having experienced two or more ACEs compared to 22% of Hispanic children
and 14% White children (Maguire – Jack, Lanier, & Lombardi, 2020). Likewise, Goldstein et al.
(2021) found the rate at which Black youth experienced at minimum 2 ACEs (33%) was elevated
compared to White and Hispanic children (20% and 26%, respectively). Similarly, Lee & Chen
(2017) observed in their sample, Black people had the highest prevalence of ACEs. Sacks &
Murphey (2018) findings further indicated youth of differing races/ethnicities do not experience
ACEs similarly with 61% of Black children experienced at least one ACE in juxtaposition to
40% of White children, 51% of Hispanic children, and 23% of Asian children.
SEX AS A MODERATOR BETWEEN ACES AND DEPRESSIVE SYMPTOMS
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Consequently, ACEs can further exacerbate mental health consequences like depressive
symptoms starting as early as childhood in Black people. For example, Black youth exposed to
ACEs were found significantly more likely to have higher major depressive scores than their non
– Black peers (Elkins et al. 2019). Additionally, Freeney et al. (2021) found a positive
correlation between exposure to four or more ACEs and a higher probability of depression
specifically among African – American adolescents. These findings suggest depressive
symptomology may be an early outcome of ACEs exposed Black youth and if the inception of
depression occurs during childhood, the risk of becoming clinically depressed in adulthood is
likely (O'Grady and Metz 1987; Freeny et al. 2021).
Sex differences in Adverse Childhood Experiences (ACEs)
Prior research has found sex differences in the type of ACEs reported, whereby being
female can be a risk factor for some types of ACEs (Espinosa et al. 2021, Espinosa et al. 2017;
Linton and Gutierrez 2020; Llabre et al. 2017). For example, Grisby et al (2020) found that
females were more likely than males to report childhood sexual abuse and domestic abuse. Fang
et al. (2016) found that males were more likely to report childhood physical abuse than females.
Likewise, in a low-income Black sample, Giovanelli & Reynolds (2021) found that 3% of
females reported sexual abuse compared to 0.6% of males and 21% of females reported domestic
violence in comparison to 19.3% of men. However, in a Hispanic emerging adult sample,
Espinosa et al (2021) found that females were more likely to report physical and emotional abuse
than males. These findings suggest the need for more research on sex differences on ACEs and
whether these differentially explain the risk for MDD in the long run. The existing evidence
suggests that there are sex differences on the impact of ACEs on mental health, with females
who experience childhood trauma more likely to report internalizing disorders such as major
SEX AS A MODERATOR BETWEEN ACES AND DEPRESSIVE SYMPTOMS
7
depressive disorder and men more likely to report externalizing disorders (e.g., substance abuse
use, alcohol use) (Cavanaugh CE, Petras H, & Martins SS, 2015; Grisby et al. 2020). Similarly,
Haahr-Pedersen et al (2020) findings demonstrated ACE – exposed females having significantly
higher levels of depression and lower levels of psychological well – being compared to ACE –
exposed males.
Current Study
The current study examines the moderating role of sex in the association between adverse
childhood experiences and depression symptoms among a sample of Black emerging adults.
Hypotheses. The following hypotheses are explored:
H1: Male and female young adults will differ in the type of childhood adverse experiences
reported.
H2: Higher adverse experiences in childhood will significantly relate to higher symptoms of
depression.
H3: Sex will moderate the relation between adverse childhood experiences and symptoms of
depression, such that the relation will be stronger in magnitude for females than for males.
METHODS
Participants & Procedure
Participants for the current study were undergraduate students from The City College of
New York (CCNY), who took part of a broader study aiming to understand factors influencing
mental health outcomes among emerging adults. We conducted study recruitment using an
online subject pool implemented by the Department of Psychology at CCNY. Participants were
presented with online informed consent forms at the start of the study which emphasized how
SEX AS A MODERATOR BETWEEN ACES AND DEPRESSIVE SYMPTOMS
8
participation is voluntary and their answers are completely anonymous. Then, participants
completed a 90-minute online survey assessing factors related to mental health outcomes. Data
collection took place from January 2021 to March 2022. These dates of data collection occurred
during the COVID 19 pandemic and may had an impact on recruitment. This study was approved
by the Institutional Review Board (IRB) at the City College of New York. All participants
received course credit for their participation.
Eligibility criteria for the current study’s sample included participants being at minimum
18 years of age, were able to read English, and identified as either Black and/or Caribbean Black.
A total of 159 college students were included in the current study. The majority was
predominantly female (72.3%) and Black (59.7%). Participants ranged from 18 to 59 years of
age with the mean age being 21.1 years old (SD = 5.6). Regarding immigration status, 25.2% of
participants were first - generation immigrants, 50.3% were second – generation immigrants,
22.6% were non – immigrants, and 1.9% identified as other.
Measures
Adverse Childhood Experiences (ACEs).
ACEs were measured using the Adverse Childhood Experiences (ACEs) Questionnaire (Felitti
et al., 1998), a 10-item tool used to measure childhood trauma. The questionnaire assesses 10
types of adversities an individual experienced before the age of 18 years. Five of the items are
personal to the individual being assessed: physical abuse, verbal abuse, sexual abuse, physical
neglect, and emotional neglect. Five items are related to other family members: a parent who’s
an alcoholic, a mother who’s a victim of domestic violence, a family member in jail, a family
member diagnosed with a mental illness, and the loss of a parent through divorce, death, or
abandonment. Responses are dichotomous (yes/no), with ‘yes’ equating to a score of ‘1’ and ‘no’
SEX AS A MODERATOR BETWEEN ACES AND DEPRESSIVE SYMPTOMS
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equating to a score of ‘0’. The total sum is an individual’s ACE score, with higher scores
equating to more ACEs. In the original ACEs study, Felitti et al (1998) reported a Cronbach’s
alpha = .88. Among this sample, the total value for Cronbach’s alpha was α = .57. However, the
ACEs measure is not required to be internally consistent (Cleary, 1981; Llabre et al, 2017;
Espinosa et al. 2021).
Depressive Symptoms.
Depressive symptoms were evaluated by the Centre for Epidemiological Studies Depression
Scale (CES-D-R 10), a 10-item Likert scale questionnaire assessing depressive symptoms in the
past week (Andresen et al. 1994). It includes three items on depressed affect, five items on
somatic symptoms, and two on positive affect. Options for each item range from “rarely or none
of the time” (score of 0) to “all of the time” (score of 3). Scoring is reversed for items 5 and 8,
which are positive affect statements. Total scores can range from 0 to 30 with a score of 10 and
higher suggesting greater severity of depressive symptoms a score of 10 or greater was
considered as screening positive for depressive symptoms (Andresen et al. 1994). In an ethnic
minority sample, (González et al. 2017) reported Cronbach’s alphas α ≥ .70. In this sample, the
value for Cronbach’s alpha was α = .83.
Sociodemographic information. Participants self - reported their biological sex as either Male or
Female which was coded as Male = 1 and Female = 0. For the current study, we coded
race/ethnicity as Black (e.g. African – American) as 0 and Caribbean Black (e.g. Jamaican,
Belizean, Trinidadian, etc.) as 1. Participants also stated their age (in years). Immigration status
was coded for first generation immigrants (born outside the United States) as 1, second
generation immigrants (born in United States or came to the United States as a child with at least
one parent born outside the United States) as 2, non – immigrant (both participant and both
SEX AS A MODERATOR BETWEEN ACES AND DEPRESSIVE SYMPTOMS
10
parents were born inside the United States) as 3, and other was coded as 4. Participants reported
financial deprivation during childhood which explored sources of household spending and ability
to pay bills as measured by 9 items using a Likert scale ranging from 1 – 5 with higher scores
representing greater financial stress from the Financial Stress Questionnaire, (Conduct Problems
Prevention Research Group, 1994).
Data Analysis
Statistical analysis was conducted using SPSS version 28 (IBM). Descriptive statistics
(means and standard deviations) were performed to characterize the sample. To test H1, we ran
chi square tests of independence on each ACE type by sex. Then, an independent samples t – test
was ran to compare the average of cumulative ACEs by sex and effect size. To test H2, Pearson
correlations assessed the relation between total number of ACEs and symptoms of depression.
To test H3, we assessed the moderating role of sex in the relation between ACEs and depression
symptoms by way of a 2-step hierarchical regression. The first step included age, ACEs, a binary
indicator for race/ethnicity and a binary indicator for sex. The second step added the interaction
between sex and was conducted adjusting for age. As a second step, the interaction between sex
and ACEs. If significant, we will probe the interaction using a simple slopes test.
RESULTS
Descriptive Statistics
As reflected in Table 2, the mean ACE score was 2.15 (SD = 1.75), with 78% of the sample
reporting 3 or less ACEs which signify a slightly lower prevalence of ACEs compared to 80.8%
of the Black population in the original ACE who reported 3 or less ACEs (Felitti et al. 1998).
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The average depressive symptom score on the CES-D-R 10 was 11.03 (SD = 5.93) with 53.5%
(n = 85) scoring 10 and higher; which is considered as screening positive for depressive
symptoms (Andresen et al. 1994; Risser et al. 2010; Bouvier et al. 2019). This percentage is
high compared to the Black sample in the initial introduction of the CES – D 10 at 26%
(Andresen et al. 1994) and more recently, Bouvier et al. (2019)’s young adult Black population
at 18.5%. The percentage of males scoring 10 and higher was 38.5 % (n = 17) compared to
females at 59% (n = 68).
Hypothesis 1: Differences in ACEs Between Males and Females
Table 2 indicates the proportion of each participant by sex that had experienced a specific type of
ACE as well as the total amount of ACEs. The total number of ACEs were not significantly
associated with sex t(157) = 2.1, p = .076, despite females (M = 2.3, SD = 1.8) attaining higher
scores than males (M = 1.7, SD = 1.5).
Chi-square tests revealed there were important sex differences in the type of ACE reported as
hypothesized (H1). In particular, females were significantly more likely to report sexual abuse
and emotional neglect compared to males. Due to the issue of one report of sexual abuse among
males in this sample, we ran a Fisher’s exact test of independence (p = .009).
Hypothesis 2: Correlation Between ACEs and Depression
Pearson correlations indicated that the total number of ACEs (TotalACE) and total number of
depressive symptoms (TotalD) had a statistically significant linear relation (r=.44, p < .001).
This relation indicates that higher ACEs are related to higher symptoms of depression.
Hypothesis 3: Moderation Analysis
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Block 1 in the hierarchical regression produced an R Square value of .25, indicating that age,
sex, ethnicity, and total number of ACEs account for 24.9% of the variance in depression
symptoms. When the interaction between sex and ACEs were added in Block 2, the value for R
Square increased to .251, thus accounting for the 25.1% of the variance in depressive symptom
scores. The change in R2 for block 2 was .002, demonstrating virtually no relationship between
these variables. While Block 1 was found to be statistically significant, the inclusion of the
interaction for sex and ACEs in block 2 did not account for a statistically significantly increased
amount of variance in depressive symptoms, thus a moderating effect is absent as depicted by the
slopes of the lines (Figure 2).
DISCUSSION
The current study aimed to investigate the relation between depressive symptoms and
adverse childhood experiences with sex as a moderating variable in a sample of Black emerging
adults. It was hypothesized male and female young adults differ in the type of childhood adverse
experiences reported, that higher adverse experiences in childhood significantly relate to higher
symptoms of depression, and that sex moderates the relation between adverse childhood
experiences and symptoms of depression.
As hypothesized, our results indicated significant sex differences in type of ACEs
reported such that females were more likely to report sexual abuse and emotional neglect
compared to males. The reporting of sexual abuse in this sample is harmonious with previous
research findings that women are more likely to report sexual abuse. For example, in a racially
diverse sample, 14.89% of females reported sexual abuse compared to 6.21% of males (Lee &
Chen, 2017). Similarly, Alcalá, Tomiyama, & von Ehrenstein (2017) found 16.6% of females
reported sexual abuse compared to 7.1% of males. Although these differences in the experiences
SEX AS A MODERATOR BETWEEN ACES AND DEPRESSIVE SYMPTOMS
13
do not differentially inform depressive symptoms among the current study’s sample, they can
have additional implications for mental health outcomes in general as females tend to have
different mental health outcomes from men, which may be a result of the differential adverse
traumas experienced. Namely, research has shown high trauma exposed girls have higher
parahippocampal volume than compared to high trauma exposed boys which puts them at greater
risk for developing emotional disorders due to the association region of traumatic memory
processing (Badura-Brack et al. 2020). This is significant, as emotional impairment has been
linked to depression symptoms and, later MDD (Schalinski et al. 2016) which may make ACE exposed females more vulnerable due to being at higher risk of emotional disorders.
The results from the bivariate analysis revealed that the ACEs were moderately
positively correlated with depressive symptoms. This finding is in agreement with our second
hypothesis and indicates that higher categorical types of ACEs experienced, regardless of the
type, are related to higher symptoms of depression among Black young adults. This finding is in
accord with prior research regarding the link between ACEs and depression as well as H2.
Considering the COVID – 19 pandemic, 42.1% of participants reported scores of 10 and higher
before March 2020 compared to 55% of participants who reported a CES - D 10 score of 10 or
higher after the pandemic was underway. This finding suggests that factors related to COVID 19 may had further exacerbated feelings of depression among emerging adults. For example, in a
large public US college sample, 21.5% of students reported depressive symptoms before the
pandemic and increased to 31.7%, four months after the pandemic started, with being Black and
female as risk factors of increases in depression (Fruehwirth, Biswas, & Perreira, 2021).
In line with understanding how early experiences impact later life through the lends of
the life course of health theoretical framework, a consequence of ACEs was found to be depicted
SEX AS A MODERATOR BETWEEN ACES AND DEPRESSIVE SYMPTOMS
14
in the form of depressive symptomology among the current study’s sample. Further, considering
age as a factor, the participants that fell in the emerging adulthood range of 18 – 29 years of age
(Arnett, 2000, 2011), reported a score of 10 or greater on the CES – D 10 (n = 80). For many,
depressive symptoms persist or materialize in emerging adulthood (Reed – Fitzke 2019). A
history of childhood adversity is a formidable risk factor for depression in emerging adulthood
which can leave one vulnerable to emotional distress (e.g., MDD) across the lifespan (Cohen,
2019).
One reason why depressive symptoms may manifest later in life is due to the socio -cultural
factor of a young person’s unwillingness to seek help for family – based stressors due to stigma
against mental health services. Additionally, factors such as the lack of trust in medical
institutions rooted in a history of racial discrimination and inadequate quality of healthcare,
especially for African American youth, may discourage them from seeking help from providers
(Forster et al. 2019) which further exacerbate mental health outcomes. Further, African –
Americans tend to have more risk factors for depression (e.g., less financial resources) compared
to Caribbean Black people and are more likely to report depression than other ethnic groups
(Robinson et al. 2022). However, findings from this study showed no significant observed
differences between these two ethnic subgroups. One explanation for this, may be due to the
adequacy of funds available during childhood being fairly even between both subgroups.
Another reason for no observed differences may be attributed to immigration status of the
participants. While previous literature argue Caribbean Black people are more likely to be first –
generation (Robinson et al. 2022), the current sample’s Caribbean Black people were mainly
comprised of second – generation individuals. This is significant to note, as similarly to Black
people, they may also experience relevant cultural factors from childhood that may put them at
SEX AS A MODERATOR BETWEEN ACES AND DEPRESSIVE SYMPTOMS
15
greater risk for depressive symptoms, such as perceived discrimination. To this point, research
has shown Black Caribbeans whose parents were born outside the United States report fewer
depressive symptoms than those who parents were born within the United States (Robinson et al.
2022).
Lastly, moderation analysis indicated that although females experienced different
ACEs than males, said differences did not influence how ACEs relate to symptoms of
depression. However, in previous studies, findings reflect sex differences in type of ACE
experienced have clinical implications. For instance, a recent study that examined substance use
in emerging adulthood, showed females had a higher count of ACEs compared to males and the
type of ACE had a differential impact on substance use (Espinosa et al. 2021).
Cultural norms related to masculinity and femininity may be one reason why sex did
not moderate the relation between ACEs and symptoms of depression in our sample. Cultural
expectations may cause reporting biases that affect rates of psychopathology between males and
females (White & Kaffman, 2019). All too often, Black men are raised to “man up” and not
reflect and/or share their emotions.
Another reason why sex did not moderate the relation between ACES and symptoms of
depression in this sample may be due to the how the questions in the CES – D 10 are presented.
Depressive symptoms among the Black population may be reported differently than our
traditional understanding of reporting this mental health outcome as illustrated in the DSM – 5
(Walton & Payne, 2016). Contrary to past studies, recent research has shown Black men from
low socioeconomic backgrounds experience depressive symptoms at rates similar to or higher
than those reported by White men & women (Kogan et al. 2017). Typical assessments of
depression may had led to under – reporting among this population of men. When characteristics
SEX AS A MODERATOR BETWEEN ACES AND DEPRESSIVE SYMPTOMS
16
of anger and frustration are operationalized as depressive symptoms for men, rates of depression
typically increase (Kogan et al. 2017).
CONTRIBUTIONS
Strengths of the current study include the use the investigation of an under-researched
population. The current study contributes to the limited literature examining the relationship
between childhood adversity and depressive symptoms among a Black population. Particularly,
we sought to investigate the impact of childhood adversity on depressive symptoms at the
intersection of sex among Black emerging adults. Studies that do address depressive symptoms
in the Black population, mainly discuss these symptoms without making a distinction between
sex (Walton & Payne, 2016). Thus, the need to increase awareness that sex differences matter
regarding consequences of ACEs on differential mental health consequences is imperative.
LIMITATIONS
As stated previously, data collection occurred during an unexpected multi - year global
public health crisis, COVID – 19, which may have an impact on depressive symptomology
among our sample. Additionally, the current student included a sample of only college students
and further, a higher percentage of females compared to males, thus the generalizability of our
findings across other universities and institutions may be limited. Another limitation is that all
survey measures used were dependent on self – report of the participant and may have been
influenced by selective disclosure or withholding of information. Lastly, due to the cross –
sectional nature of our data, we are unable to infer a causal relationship between total number of
ACEs and total number of depressive symptoms.
CLINICAL IMPLICATIONS
SEX AS A MODERATOR BETWEEN ACES AND DEPRESSIVE SYMPTOMS
17
Limitations notwithstanding, the current study’s findings provide several
implications for future research and application. Considering that a college education can
alleviate outcomes from early life adversity (Grisby et al. 2020), academic institutions like
CCNY can play a vital aspect in developing and administering resources related to trauma –
focused interventions. For example, incorporating mindfulness techniques with ACE – exposed
students can involve observing the present moment, describing personal experiences in the
present moment, acting with awareness by being conscious of one own’s personal thoughts and
emotions in the present time, nonjudgement in comprehending a personal experience and not
placing judgment, and non – reactivity, as in taking time to accept personal experiences and
emotions surrounding them as they are and not making rash decisions regarding these
experiences and emotions (Roche et al., 2019) to manage varying emotions including negative
ones. Further, many interventions created to improve mindfulness capabilities have been shown
to be constructive in reducing psychological distress (e.g., depression) and improving resilience
among college students (Anderson, Gardner, & Hunt, 2021).
While the evidence indicates the need for ACE – focused interventions in college
settings, culturally focused interventions that address the needs of both Black and Caribbean
Black individuals are additionally essential. One component that should be incorporated in
culturally sensitive ACE prevention interventions for Black people should include spirituality, as
it is significant in the Black community and is a source of hope and healing and provides a sense
of community (Freeny et al. 2020). Further, among emerging adults, high spirituality has been
found to be associated with less depression compared to those with low spirituality (Barton and
Miller, 2015). Within this intervention, constructs can include meaning – focused mediation,
reading scriptures, and other similar activities. Similarly Caribbean Black people hold spirituality
SEX AS A MODERATOR BETWEEN ACES AND DEPRESSIVE SYMPTOMS
18
in high regard however their practices tend to incorporate West African supernatural entities
such as Orishas (Taylor et al. 2009).
CONCLUSION
While there is an abundance of literature on the negative outcomes of ACEs and sex
differences on depressive symptoms, the relationship between these two factors are often not
studied together. Further, the current study contributes to the existing body of literature
examining depressive symptomology, ACE exposure and sex differences among emerging
adults. Using a life course of health framework, the current study underscores the impact of the
differential ACEs reported by sex as well as the positive correlation between number of ACEs
reported and number of depressive symptoms experienced. Our findings reinforce the need for
culturally sensitive and college setting-based interventions targeting Black and Caribbean Black
people in an effort to better address ACEs and existing sex differences, and the association
between them on depressive outcomes.
SEX AS A MODERATOR BETWEEN ACES AND DEPRESSIVE SYMPTOMS
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Table 1. Participants’ Characteristics by Ethnicity
Variable
Sex
Male
Female
Immigration Status
First - Generation
Second - Generation
Non - Immigrant
Other
Age Range
18 - 29
30 +
Financial Distress
Depressive Symptoms
Black = 95 (59.7%)
Caribbean Black = 64 (40.3%)
n, %
27 (16.9%)
68 (42.7%)
17 (10.7%)
47 (29.5%)
22 (13.8%)
41 (25.8%)
30 (18.9%)
2 (0.01%)
18 (11.3%)
39 (24.5%)
6 (0.04%)
1 (0.01%)
84 (52.8%)
11 (0.07%)
21.48 (6.69)
10.78 (5.81)
62 (39%)
2 (0.01%)
21.95 (6.13)
11.39 (6.12)
n, %
n, %
(M, SD)
(M, SD)
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32
Table 2. Distribution of Adverse Childhood Experiences by Sex
Variable
Type of ACEs
Verbal Abuse
Physical Abuse
Sexual Abuse
Emotional Neglect
Physical Neglect
Parent Divorced/Separated
Witness Domestic Violence
Household Member with SA
Household Member with MI
Household Member in Prison
Cumulative ACEs
Total
Male
Female
χ2
p
φ
61(38.4)
51(32.1)
20(17.4)
52(32.7)
1(0.6)
70(44)
12(7.5)
22(13.8)
38(23.9)
14(8.8)
2.15 (1.75)
13(29.5)
13(29.5)
1(2.3)
8(18.2)
0(0)
19(43.2)
4(9.1)
6(13.6)
9(20.5)
1(2.3)
1.68 (1.49)
48(41.7)
38(33)
21(13.2)
44(38.3)
1(0.9)
51(44.3)
8(7)
16(13.9)
29(25.2)
13(11.3)
2.33 (1.81)
2.00
0.18
6.35
5.83
0.39
0.02
0.21
0.00
0.40
3.23
0.16
0.67
0.01
0.02
0.54
0.90
0.65
0.96
0.53
0.07
.076
0.11
0.03
0.2
0.19
0.05
0.01
0.04
0.00
0.05
0.14
(n, %)
M, (SD)
Note: Table presents descriptive information for the sample. Independent samples t – tests and χ2 tests of independence compared type of
ACE with sex of participants.
SEX AS A MODERATOR BETWEEN ACES AND DEPRESSIVE SYMPTOMS
33
Table 3. Hierarchical Regressions for Total ACEs and Sex Predicting Depressive Symptoms
Variable
B
SE
t
p
R²
R²adj
delta R²
Constant
12.963
1.8
7.199
0.001
0.249
0.229
0.249
Age (in years)
-0.219
0.075
-2.94
0.004
Ethnicity
0.008
0.855
0.01
0.992
Sex
-1.501
0.935
-1.604
0.111
ACEs
1.448
0.24
6.03
0.001
Sex X ACEs
-0.401
0.598
-0.671
0.503
0.251
0.227
0.002
Block 1 Summary: F = 12.754, df (4,154), p < .05
Block 2 Summary: F = 10.257, df (1,153), p = .503
SEX AS A MODERATOR BETWEEN ACES AND DEPRESSIVE SYMPTOMS
Figure 2. Moderation Model Including Depressive Symptoms, ACEs and Sex
Note: The interaction between sex and total number of ACEs as predictor of depressive symptoms was
not significant.
34
SEX AS A MODERATOR BETWEEN ACES AND DEPRESSIVE SYMPTOMS
35
Appendix A. Adverse Childhood Experiences (ACEs) Questionnaire (Felitti et al., 1998)
SEX AS A MODERATOR BETWEEN ACES AND DEPRESSIVE SYMPTOMS
Appendix B. Centre for Epidemiological Studies Depression Scale (CES-D-R 10),
(Andresen et al. 1994)
36