Introduction

Adverse childhood experiences (ACEs) are associated with higher mental and physical illness and substance use disorders in adulthood. However, little is known about the prevalence of ACEs among student pharmacists and the factors associated with exposure. Our objective was to determine the prevalence of ACEs, resilience, and maladaptive coping strategies among student pharmacists in California.

Methods

Student pharmacists from 14 California pharmacy schools completed a 24-item online survey in 2020. This survey instrument comprised the ACEs questionnaire and collected data on the students’ demographic characteristics, coping strategies, and resilience.

Results

Most respondents were Asian/Pacific Islander (n = 186, 61.0%), female (n = 216, 70.8%), and aged between 25 and 31 years (n = 154, 50.7%). Many (n = 137, 44.9%) students had more than 1 ACE exposure; 66 students (21.6%) had more than 3 ACEs. Many students indicated that they were diagnosed or suspected to be diagnosed with a mental health condition (n = 105, 34.4%) and agreed/strongly agreed that they struggled to manage the workload of pharmacy school (n = 119, 39.9%). Respondents with higher ACE scores (> 3) were more likely to report struggling with managing the workload of pharmacy school, have or suspect having a mental health condition, drink alcohol in the last 12 months, and/or have multiple sexual partners than students with lower ACE scores.

Discussion

More than 1 in 5 student pharmacists in this study were exposed to more than 3 ACEs. The student pharmacists’ ACE exposure was associated with higher likelihood of mental health conditions and high-risk health behaviors. Further studies are needed to investigate this topic among student pharmacists.

An estimated 1 in 5 US adults lived with a mental illness in 2021.1  Mental health is a significant problem among the general public, higher education, and health profession students.2  Many student pharmacists experience symptoms of psychiatric disorders, such as depression and anxiety.3  Reports indicate that student pharmacists often feel excessive worry, intense anxiety, hopelessness, and desperation; have panic attacks; and can experience suicidal ideation.3  In comparison with medical students, more student pharmacists reported having moderate-to-severe depression, endorsed all symptoms of major depression, and endorsed feeling more of the intense affective state symptoms.3  Many student pharmacists have been found to have clinically significant depression (35%) and anxiety (21%) symptoms.3–5  Additionally, student pharmacists who score high on perceived stress questionnaires have lower health-related quality of life (mental health component).3,6  The psychiatric symptoms and stress may negatively impact academic performance.7 

A risk factor for psychiatric and physical health problems is exposure to adverse childhood experiences (ACEs).8  ACEs are defined as stressful or traumatic experiences that individuals face prior to the age of 18 years.9  ACEs are associated with higher psychiatric and physical illnesses and substance use disorders in adulthood among the general population.10–12  Many college students have been identified as having a history of exposure to childhood adversities.13–18  A study conducted in third-year medical students reported that 51% had exposure to at least 1 ACE.19  ACEs are found to be associated with poor mental and physical health and high-risk health behaviors that include substance misuse, smoking, having multiple sexual partners, and maladaptive coping behaviors among college students.13–15,18,20  Psychological resilience—the ability for one to emotionally and mentally cope with a crisis—is highly variable among individuals.21  An individual with increased resilience may be protected against downstream consequences of ACEs; individuals with low resilience may be at higher risk of poor outcomes.22–24  In addition to reductions in mental and physical health, ACEs are associated with poor academic outcomes, such as lower grade point average (GPA), and poor adaptation.25  An individual’s resilience may also be related to the individual’s academic performance in instances of coping with stressful doctor of pharmacy degree programs. Thus, both ACEs and measures of resilience have been shown as correlates of academic performance and negative health outcomes.26  No known study investigates the prevalence of emotional, psychological, and physical health consequences associated with exposure to ACEs among student pharmacists.

The purpose of this study is to determine the prevalence of ACEs among students in California doctor of pharmacy programs and the potential consequences associated with ACE exposure. The specific objectives of the study are the following:

  • Determine the exposure to ACEs among student pharmacists.

  • Determine the self-reported level of resilience among student pharmacists.

  • Determine the maladaptive coping strategies utilized among student pharmacists.

  • Determine the association between exposure to ACEs and demographics/personal characteristics among student pharmacists.

Students enrolled in 14 doctor of pharmacy programs in California (n = 5021) were eligible to participate in this cross-sectional study. The survey was administered online using Qualtrics software. This study was determined exempt by the Western University of Health Sciences institutional review board. A hyperlink to the survey was emailed to students at each pharmacy school in California by a California Pharmacy Student Leadership (CAPSLEAD) faculty advisor in May 2020. All students were requested to provide informed consent prior to completing the survey. The survey remained open for 2 months, and students were provided the opportunity to enter a raffle drawing to win one of 4 Amazon gift cards worth $10 each if they entered an email address at the end of the survey. The students were informed through an email that their email addresses would not be linked to their survey responses to ensure confidentiality.

The Survey Instrument

The study used a 24-item survey. The core of the survey consisted of the validated 10-item ACEs questionnaire, which measures adversity in the household prior to the age of 18 years.11  The ACEs questionnaire includes questions regarding child abuse (eg, emotional, physical, and contact sexual abuse) and exposure to household dysfunction (eg, substance abuse, mental illness, domestic violence, and incarceration). Students were asked to respond with yes or no if they had been exposed to any of these 10 adversities prior to turning 18 years old. The ACEs questionnaire is widely utilized to understand the effect of childhood trauma on the subsequent health of patients during adulthood. Therefore, respondents were also asked to indicate if they believed adverse experiences affected their health.

Four survey items measured students’ potential maladaptive coping mechanisms, such as the frequency of alcohol consumption, using drugs other than the ones needed for medical reasons, and tobacco use in the last 12 months. Responses included never, monthly or less, 2 to 4 times a month, 2 to 3 times a week, 4 or more times a week, or prefer not to answer. The fourth survey item measured the number of lifetime sexual partners and included responses of 0, 1 to 5, 6 to 10, 11 to 30, > 30, or prefer not to answer.

The survey inquired whether students have ever been suspected to have or diagnosed with a mental health condition with responses of yes, no, or prefer not to answer. If the answer was yes, the student was prompted with a follow-up question to assess how the student managed the mental health condition with responses of medication, therapy, counseling, other or alternative treatment, I am not currently receiving treatment, or prefer not to answer.

The survey utilized 2 Connor-Davidson Resilience Scale items to measure the resilience of student pharmacists.27  These 2 items measured the students’ adaptability to change and their ability to bounce back after illness, injury, or other hardship.

The survey also included a total of 5 demographic and academic items, including an age category, gender, ethnicity, and GPA and a single item measuring the struggle to manage the workload of pharmacy school on a Likert scale.

Data Analysis

Descriptive statistics (eg, means, medians, frequencies, and standard deviations) were computed for all study variables as appropriate. Respondents’ ACE scores were computed by adding the yes (yes = 1, no = 0) responses. The total ACE scores ranged from 0 (no exposure to any adverse experiences) to 10 (exposure to all 10 experiences). Higher scores for ACEs signify increasing risks of adverse health outcomes. ACE scores 1 to 3 (low ACEs) signified few adverse experiences. An ACE score of 4 or greater is associated with the greatest risk of severe negative health outcomes, including risk of suicide, drug use, and depression.

Responses to both resilience items were recorded as follows: not true at all = 0, rarely true = 1, sometimes true = 2, often true = 3, and true nearly all the time = 4. The resilience scale scores ranged from 0 to 8 points. Participants with a greater score were determined to be more resilient.

A Mann-Whitney U test was used to compute the differences in mean rank ACE scores by gender and mental health condition (yes/no). A chi-square test was used to determine the association between the ACE score groups (high/low) by mental health condition, workload management, alcohol use, tobacco use, number of sexual partners, resilience, and gender. A Kruskal-Wallis test was used to determine if there were any significant differences by ethnicity, GPA, and age group in mean rank ACE scores. Spearman correlation was used to compare the association between ACE scores by use of alcohol, use of drugs other than the ones needed for medical reasons, tobacco use, and number of sexual partners. A two-tailed level of statistical significance of less than .05 was used for all statistical comparisons. All statistical analyses were performed using IBM SPSS version 27.

A total of 354 students attempted the survey; however, only 305 responses were deemed complete. Respondents were primarily Asian/Pacific Islander (n = 186, 61.0%), female (n = 216, 70.8%), and between 25 and 31 years of age (n = 154, 50.7%) (Table 1).

TABLE 1

Student demographics

Student demographics
Student demographics

Student Behaviors and Resilience

Many students suspected having or were diagnosed with a mental health condition (n = 105, 34.4%) and also agreed or strongly agreed that they struggled to manage the workload of pharmacy school (n = 119, 39.9%). Most students reported consuming an alcoholic beverage at least monthly in the last 12 months (n = 213, 70.1%). Fewer students reported that they used drugs other than the ones they needed for medical reasons at least monthly (n = 41, 13.5%) or used tobacco products (n = 39, 12.8%) at least monthly or had more than 6 sexual partners in their lifetime (n = 40, 13.2%). Fifty-nine students (19.3%) indicated that they were able to adapt nearly all the time when change occurs, and 55 students (18.0%) indicated that they tended to bounce back nearly all the time after illness, injury, or other hardships. The average resilience scale score of all the student pharmacists was 5.61. The resilience score was not statistically significantly associated with ACE scores or the demographic characteristics of the students (Table 2).

TABLE 2

Student behaviors and resilience

Student behaviors and resilience
Student behaviors and resilience

Prevalence of ACEs

A comprehensive list of responses to each of the 10 items in the ACEs questionnaire is provided in Table 3. The adversity that was reported by the highest number of students was verbal abuse (question 1) (n = 109, 35.7%). Furthermore, 78 (25.6%) students reported that their parents separated or divorced prior to turning 18 years old (Table 3).

TABLE 3

Student responses to adverse childhood experience questionnaire items

Student responses to adverse childhood experience questionnaire items
Student responses to adverse childhood experience questionnaire items

Most students reported experiencing at least one ACE before turning 18 years old (n = 197, 64.6%) with 60 (19.7%), 41 (13.4%), and 30 (9.8%) students reporting 1, 2, and 3 ACEs, respectively. One hundred thirty-seven (44.9%) students reported experiencing multiple ACEs. Sixty-six students admitted to having more than 3 ACEs (21.6%). The overall mean ACE score was 1.86 (SD = 2.0; range: 0 to 9).

Students’ Behavior, Life Experiences, and ACEs

The majority of the respondents (n = 194, 63.6%) indicated that they were affected by the ACEs to which they were exposed. Sixty-six (21.6%) of these students indicated that they were significantly affected by ACEs. Students with higher ACE scores (> 3 adverse experiences) were more likely to report having been suspected to have or been diagnosed with a mental health condition than those who had lower ACE scores (≤ 3; r = −.416, p < .001) (Table 4). Students with higher ACE scores were significantly more likely to report struggling to manage the workload of pharmacy school (r = .135, p = .020), drinking alcohol in the last 12 months (r = .161, p = .005), or having more sexual partners (r = .201, p < .001) than those with lower ACE scores. There was no statistically significant correlation between ACE scores and the use of drugs other than the ones needed for medical reasons; using tobacco products in the last 12 months; ability to adapt when changes occur; or ability to bounce back after illness, injury, or other hardships (p > .05) (Table 4).

TABLE 4

Correlation between total adverse childhood experience scores and student behaviors

Correlation between total adverse childhood experience scores and student behaviors
Correlation between total adverse childhood experience scores and student behaviors

Demographic Characteristics and ACEs

There was no statistically significant difference in the number of ACEs reported by the students based on self-reported ethnicity (Kruskal-Wallis H [df = 4] = 9.247, p = .055). A greater proportion of female students (n = 55, 83.3%) reported having more than 3 ACEs than male students (n = 11, 16.7%) (X2 = 6.565, df = 2, p = .038). There were also no statistically significant differences in ACE scores (high/low) by age group, resilience, or GPA.

Roughly one-fifth of student pharmacists in this study (21.6%) reported having more than 3 ACEs, consistent with findings from a study of Vietnamese medical students.18  The prevalence of ACEs in this study is higher than rates reported in a large sample of privately insured adults (12.5%), Korean college students (12%), and US medical students (12%).11,15,19  The average ACE score reported in this study (1.86, SD = 2.0) is greater than 0.85 (SD = 1.1) obtained among California undergraduate college students.13  The study finding that nearly two-thirds of the students reported a history of at least 1 ACE exposure before their 18th birthday (n = 197, 64.6%) is greater than the nearly 50% of students who reported a family-based history in a previous study.13  Furthermore, 44.9% of students with multiple ACE exposures is greater than 23% reported among California college students.13  The data suggest that California student pharmacist respondents may have a higher prevalence of childhood adversities than found in previous studies of adults, including college-aged young adults.11,15,18,19 

Approximately one-third of student pharmacist respondents indicated that they had been diagnosed with or suspected of having a mental health condition. The number of student pharmacists who reported poor mental health in this study is higher than 21% and 19% of student pharmacists and pharmacy residents who were found to have clinically significant anxiety and depression symptoms, respectively, in previous studies.4,28  Data from the 2021 Substance Abuse and Mental Health Services Administration shows that 22.8% of all US adults had mental illness.1  In this study, students with higher ACE scores were significantly more likely to report mental health conditions than students with lower ACEs scores. Similarly, medical students perceived that ACEs impacted them and their mental health.19 

About 12.5% of student pharmacists reported misusing drugs and using tobacco products monthly or at least in the last 12 months. Furthermore, 70% of the students consumed alcohol at least monthly in the last 12 months, and 13% had more than 6 sexual partners in their lifetime. However, only alcohol use and number of sexual partners were correlated with ACE scores. Previous studies also report similar engagement in risky behaviors among other college students.13,15  Student pharmacists engage in risky health behaviors, which can negatively impact their health and wellness.29  Increased ACE scores are reported to be associated with a higher likelihood of risky health behaviors and maladaptive coping mechanisms, which may further contribute to the development of social and emotional challenges.12,13,30–34  Colleges and schools of pharmacy should be prepared to help students who may be struggling with long-term effects of functional impairments due to ACEs through implementing stress-reduction programs.30 

Many student pharmacist respondents reported struggling to manage the workload of pharmacy school. Similarly, Fuller and colleagues found that many student pharmacists were stressed, exhausted, and overwhelmed by the high demands of pharmacy school.35  Chronic and unrelieved stress may result in burnout, which is reported to be associated with numerous negative consequences, including alcohol use disorder, academic dishonesty, and other unprofessional behaviors among medical students.36–38  A study among community-based pharmacists licensed in Ohio found that 67.2% were experiencing burnout, highlighting the significant issue of burnout within the pharmacy profession.39  Burnout is also common among healthcare students, for which upward of 50% may experience it during their training.40  The respondents’ struggle to manage the workload of pharmacy school was associated with having higher ACEs in this study. Student pharmacists with higher ACE levels may have heightened vulnerability to burnout and the resultant negative outcomes. Burnout is also found to be positively associated with ACE levels among nursing students, physicians, and early childhood educators.41–44 

There was a statistically significant relationship between high ACE scores and gender with female student pharmacists having higher ACE scores. Similarly, female medical students were found to have higher ACEs scores than males.19  Furthermore, females were reported to have higher trauma exposure, severity, and impact than males.16,45–47  Female student pharmacists and medical students were found to have a higher prevalence of academic stress than male students.30,48–52  The significance of this study’s findings becomes apparent when considering that the majority of student pharmacists in both this sample and nationwide are female. More research is needed to further explore the relationship between gender and ACEs.

There was no statistically significant relationship between student pharmacists’ ACE scores and their ethnicity. The relationship between ethnicity and ACEs is understudied in the literature.13  It is unknown whether ethnicity independently predicts ACE exposure among the general population or college students. Moreover, there was no significant association between ACE exposure and GPA or academic performance, contrary to findings from previous studies.7,25  Further studies are needed to explore the relationship between ACEs and academic performance.

Student pharmacist respondents had a mean resilience scale score of 5.61, which is similar to 5.6 obtained for trauma survivors in the United States, but lower than 6.8 and 6.9 found for the general population.53,54  There was no correlation between the students’ resilience and ACE scores. Resilience has been shown to buffer individuals against negative effects of ACEs and help students bounce back from trauma and stress.23  Student pharmacists exposed to ACEs and other stressors without protective factors may have a higher likelihood of developing health conditions. Previous studies find that resilience mediates about 40% of the correlation of ACEs with future opioid misuse.24  Many student pharmacist respondents were managing their mental health conditions through medication (18.4%), therapy or counseling (19.9%), or other or alternative treatment (19.1%). These treatments may help student pharmacists overcome the challenges posed by ACEs. However, 41.9% of the student pharmacists surveyed indicated that they were not currently receiving treatment for their psychiatric conditions. Similarly, most of the US adults and university students with a mental illness do not receive any mental health services.1,55,56  There exists widespread disparities in mental health access and treatment across various populations or groups.57  Many people do not receive mental health care that they need due to stigma, lack of perceived need, insufficient mental health professionals, skepticism about treatment effectiveness, lack of awareness about services offered or insurance coverage, lack of time, or resource constraints among others.56–60  More can and should be done to help student pharmacists manage their psychiatric conditions by identifying and removing the barriers concerning access to mental health care. Mental health awareness campaigns are reported to be effective at increasing the uptake of mental health services by university students.58  The American Association of Colleges of Pharmacy (AACP) has convened conferences to draw attention to the issues of well-being, burnout, depression, and suicidality. The AACP “encourages schools and colleges of pharmacy to proactively promote overall wellness and stress management techniques to students, faculty, and staff.”61  Further investigation is needed to aid schools and colleges of pharmacy in developing interventions. Perhaps schools and colleges of pharmacy can develop tailored interventions that utilize student pharmacists’ ACE history alongside other clinical information.

Limitations of the Study

This study has several limitations. First, the study included student pharmacists from 1 state. Therefore, the study findings may not be generalizable to student pharmacists in other states. This is more so given that the ethnicity mixture of this study’s respondents was not representative of student pharmacists nationally (61% Asian/Pacific Islander vs 25.3% Asian American and Pacific Islanders who received the doctor of pharmacy degree nationally in 2020). Second, recall bias may be a problem in this study as students were asked to recall information from the past. Third, the study was conducted during the COVID-19 pandemic, which may have contributed to the maladaptive behaviors reported by the students. The COVID-19 pandemic may have elevated the students’ psychological distress and dysfunction and the intensity of maladaptive behavior.62  Fourth, no causal inferences can be determined from this study given its cross-sectional design. Prospective longitudinal studies are recommended to investigate the impact of ACEs on student pharmacists’ health, wellness, academic outcomes, and behaviors. Fifth, given that student pharmacists are reported to have high levels of stigma and be less willing to seek mental health treatment, it is possible that some students did not disclose all their childhood adversities.4  Consequently, prevalence rates reported in this study may be an underestimation of the actual prevalence rates that exist in the population of California student pharmacists.

ACE is a critical issue besetting student pharmacists with more than 1 in 5 student pharmacist respondents reporting exposure to more than 3 childhood adversities. About two-thirds of the students reported exposure to multiple ACEs. The ACE exposure among student pharmacists was associated with mental health problems and high-risk behaviors. Schools and colleges of pharmacy should prioritize providing mental health resources and services to meet the needs of their students.

We thank Western University of Health Sciences College of Pharmacy for the support and funding of the California Pharmacy Student Leadership 2019-2020 team.

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Disclosures: All authors do not have any conflict of interest to declare.

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