Adverse childhood experiences and adolescent mental health: trajectories of internalizing, externalizing and prosocial behaviour in a longitudinal cohort study

Abstract

Abstract Aims Adverse childhood experiences (ACEs) shape children’s socioemotional development, yet longitudinal evidence from low- and middle-income countries remains limited. This study examined how ACEs relate to internalizing, externalizing and prosocial behaviours from childhood to adolescence in a rural Pakistani cohort. Methods Data were drawn from the Bachpan Cohort, a longitudinal study including 1,791 observations across three waves: ages 4–5, 8–9 and 12–15 years. ACEs were assessed using an adapted ACE-International Questionnaire. Outcomes were measured using the Strengths and Difficulties Questionnaire. Network analysis, dose-response modelling and moderation analyses were employed. Results Emotional neglect was the most prevalent ACE (83.7%). Parental psychiatric issues, parental trauma exposure and emotional neglect were the most central ACE stressors. A dose-response relationship emerged: compared to children with no ACEs, those with four or more ACEs showed higher internalizing (incidence ratio [IR] = 4.24) and externalizing problems (IR = 3.42) and lower prosocial behaviour (IR = 0.90). Girls showed greater internalizing vulnerability; boys showed more externalizing problems. ACE effects on internalizing problems strengthened with age. Conclusions ACEs are strongly associated with internalizing, externalizing and prosocial outcomes from childhood to adolescence. Findings highlight the need for tiered, gender-sensitive and developmentally appropriate interventions in low-resource settings.