Impact of adverse childhood experiences on alcohol use in emerging adults in Montenegro and Romania

Alcohol has been identified as a leading and one of the most harmful risk factors for global disease burden (1, 2, 3). Until recently, research has been focused on harmful alcohol use/abuse or early initiation of alcohol use/abuse. However, the recent work of the Global Burden of Disease (GBD) 2016 Alcohol Collaborators’ Group has shown that use of alcohol at relatively low levels is not beneficial and, in fact, may be harmful even at levels considered today as moderate. Consequently, any alcohol use (AU) should be considered as harmful (4). Especially vulnerable to AU are adolescents and young people in transition to adulthood (5, 6).

Factors associated with AU are numerous and among them are included adverse childhood experiences (ACEs) (7, 8, 9, 10). Evidence shows that AU is a common copying strategy adopted by ACEs victims to deal with the trauma (11), or to gain control over the negative experience (12).

In a special developmental stage, situated between late adolescence and adulthood (13) (young people aged 18– 29), AU is frequently observed (14). The reason for this lies in the fact that, while addressing many development tasks, emerging adults tend to engage in risk-taking behaviours due to underdeveloped coping mechanisms, with AU being among them (13, 15). While a vulnerability to AU can be increased additionally in those with ACEs (16).

The biggest burden of AU is recorded in the European Region (3, 17). Within this region, in all the South Eastern Europe (SEE) countries with available data (Albania, Bosnia, Bulgaria, Croatia, Montenegro, Northern Macedonia, Romania, Serbia and Slovenia) alcohol per capita consumption (APC) in litres of pure alcohol (2015– 2017 average, adjusted for tourist consumption) in males is well above the average APC in Europe as a whole (9.8 litres) (3). In Bulgaria, Romania, Serbia and Slovenia the APC is also above the European region average in terms of total population.

According to our knowledge, there were no studies yet

to investigate the association between AU and ACEs in emerging adults in SEE countries in details yet. A better understanding of the ACEs underlying the risk for AU is critical for developing more effective prevention and early intervention measures in this part of Europe.

Aiming at generating evidence for formulating targeted and cost-effective public-health interventions for effective control of AU in emerging adults in the SEE region, the study objective was to assess if alcohol users experienced ACEs more often than non-users.

The results of the present study show that among emerging adults in the observed countries the prevalence of key phenomena, AU and experiencing at least one ACE type during childhood, are both very common. The deeper insight into the relationship between them suggests that physical type of ACEs is more strongly associated with AU patterns than emotional type, since no ACE of emotional type were included in the multivariate model. Among household dysfunction factors, growing up in a home with alcohol abuse or mentally ill household members proved to be the only significant predictor of AU patterns.

A comparison of the results of our study to older research, which has only focused on harmful or early use of alcohol, was not easy. Nevertheless, we were able to make some comparisons. Finding that physical abuse is associated with AU is consistent with the study of Kauhanen et al., which stated that a punishing parenting style increased the risk of early AU as early as adolescence (8). Results from a US community survey indicated that physical punishment in teenage years significantly increased AU in adulthood (22). Shin et al. reported that physical abuse victims adopt maladaptive coping styles, including AU, when peer and social environments provide drinking opportunities for young victims who are poorly equipped over time to handle a variety of developmental challenges. Additionally, they claim that reduced social control and adoption of “adult” roles, both common in emerging adults, have the potential to increase AU problems (23). Surprisingly, frequent experience of no person to take to the doctor, if necessary, was included in the final model and even more, as a protective factor. This could be related to sense of coherence, the core construct of the Antonovsky’s salutogenic model (24, 25). Children growing up in unfavourable environments, as long as the experiences are not heavily traumatizing, can also develop intrinsic coping mechanisms, strengthening their ability to resist some unhealthy behaviours, including AU. This hypothesis is supported by the results of studies in the past (25), as well as some newer studies, e.g. the study of Mendes Moutinho et al. (26).

As suggested by others, children’s environments determine the development of health behaviours (27). As reported by Chartier et al., parents demonstrating negative role models are promoting poor health habits in their children (28). Greater susceptibility to AU in respondents who grow up with an alcoholic, is consistent with evidence on familial alcoholism as a strong risk factor for alcohol dependence (9, 29). It was reported by Bennett et al. that children of alcoholics are four- to five-times more likely to become alcoholics than other children, while biological children of alcoholics who are adopted to other homes have a two- to nine-fold increased risk of developing alcoholism (30). Consequently, it should not be neglected that genetics may also play its role in the observed association (8, 9). However, some evidence suggests that a strong effect of early adversity on the risk of AU was independent of family history (31).

Among other important results, there are two key findings. Our finding that AU is more common among male ACE victims compared to females, which echoes evidence from previous research on gender differences in adult drinking patterns related to ACE exposure (32). However, the findings on the impact of gender on association between ACEs and AU seem to be inconsistent. One of the most rigorous longitudinal studies of ACEs (33) found that maltreatment during childhood was unrelated to men’s alcohol use in early/middle adulthood, while female ACE victims were at significantly higher risk compared to non-victims. Other studies report that there were no gender differences in the effects of early child abuse on AU (34, 35). As suggested by Strine et al., it is possible that gender stereotypes describing men/boys as being resilient contributed to having much of the research to date examining the association between ACEs and problem drinking in females (32). Another important result of our study suggests that mother’s unemployment could be a protective factor. It seems that unemployed mothers have better prospects for continuous parental monitoring, better opportunities to promote family attachment and/ or prosocial involvement as a guard against externalizing problem behaviours (32).

The study has some potential limitations. First, only students were included in the study, which could mean that findings are hardly representative of the general population, but the similarity of the study findings to those of population-based studies suggests that findings are applicable in other settings as well (10, 36). However, one needs to be careful when interpreting them. On the other hand, the very carefully conducted process of sample selection in both countries allows for generalizing the findings to the overall student population in Montenegro and Romania, while very high response rates minimize different kinds of biases, including information bias (18, 19). It is not expected that a slight difference in sampling procedures and response rates between both countries would have any major influence on the conclusions. Next, the different cultural backgrounds of respondents – coming from one country historically belonging to the former USSR influence zone and the other being a former Yugoslav country – might be seen as a potential cause for differential reporting between the respondents. However, shared contemporary EU perspectives and the values of both countries relativize the potential of biased reporting in this regard. Next, respondents may have certain difficulty recalling ACEs, leading to an underestimate of their actual occurrence. However, the young age of our respondents makes problems of recall bias less likely. Finally, while having similarities with a study recently published by Bellis et al. (37), we used a different methodology (individual ACEs and not only the number of ACEs were considered). The methodology could be additionally improved by the inclusion of potential interactions between countries and the other background variables; however, this extension of analysis was out of the scope of this study and should be addressed in further research.

On the other hand, the study has several strengths that draw important public health implications. The most important is that the present study builds on the latest evidence that any alcohol use is harmful (4). This sets a new perspective on public health measures for alcohol harm reduction – measures focused on decreasing population-level consumption through tackling the affordability and availability of alcohol should be prioritized. Next, the study provides a special message that some phenomena regarded as nearly ubiquitous (here AU) may partly be a result of other very common phenomena (here ACEs). This means that, e.g. by targeting healthcare professionals’ attitudes toward domestic violence (38), the burden of ACEs could be reduced and, consequently, partly also the burden of AU. Thus, the presented evidence suggests that strategies for AU prevention and control should integrate interventions for managing early adversities, which is true not only for Montenegro and Romania, but also for other countries in transition with similar socio-economic and cultural conditions. As evidence from countries neighbouring Montenegro and Romania shows, a holistic approach is needed in addressing unhealthy behaviour in young people (39). On this basis, we can conclude that the study findings could be effectively used to orient policymakers in designing evidence-based responses to child maltreatment, targeting the population subgroups prone to harmful use of alcohol while ensuring the efficient use of scarce resources for prevention.

Further research in the field is needed. First, the extension of the present study in terms of assessing potential interactions between the two countries and the other key background variables would be necessary. Next, it would be interesting also to identify the high-risk-for-AU profiles, which would be targeted with focused and consequently more cost-effective prevention interventions. A similar approach has already been suggested in addressing suicidal behaviour (40). However, both extensions of analysis were out of the scope of this study. Finally, a similar study in the non-student part of the population of emerging adults would be of great importance, broadening the knowledge about the problem in this subgroup, although more difficult to reach than the student population (41).

It can be concluded that the effect of exposure to childhood adversities on AU persists into emerging adulthood. Along with the most recent views on the problem that AU, even at moderate levels, may be harmful, this should be considered when planning preventive measures for the reduction of AU in younger age groups. Keeping in mind these facts, the study provides guidance for developing a cost-effective response to the AU burden through targeted interventions, in particular in scarce resources settings.