📄 public and global health

Adverse and benevolent childhood experiences and depression among women in rural Pakistan

This study of 804 women in rural Pakistan reveals that while adverse childhood experiences increase the risk of maternal depression, benevolent childhood experiences independently reduce depressive symptoms and buffer the negative impact of low-to-moderate adversity, highlighting the importance of fostering positive developmental resources alongside reducing exposure to trauma.

Original authors: Gallis, J. A., Pan, Y., Wright, R., Kachoria, A., Lin, W.-C., Frost, A., Kim, M. K., Sikander, S., Maselko, J.

Published 2026-07-24

📖 5 min read🧠 Deep dive

CC BY 4.0

Original authors: Gallis, J. A., Pan, Y., Wright, R., Kachoria, A., Lin, W.-C., Frost, A., Kim, M. K., Sikander, S., Maselko, J.

Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). ⚕️ This is an AI-generated explanation of a preprint that has not been peer-reviewed. It is not medical advice. Do not make health decisions based on this content. Read full disclaimer

Imagine your mind is like a garden. Some gardens are planted in soil that has been through a storm—maybe the ground was shaken by earthquakes, or the trees were struck by lightning. In the world of science, we call these rough patches "Adverse Childhood Experiences" (ACEs). These are tough things that happen to kids before they turn 18, like violence at home, being ignored, or family members struggling with addiction or mental health. We know from many studies that if a garden starts with a lot of storm damage, the plants inside often struggle to grow tall and strong later in life, sometimes leading to feelings of sadness or depression.

But here is the twist: a garden isn't just defined by the storms it survived. It's also defined by the sunshine, the rich water, and the sturdy fences that protected it. Scientists call these the "Benevolent Childhood Experiences" (BCEs). These are the good things: having a safe hug from a caregiver, a teacher who believed in you, or just feeling like you belonged in your neighborhood. For a long time, researchers mostly looked at the storms and wondered if the sunshine could fix the damage. They wanted to know: If a garden has both a lot of storms and a lot of sunshine, does the sunshine cancel out the storms? Or does the storm win anyway? This question matters because understanding how these two forces mix helps us figure out how to help people who are struggling with sadness, especially mothers who are trying to raise families.

This paper takes a deep dive into that question by looking at the lives of 804 women in rural Pakistan. The researchers wanted to see how the "storms" (ACEs) and the "sunshine" (BCEs) from these women's childhoods affected their mental health from the time they were pregnant all the way through eight years after having their babies. They didn't just count the bad and good things separately; they looked at how they mixed together, like ingredients in a recipe.

The team found that the "storms" were quite common. More than half of the women (58.5%) experienced at least one bad event in their childhood, and a small group (6.2%) faced four or more. The most common "storms" were things like violence happening inside the home, being neglected, or family members dealing with serious emotional or mental struggles. On the flip side, the "sunshine" was surprisingly bright. Nearly half of the women (45.3%) remembered having all ten of the positive experiences the researchers asked about, and over half remembered having six to nine of them. Things like having a safe caregiver, feeling good about themselves, and having good neighbors were reported by almost everyone.

When the researchers mixed these ingredients together, they found a fascinating pattern. First, the bad stuff and the good stuff acted like two separate forces. Having more "storms" (ACEs) was linked to higher levels of sadness and depression, while having more "sunshine" (BCEs) was linked to lower levels of sadness. But the real magic happened when they looked at how they interacted.

The study suggests that the "sunshine" acts like a shield, but only up to a point. For women who had a moderate amount of "storms" (between one and three bad experiences), having a lot of "sunshine" really helped buffer the pain. It was like having a strong umbrella during a heavy rain; the rain still fell, but you stayed much drier. However, the paper found that this shield didn't work for everyone. For women who had no "storms" at all, the extra "sunshine" didn't change much because they were already doing fine. More importantly, for the women who faced a massive amount of "storms" (four or more bad experiences), the "sunshine" wasn't enough to stop the damage. It's as if the storm was so violent that even the best umbrella couldn't keep you dry.

The researchers also used a special method to group the women based on their unique mix of experiences. They found four main groups:

The Lucky Group: Low storms, high sunshine (the most common group).
The Resilient Group: High storms, high sunshine.
The Quiet Group: Low storms, low sunshine.
The Vulnerable Group: High storms, low sunshine.

The women in the "Vulnerable Group" (High storms, low sunshine) had the heaviest burden of sadness. This suggests that while having a lot of good experiences is great, it's not a magic cure-all if the bad experiences are too overwhelming. The paper concludes that to help mothers stay mentally healthy, we need to do two things at once: try to stop the "storms" from happening in the first place, and make sure every child has access to as much "sunshine" as possible. But for those who have already been through the worst storms, we need to offer extra support because a little bit of sunshine might not be enough to fix a garden that has been battered by a hurricane.

Technical Summary: Adverse and Benevolent Childhood Experiences and Depression Among Women in Rural Pakistan

Problem Statement
Maternal depression is a significant public health challenge, particularly in low- and middle-income countries (LMICs), where prevalence rates often exceed 30%. While Adverse Childhood Experiences (ACEs) are well-established risk factors for adult depression, the role of Benevolent Childhood Experiences (BCEs) as potential buffers or promotive factors remains underexplored, especially in non-Western, low-resource settings. Existing literature often treats ACEs and BCEs as independent constructs using aggregated scores, potentially obscuring the complex, co-occurring patterns of early-life experiences. Furthermore, there is limited evidence on whether BCEs can mitigate the adverse effects of ACEs (interaction effects) or if they operate independently to promote mental health. This study addresses these gaps by investigating the joint effects of ACEs and BCEs on maternal depression from the third trimester of pregnancy through eight years postpartum among women in rural Pakistan.

Methodology
The study utilized a longitudinal analysis of 804 women from the Bachpan cohort study, a cluster randomized controlled trial in rural Pakistan.

Data Collection: Depressive symptoms were measured at nine time points (baseline through 8 years postpartum) using the Patient Health Questionnaire-9 (PHQ-9). ACEs were assessed at 3 years postpartum using the Adverse Childhood Experiences-International Questionnaire (ACE-IQ), adapted for the local context (excluding sexual abuse items due to reporting concerns). BCEs were assessed at 7 years postpartum using a 10-item scale.
Statistical Approach: The analysis employed two primary methodological frameworks:
1. Aggregated Scores: Linear mixed-effects models were used to estimate independent effects of ACE and BCE total scores on PHQ-9 trajectories. The models included interaction terms and subgroup analyses (stratified by ACE and BCE levels) to detect non-linear interactions.
2. Latent Class Analysis (LCA): A person-centered approach was used to identify distinct subgroups based on co-occurring patterns of 12 ACE and 10 BCE binary items.
Adjustments: Analyses accounted for the oversampling of depressed women using sampling weights and addressed informative missingness via stabilized inverse probability of censoring weights (IPCW). Models adjusted for maternal age, family history of mental illness, and primary education completion (as a proxy for childhood socioeconomic status).

Key Results

Prevalence: 58.5% of women experienced at least one ACE, with home violence (39.3%), neglect (19.7%), and family psychological distress (15.2%) being the most common domains. Conversely, BCEs were highly prevalent; 45.3% of women reported all ten BCEs, and over half reported 6–9 BCEs.
Independent Effects: Higher ACE exposure was independently associated with increased depressive symptoms ( $\beta = 0.44$ ), while higher BCE exposure was independently associated with reduced symptoms ( $\beta = -0.25$ ), even after mutual adjustment.
Interaction Effects: While the linear interaction term was not statistically significant, subgroup analyses revealed non-linear patterns. The protective effect of BCEs was significant for women with 1–3 ACEs ( $\beta = -0.56$ ) but was negligible for those with no ACEs or those with four or more ACEs. Conversely, the harmful effect of ACEs was strongest among women with low levels of BCEs.
Latent Classes: LCA identified four distinct profiles: Low-ACE/High-BCE (58.6%), High-ACE/High-BCE (19.5%), Low-ACE/Low-BCE (13.8%), and High-ACE/Low-BCE (8.1%). Women in the High-ACE/Low-BCE class exhibited the highest depressive symptom burden, significantly higher than the reference group (Low-ACE/High-BCE).
Domain Specificity: Home violence, family psychological distress, and community violence showed stronger associations with depression than neglect. BCEs demonstrated a consistent protective effect across all ACE domains.

Significance and Claims
The authors claim this is the first investigation of the joint patterns of ACEs and BCEs on maternal depression in Pakistan. The study supports multiple resilience theory frameworks:

Compensatory Model: BCEs operate as independent promotive factors that directly reduce depressive symptoms regardless of ACE exposure.
Protective Factor & Challenge Models: BCEs act as protective buffers, mitigating the negative impact of ACEs, but only when the level of adversity is not overwhelming (i.e., effective for 1–3 ACEs but insufficient for $\ge$ 4 ACEs).

The paper concludes that understanding maternal depression in low-resource settings requires examining both adverse and benevolent experiences. It suggests that interventions should aim to reduce adversity exposure while simultaneously fostering positive developmental resources. However, the authors note that for women exposed to severe, high-burden adversity, benevolent experiences alone may be insufficient to offset risks, necessitating additional psychosocial support.

Limitations
The study acknowledges limitations including retrospective recall bias, the exclusion of sexual abuse from the ACE measure (potentially underestimating prevalence), the use of education as a proxy for childhood socioeconomic status, and the potential for differential misclassification due to the mental health state of participants at the time of reporting.

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