Adverse childhood experiences (ACEs) are potentially traumatic events occurring before the age of 18, including physical, emotional, and sexual abuse, physical and emotional neglect, and household dysfunction, including domestic violence, substance abuse, mental illness, parental separation, and incarceration (1, 2). Exposure to ACEs is linked to the development of various psychological disorders, particularly post-traumatic stress disorder (PTSD) (3, 4). In a study involving young girls, a gradual increase in the likelihood of probable PTSD was observed with higher ACE exposure levels, with a single ACE exposure such as firearm abuse or rape, increasing the likelihood of probable PTSD nearly fivefold (5).

Symptoms of PTSD in children and adolescents include reliving the trauma through intrusive thoughts and flashbacks, avoiding trauma-related triggers, experiencing negative mood shifts, and heightened arousal and reactivity, which can hinder a child's development, influencing their emotional, cognitive, and social progress (6). PTSD in children is linked to depression, aggression, academic struggles, and social challenges (7, 8). Also, the prolonged psychological distress associated with PTSD can increase the likelihood of developing chronic diseases and conditions such as hypertension, hyperlipidemia, obesity, and cardiovascular disease (9, 10).

Recent findings from a nationwide survey highlighted major mental health and psychosocial challenges among children and adolescents in Jordan (11). In general, Jordan faces a combination of challenges including regional instability, a large influx of refugees, economic hardship, specific cultural norms surrounding mental health, such as stigma and limited mental health resources. This creates a complex environment in Jordan that heightens the risk of negative mental health outcomes, including ACEs and PTSD, among children and adolescents, particularly among refugee populations (12). A comprehensive study from Jordan revealed a high prevalence of child abuse and its negative consequences, coupled with a lack of awareness about child abuse and its impacts (13).

Despite PTSD's profound impact on children, most studies on ACEs and PTSD lack representative samples and few focus on low-income countries (14, 15). In Jordan, few studies have examined PTSD and its relationship with ACEs, particularly using a representative sample that includes a broad age range encompassing both children and adolescents (16). Additionally, children and adolescents form a large share of Jordan's population, and Jordan hosts one of the world's largest refugee populations relative to its size (17, 18). Also, both refugee and host-community youth in Jordan face significant stressors. Refugee children experience displacement, loss, and instability, while host-community children often face overcrowded schools and strained services (19, 20). These overlapping pressures increase vulnerability in both groups. Therefore, this study aimed to determine the prevalence rates of ACEs and high PTSD symptoms and to investigate the association between ACE and PTSD among children and adolescents living in Jordan. This study is crucial to inform the development of interventions and prevention policies specifically tailored to this population. Findings are important for mental health practitioners, educators, policymakers, and caregivers, enabling them to provide effective support and minimize the enduring effects of trauma.

High rates of PTSD symptoms among children and adolescents in Jordan were found. Studies in Jordan reveal varying prevalence rates of PTSD between 16.2% and 65.1% (16), likely due to differences in trauma type, population studied, and methodologies. Despite these differences, findings highlight an alarmingly high prevalence, particularly among females and refugees (25–27). PTSD symptoms were higher in adolescents, likely due to the unique characteristics of this developmental stage, with being particularly susceptible to experiencing multiple types of ACEs (28, 29). Adolescence involves biopsychosocial changes, such as evolving relationships and increased reliance on peers, which may lead to risky behaviors and traumatic events, contributing to PTSD vulnerability (30).

The higher rates of PTSD symptom levels in adolescent females than males were consistent with other studies (31, 32). These rates could be explained from different perspectives. Societal norms may encourage females to express emotions, possibly leading to higher reported PTSD rates, while males may underreport. Psychologically, females have a higher tendency for rumination and dwelling on distressing thoughts and feelings, which can exacerbate PTSD symptoms and make females more likely to express greater levels of stress and often internalize traumatic events, contributing to the higher incidence of anxiety, depression, and consequently PTSD. Biologically, hormonal factors like estrogen and differences in brain structures regulating emotions and memory may contribute to this susceptibility (33–36). Another explanation may be that female children and adolescents are at higher risk of certain types of abuse, particularly emotional abuse and psychological maltreatment (37) and female youth exposed to violence exhibit higher trauma symptoms, including PTSD-related symptoms (38).

Children feeling emotionally disregarded by their families had the highest odds of PTSD, consistent with attachment theory. Secure attachment is essential for healthy development, and feelings of neglect can lead to emotional dysregulation and increased PTSD risk (39). Children who feel unloved or emotionally disregarded by their family members often lack sufficient emotional support and guidance in managing stress, impeding their ability to develop effective coping mechanisms, and making them more prone to developing PTSD when exposed to trauma (40–42). Also, the perception of being unloved or unsupported can intensify feelings of isolation and helplessness, which are critical factors in the development of PTSD. Social support is a well-documented protective factor against PTSD, and the absence of perceived familial support significantly increases PTSD risk (43, 44). Findings showed that the sudden accidental death of a family member significantly increased the likelihood of developing PTSD. The sudden and unexpected nature of deaths leaves children particularly vulnerable to PTSD due to the sense of shock and disruption, along with a lack of preparation for the loss (45–47). Studies emphasize the importance of timely and effective psychological interventions to support bereaved young children and adolescents, along with providing targeted mental health care and fostering resilient coping mechanisms (45–47). The higher odds of PTSD in children or adolescents who experience food insecurity and have to wear old clothes suggest a possible association with SES (48).

Exam failure was strongly linked to elevated PTSD symptoms in children. Children encounter significant pressure to perform academically, and failing an exam can be viewed as a major threat to their social standing and self-esteem (7, 49, 50). Unlike adults, coping strategies for children may be inadequately developed to manage such setbacks, making them especially susceptible to stress responses (49). Research indicates that children commonly display intense emotional reactions to academic failures, including shame, fear of punishment, and anxiety about future academic performance (7, 49, 50). COVID-19 infection emerged as the most reported ACE, with stressors like school closures, isolation, and misinformation contributing to PTSD symptoms (51) with findings in line with other studies, highlighting the adverse effects of social isolation and disrupted routines during this pandemic (52, 53).

Research consistently demonstrates that psychological abuse by parents are significantly related to mental health problems in adolescents (54), including PTSD (55) and to extending effects as poor performance in school (56). The long-term effects of severe parental abuse have also been emphasized in the literature, with American psychiatrists studied 156 children who had experienced severe parental abuse and found that 62 (40%) met the diagnostic criteria for PTSD, with 33% continuing to meet the criteria even after two years (57). Moreover, PTSD in these children was associated with internalizing disorders such as anxiety and depression (57).

An increased number of ACE was significantly associated with increased odds of having high PTSD symptoms, in line with the results of previous studies (58–60), which can be explained by various interrelated factors. First, the accumulation of stress overwhelms the development of cognitive and emotional systems among children and adolescents (60). Multiple traumatic experiences increase the psychological burden, which impairs the ability to process and manage stress. Second, exposure to multiple ACEs can adversely impact crucial developmental processes, such as emotional regulation, self-concept, and forming secure attachments (61). These disruptions may reduce children's ability to develop resilience and healthy coping mechanisms, which ultimately increases the odds of high PTSD symptoms (61, 62). Last, each additional traumatic event can intensify or exacerbate the psychological effect of previous traumas (62, 63). A comprehensive approach tailored to the specific needs of adolescents is therefore needed and healthcare professionals should focus on assessing the full spectrum of traumatic experiences, rather than concentrating solely on the most prominent events.

The high prevalence of PTSD and ACEs among children in Jordan requires urgent attention. Evidence-based interventions to prevent ACE and reduce its impact encompass a range of approaches, including community-wide interventions, parenting programs, home visits, economic and social service interventions, psychological therapies, and school-based programs (64). In Jordan, school-based programs emerge as a suitable option due to the limited accessibility and societal acceptance of psychological therapies, which also applies to other interventions such as parenting programs and home visits. Additionally, school-based programs are supported by evidence for cost-effectiveness (65).

Interventions should adopt a holistic approach that acknowledges the cumulative and collective burden of multiple ACEs, rather than addressing them as isolated events, along with accounting for the broader socioeconomic and environmental factors contributing to adverse experiences (66). The root causes of ACEs extend beyond parenting practices and are also linked to socioeconomic disparities and systemic inequalities. For example, the education ban on females in Afghanistan was found to correlate with a wide range of negative mental health outcomes among females (67). This highlights the necessity of strong social welfare programs, mental health support systems, and other components to create a protective environment that mitigates childhood trauma in a multi-layered approach.

One limitation of this study is its cross-sectional design, which identifies correlations but does not establish causal relationships. Another limitation is the potential for underreporting bias, particularly in sensitive mental health-related topics such as childhood experience. Sensitive issues such as emotional abuse and neglect may be especially susceptible to underreporting, particularly in cultural contexts where stigma, limited awareness, or the tendency to present a socially desirable family image influence response. This potential underreporting may contribute to the underestimation of both the prevalence of ACE and its impact on PTSD symptom levels.

Future research would benefit from employing longitudinal designs to assess the impact of ACEs on mental health outcomes, including PTSD, with stronger causal evidence. Additionally, further studies are encouraged to focus on developing and evaluating intervention programs to determine their effectiveness in addressing ACEs and PTSD.

The findings highlight a high prevalence of PTSD among children and adolescents exposed to ACEs, with multiple ACEs being associated with high levels of PTSD symptoms and a cumulative pattern of ACEs further increasing the likelihood of experiencing high PTSD symptoms levels. These results underscore the need for targeted interventions that address key ACEs in specific age groups and the development of holistic and comprehensive prevention programs that integrate support for parents, families, schools, communities, and broader societal contexts. In addition, interventions should be designed to mitigate the cumulative and collective effects of multiple ACEs and address different ACEs simultaneously rather than in isolation.