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The impact of childhood trauma on substance use and mental health during the SARS-CoV-2 pandemic among young adults

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The impact of childhood trauma on substance use and mental health during the SARS-CoV-2 pandemic among young adults

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Content Copyright [2023] Sheila Pakdaman
THE IMPACT OF CHILDHOOD TRAUMA ON SUBSTANCE USE AND MENTAL
HEALTH DURING THE SARS-COV-2 PANDEMIC AMONG YOUNG ADULTS
By
Sheila Pakdaman, MS
A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(PREVENTIVE MEDICINE)
August 2023

ii
DEDICATION
This dissertation is dedicated to my father, Mo, who is the strongest man I have ever
known. He has fought one of the toughest medical battles of early-onset Parkinson’s that I have
ever witnessed, and yet he continues to live life to the fullest. Dad, your battle with your
behavioral addiction to gambling, which was a result of Parkinson's medication, inspired me to
pursue a career in addiction research. Although it was a difficult battle for you to conquer, and at
times, it was challenging for me as well, through this Ph.D. I have gained a deeper understanding
of the mechanisms and etiology of addiction, which has helped me come to terms with the fact
that addiction can be beyond our control.

iii
ACKNOWLEDGMENTS
First and foremost, I would like to thank my mom, Afsaneh for playing the role of both
parents when we were growing up. Statistically speaking (the only time you will hear me say this
in the dissertation, by the way), mothers who pursue higher education, raise daughters who also
go on to pursue the same. To my sister, Shaina, for being my favorite human that somehow is the
bane of my existence, too. Dad, this is already dedicated to you, so. To my family, thank you for
being so loving, kind and supportive, namely my Khaleh Azi, Baba and Shahab. To Mish Mish
and Bunny, what would I do without you two? My emotional support and unconditional love,
what did I do to deserve dogs? To my heavenly angel, Maman, I know your dream before
passing was to see your first female granddaughter turn into a Doctor. I hope you’re watching
over and proud of us all. To my best friends, Stephanie, Beina, Diana, Allee, Eli, Sharona &
many more thank you for being there with me through and through in life’s trials and
tribulations. To my friends, thank you for bringing so much joy into my life and for being there,
always. To my colleagues and cohort mates, you have validated this experience in ways you can
never imagine. To Laughing Frog Yoga, for being my second home all 5 years of my PhD, my
mat is where peace lives. To Dr. Unger, who has been a gem of a primary mentor these past 5
years. To my committee members (Drs. Barrington-Trimis, Davis, Steinberg and Clapp) and
mentors (so many of you!), thank you for being the light that has guided me through this journey,
it would not have been possible without you.

iv
TABLE OF CONTENTS
DEDICATION_______________________________________________________________ii
ACKNOLWEDGEMENTS____________________________________________________iii
LIST OF TABLES ___________________________________________________________ vi
LIST OF FIGURES _________________________________________________________ vii
ABSTRACT ________________________________________________________________ viii
Chapter 1: INTRODUCTION __________________________________________________ 1
INTRODUCTION____________________________________________________________ 1
Childhood Trauma – Adverse Childhood Experiences (ACE) ____________________ 1
SUBSTANCE USE & COVID-19 ______________________________________________ 4
ACE & Substance Use (alcohol, cannabis, non-prescribed drugs) ________________ 5
MENTAL HEALTH (ANXIETY/DEPRESSION) & ACE __________________________ 5
OVERALL THEORETICAL MODEL __________________________________________ 8
Gaps in the literature _____________________________________________________ 9
Objectives______________________________________________________________ 10
FIGURE _______________________________________________________________ 11
Chapter 2: Associations of COVID-19 stress with mental health and substance use among
young adults: the moderating role of Adverse Childhood Experiences________________ 12
ABSTRACT ________________________________________________________________ 12
INTRODUCTION___________________________________________________________ 13
METHODS ________________________________________________________________ 16
RESULTS _________________________________________________________________ 22
DISCUSSION ______________________________________________________________ 25
CONCLUSIONS ____________________________________________________________ 28
Table 4. CES-D-10 scale __________________________________________________ 36
Table 5. GAD-7 scale ____________________________________________________ 37
Table 6. ACE Scale ______________________________________________________ 38
Chapter 3: “Being lonely and just dreading in my thoughts about my childhood and all that
literally came back to me when I was alone” A qualitative examination of substance use,
mental health, and mental healthcare behaviors in young adults with adverse childhood
experiences during COVID-19_________________________________________________ 39
ABSTRACT ________________________________________________________________ 39
INTRODUCTION___________________________________________________________ 40
METHODS ________________________________________________________________ 42
Thematic Analyses _________________________________________________________ 43

v

RESULTS _________________________________________________________________ 45
DISCUSSION ______________________________________________________________ 50
CONCLUSION _____________________________________________________________ 55
Chapter 4: Discussion ________________________________________________________ 58
Implications ______________________________________________________________ 60
Future Directions __________________________________________________________ 63
Conclusions ______________________________________________________________ 67
REFERENCES _____________________________________________________________ 68

vi
LIST OF TABLES

Study 1: Associations of COVID-19 stress with mental health and substance use among young
adults: the moderating role of Adverse Childhood Experiences
Table 1. Demographics…………………………………………………………………..30
Table 2. Main Effects of ACE……………………………………………..…………….32
Table 3. Main Effects of COVID-19 Stress……………………………………………...34
Table 4. CES-D-10 Scale…………………………………………………………….…..35
Table 5. GAD Scale……………………………………………………………………...36
Table 6. ACE questionnaire……………………………………………………………...37
Study 2: “Being lonely and just dreading in my thoughts about my childhood and all that literally
came back to me when I was alone” A qualitative examination of substance use, mental health,
and mental healthcare behaviors in young adults with adverse childhood experiences during
COVID-19
Table 7. Themes and Definitions…………………………………………..…………….45
Supplementary Table 1. Interview Questions…………………………….……………...57

vii
LIST OF FIGURES

Introduction & Overview of Studies
Figure 1. Overview of Studies………………………………………..11
Study 1: Associations of COVID-19 stress with mental health and substance use among young
adults: the moderating role of Adverse Childhood Experiences
Figure 2. Interaction Plot……………………………………………………………….35
Discussion
Figure 3. Future Study Moderation Analysis……………………………………….……66
Figure 4. Future Study Moderation Analysis………………………………………….…66

viii
ABSTRACT

The overall goal of this dissertation was to examine associations of ACE and substance
use, mental health and mental healthcare among young adults during COVID-19. Young adults
with ACE have a disproportionally greater risk of developing maladaptive coping mechanisms
during stressful times, such as a pandemic. The vulnerabilities that young adults with ACE face,
coupled with studying the effects of a pandemic since ACE was identified as a risk factor, were
the aim of this dissertation. Study 1 explored ACE and COVID-19 stress on mental health and
substance use among young adults. The results of the study indicated that COVID-19 stress may
have a significant impact on anxiety levels, particularly in young adults who have experienced
varying levels of ACE. As COVID-19 stress levels increased, so did anxiety, and this association
was found to be more pronounced in those with a history of ACE. Study 2 took a qualitative
approach and thematic analysis of interviews with young adults with ACE during COVID-19
reveals several factors impacting their substance use and mental health behaviors, including
isolation, grief, financial and employment disruption, problematic interpersonal relationships,
and health-related anxiety. The study highlights the need for future pandemic responses to
include a focus on mental well-being for young adults with ACE. That said, future pandemic
responses should include giving young adults mental health and substance use resources.

1
CHAPTER 1: INTRODUCTION
Introduction
Adverse Childhood Experiences (ACE) are associated with substance use and mental
health problems among young adults.
1
The COVID-19 pandemic that began in 2020 increased
the risk for maladaptive behaviors (i.e., substance use and faltering mental health)
2
among young
adults due to social distancing, isolation, and financial and academic stressors.
3
This dissertation
aimed to examine how the COVID-19 pandemic is impacting young adults with ACE by
assessing their substance use, mental health, and mental healthcare experiences.
Childhood Trauma – Adverse Childhood Experiences (ACE)
ACE are traumatic events that occur during childhood including homelessness; physical,
sexual, or emotional abuse; parental intimate partner violence; household substance abuse;
divorce, and familial incarceration.
1,4,5
ACE can lead to a multitude of poor health outcomes and
has been studied more in recent years, with the Substance Use and Mental Health Administration
(SAMHSA) deeming it in 2018 as a ‘chronic public health problem’ in America.
4
For young
adults, in particular, one study found that ACE leads to the highest incidence of negative health
outcomes such as poor mental health, when compared to other age groups.
6
Young adulthood is
defined as the 18-29 year old age range, a period of transition from adolescence to adulthood.
The developmental transitions that occur during the period between adolescence and young
adulthood can increase the risk for negative health outcomes
7
, and impact the stress response to
trauma. Such stress can disrupt the development of emotional regulation, which may lead to
maladaptive behaviors such as higher rates of substance use and mental health disorders.
1

Research suggests that individuals who have experienced trauma are more likely to exhibit these
negative outcomes compared to those who have not experienced trauma when compared to
individuals who did not experience trauma. Given the link between trauma and negative health

2
outcomes, there is a need for trauma-informed prevention research to better understand this
relationship.
8–10
Moreover, McManus and Ball argue that the current COVID-19 pandemic
should be included as an ACE, especially for tailored trauma-informed care.
11

Young adulthood is a time where substance use peaks
12
, thus more research is needed to
understand the behaviors of this population, especially during the COVID-19 pandemic, which
was found to be a stressful time.
13
It has been found that young adults with ACE have poorer
health outcomes (i.e., substance use and mental health implications) than when compared to their
non-ACE peers.
1
However, the COVID-19 pandemic is something that this nation has not
experienced since the Polio epidemic, thus, understanding substance use and mental health
behaviors will be beneficial for young adults, especially with ACE.
37
Traumatic events can have
a significant impact on mental health and substance use and can create widespread concern about
health, exposure to loss, and disruption to social systems.
14
However, we are still understanding
how individuals with ACE will react in these unprecedented times. With that said, Kessler and
colleagues found that socially impacted conditions such as pandemics have made stress and
coping mechanics important public health concerns for researchers.
2

COVID-19
After the emergence of the COVID-19 pandemic, the US went into lockdown beginning
in March 2020. This included social/physical distancing as well as working, schooling, and
constant cohabitation with household members. Jobs were furloughed and schooling transitioned
to online platforms.
15
Additionally, the fear of COVID-19 was lingering, and globally, anxiety
and stress were peaking
16–18
and increased reports of loneliness, stress, anxiety and depression
were found.
19,20
The unintended consequences of the social distancing of the pandemic also
impacted substance use, as various countries reported an increase in overall substance use when

3
compared to pre-pandemic.
21–23
With that said, vulnerable populations (i.e., those with a history
of trauma) were impacted by the pandemic in different ways.
24
These individuals who are at high
risk of substance use, were found to also have more hardships during the pandemic, due to
COVID-19 stress.
25
For young adults in particular, higher rates of substance use and mental
health implications were found during this time.
26,27
Loneliness and isolation, particularly when
experienced in relation to depression, is one of the factors that can contribute to an increase in
substance use and mental health issues.
26,27

ACE & COVID-19
In relation to childhood trauma, we have not experienced a pandemic since ACE was
identified as a risk factor in 1998. To the best of our knowledge, the potential association
between pandemics and ACE was not extensively investigated prior to the COVID-19 pandemic.
However, the ‘collective, large scale’ traumas have always been there, either in the form of
warfare and terrorism (e.g., World War I &II and 9/11), genocides (e.g., The Holocaust and
Armenian genocide), natural disasters (e.g. Haiti earthquake)
28–31
and other epidemics and
pandemics (Polio epidemic, Spanish Flu pandemic).
32,33
Given the importance of understanding
how important ACE is to health outcomes, it was important to explore how traumas are
impacting young adults. In line with this, Knell and Colleagues found that young adults are more
likely to be vulnerable to pandemic-related stress.
3

Young adults may be vulnerable to the COVID-19 pandemic beyond the transmission of
the virus itself. This study aimed to fill in critical gaps in the literature by examining the
behavioral outcomes of substance use and mental health in young adults. By examining the
impact of the COVID-19 pandemic on young adults with ACE, this approach will help us to
better understand their mental health and substance use behaviors during this time. There is an

4
overwhelming overlap between the ACE, substance use and the mental health relationship,
especially in young adults, as they are at high risk for using substances as a means to cope with
stressors.
23

SUBSTANCE USE & COVID-19
Numerous studies have already been conducted on substance use during the COVID-19
pandemic.
16,23,34–36
According to the 2022 Monitoring the Future National Survey results on drug
use, cannabis use has increased slightly in 2021.
37
For alcohol, drinking behaviors were found to
have increased during the early stages of the pandemic (March-July 2020).
22
Moreover, prior to
the COVID-19 pandemic, the nation was fighting an epidemic of drug use, which only worsened
after the onset of the COVID-19 pandemic. Dating to January 2019, the CDC reported 67,631
deaths from drug overdoses, that number increased to 73,343 in January 2020, and then further
increased to 96,779 in January 2021 (an estimated 30% increase in drug overdose fatalities).
38

Furthermore, the relapse rates were the highest in 2020 compared to previous years, which can
be associated with the overall social disruption of COVID-19, financial and economical
stressors, and found psychiatric sequelae after recovering from COVID-19.
35(p19)

Alcohol. In the literature, both an increase and decrease in alcohol use was found during
the pandemic.
3,21,22,39–49
Despite the disruption of drinking events (i.e., parties, sport gatherings
and other social events) during the COVID-19 pandemic, young adults in particular were found
that social isolation increased binge drinking and increased solidarity drinking behaviors which
is a marker for depression.
40
On the other hand, Laghi and colleagues
21
found that the majority
of adult participants were not at risk for problematic alcohol use. However, among those who
were at risk, there was a correlation with higher levels of self-reported alcohol use prior to the
pandemic.
21

5
Cannabis. Cannabis use was also studied to assess levels during the pandemic.
24,39,44,45,47

Papp and Kourous found that young adults reported an increase in cannabis use in an ongoing
study when compared to the pre-pandemic baseline assessment.
39
Early pandemic research also
found an increase in cannabis use among existing users.
47
Another study on cannabis use found
that increased cannabis use among young adults was used as a coping mechanism
50
for increased
negative emotions, such as stress, depression, and loneliness.
24
However, no changes in cannabis
use were identified in a few studies during this time
45,51
, despite its use increasing during past US
traumas such as Hurricane Katrina
52
and the September 11
th
terrorist attacks.
52,53

ACE & Substance Use (alcohol, cannabis, non-prescribed drugs)
ACE have been linked to substance use and misuse, such as alcohol
54
, cannabis, and
other drug use among young adult populations.
55–59
Studies have found that childhood
maltreatment can impact substance use later in life.
54,60–62
The impact of the pandemic on young
adults who are highly vulnerable, such as those with ACE and pre-existing mental health issues
that have been exacerbated, and who may turn to substance use as a form of self-medication, is
an area of research that is continuing to be studied . Young adults with higher ACE scores report
higher use of alcohol and cannabis.
11
A history of ACE warrants exploring young adult health
behaviors, specifically maladaptive ones such as substance use. This relationship can be further
exacerbated by the COVID-19 pandemic. COVID-19-related life stressors may result in
substance use among young adults, exacerbating potential underlying and unaddressed mental
health issues, particularly for those with ACE. Treating the potential underlying mental health
conditions in individuals with ACE or the trauma related to emotional dysregulation and distress
may help avoid substance use.
MENTAL HEALTH (ANXIETY/DEPRESSION) & ACE
Anxiety

6
Anxiety is a response mechanism that is defined by the American Psychological
Association (APA) as tense emotions and worried thoughts that are sometimes coupled with
physical reactions.
63
However, once anxiety is excessive or persistent, it is defined as an anxiety
disorder.
64
The DSM-5 diagnostic criteria for generalized anxiety disorder (GAD) includes the
following 6 symptoms: restlessness, easily fatigued, difficulty concentrating, irritability, muscle
tension, and sleep disturbance.
64
Anxiety disorders can impact everyday activities including
work, school and relationships.
65
Globally, 3.4% of the population has anxiety with WHO
ranking it as the 6
th
largest contributor to global disability.
66
In the US alone, the National
Institute of Mental Health (NIMH) found that lifetime anxiety disorder is 31.1% in US adults,
with the prevalence being similar across all age groups.
65

Childhood trauma and adult anxiety have been widely studied. The DSM-5 lists child
abuse and neglect as an identified risk factor for anxiety.
64
There are different speculations for
this, such as childhood trauma impacting emotional regulation.
67
Another study found that 4 or
more ACE increases the prevalence of later life anxiety.
68
Moreover, individuals with a history
of childhood trauma, have a higher incidence of anxiety when compared to their non-ACE
peers.
69,70,71
Higher ACE score and adult onset of mental health conditions have been found to be
correlated
72
, particularly in young adults.
73,74
Zhang and colleagues found that ACE scores of 3
or higher led to increased odds of anxiety symptoms, and depression symptoms when compared
to young adults with no ACE.
74
When looking at latent class analysis done on individuals with
ACE (child maltreatment) significantly higher levels of depression and anxiety have been
found.
73
In particular, 1.56 higher odds of depression and 1.31 higher odds of anxiety when
compared to a “low adversity” class.
73

Depression

7
Depression is the most common mental health disorder, with the National Institute of
Mental Health (NIMH) listing usual symptoms as persistent sadness, hopelessness, irritability,
loss of interest and aches and pains to name a few.
75
Although depression is common, it is also
serious, with long-term effects leading to poor health outcomes such as substance use and
suicide.
76
According to WHO, depression is the main cause of disability on a global scale, and it
can affect children, adolescents, and adults of all ages.
76
That is, depression is a contributor to
both morbidity and mortality
77–79
, with young adults having the highest prevalence of depression
(15.2%) when compared to other adult age groups.
80,81
Childhood trauma and depression have
been found to be correlated. The DSM-5 lists child abuse and neglect as an identified risk factor
for depression.
64
The CDC estimates that over 21 million cases of adult depression can be
prevented by reducing childhood traumas.
1
Prevention of ACE can reduce adult depression by as
much as 44%, a percentage followed by COPD (27%) and then asthma (24%)
1
. In one study by
Ten Have and colleagues
82
, child maltreatment (defined as emotional, psychological, physical,
and sexual abuse before 16 years of age) led to a doubled risk of mental health disorders (either
first onset or recurrent; defined as mood, anxiety, and substance use). Another study found that 4
or more ACE increases the prevalence of later life depression by 7.8 times.
68

ACE, Mental Health & COVID-19
The COVID-19 pandemic increased levels of anxiety and depression in the overall global
population.
13,83–88
Contributing factors to higher rates of self-reported mental health disorders
include lack of social support, history of mental health disorders, childhood trauma and lower
resilience.
89
Individuals with a history of anxiety and depression may be at higher risk of
increased effects of symptomology during the pandemic.
90
Findings indicate that almost half of
the individuals reporting higher levels of anxiety and a third of individuals with depression had

8
elevated levels during the pandemic.
91
Young adults in particular, during the pandemic, were
reporting higher levels of anxiety and depression when compared to other adult age groups.
92

Adults who experienced childhood trauma are at an increased risk of mental health disorders
93
,
such as depression
94
and anxiety.
95
ACE has been found to be correlated to lowered resilience
and higher depression in young adults during the pandemic.
23
ACE was also found as a
significant risk factor for emotional exhaustion.
96
Specific ACE, in particular within the umbrella
of child maltreatment, have been also found to be correlated to increased adult anxiety
97
,
depression
98
and emotional distress
99
during the COVID-19 pandemic. Thus, understanding the
subjective experiences in mental healthcare during and after the COVID-19 pandemic will be
beneficial to understanding preventative care and interventions.
Mental healthcare
Children and youth who experienced childhood trauma score higher on mental healthcare
assessments when compared to their peers who did not experience childhood trauma.
100
In
adults, a longitudinal study found that those who experienced childhood trauma had higher
overall healthcare costs when compared to their peers who did not experience childhood
trauma.
101
However, there is limited research on the topic of understanding the mental healthcare
experiences of young adults who experienced childhood trauma during the COVID-19 pandemic.
OVERALL THEORETICAL MODEL
The Transactional Model of Stress and Coping
102
explains how stressful experiences are
based on individual perceptions of external stressors. The model also explains how to utilize any
potential psychological, social, or cultural resources to mitigate well-being. Thus, the theory
posits cognitive appraisal and coping as two sequential stress processes.
103,104
First, during
cognitive appraisal individuals are in the primary appraisal process, where they gauge if the
stressors they are experiencing are threatening.
104
Then, individuals are in the secondary

9
appraisal process where they evaluate if they have the appropriate tools and means to cope.
103

During each appraisal process, individuals will respond in varying degrees that are unique to
their own cognitive capacities (i.e., based on the intensity of the stressor, and the cognitive
capacity to respond).
104
Once the individual has deemed that they have inadequate resources to
address the stressors, they experience higher levels stress.
105
In order to mitigate the feelings of
stress and mental health implications, individuals can engage in poor health behaviors, such as
substance use.
105
On the contrary, individuals who deem that they have sufficient resources to
address stressors are more likely to exhibit resiliency during stressful times. Thus, the response
to and coping with the stressors is contingent upon the intensity of stress, while the intensity of
stress experienced is contingent upon individual and related elements.
In relation to the pandemic, Lazarus’ Transactional Model of Stress and Coping
102
has
been heavily used as a theoretical framework for understanding health outcomes during the
pandemic.
106–111
Young adults have been studied during the pandemic, to assess their stress
responses and substance use behaviors
112
with the guiding theoretical framework of
Transactional Model of Stress and Coping.
102
However, in relation to implementing this
framework during the pandemic for young adults who have experienced childhood trauma,
studies have not been conducted to our knowledge. Therefore, the proposed study aims to
investigate whether young adults with a history of ACE may be better equipped to deal with
tumultuous experiences due to their past experiences; such that a pandemic and nationwide
lockdown (related elements) would not disrupt their lives (and influence their substance use and
mental health as means to cope), or on the contrary are they affected even more than their peers
who do not have a history of ACE.
Gaps in the literature
The notable gaps will be addressed in a series of 2 studies in this dissertation.

10
1. Understanding how young adults with a history of ACE were impacted during
the COVID-19 pandemic by assessing their substance use and coping with substance use
(alcohol and cannabis use) and their mental health (anxiety/depression) when compared
to their peers who did not experience ACE.
2. Understanding how COVID-19 stress is impacting substance use and coping
with substance use (alcohol and cannabis use) and mental health (anxiety/depression)
problems in young adults. Additionally, understanding how this association impacts
young adults with different levels of ACE.
3. Interviewing young adults with a history of ACE and investigating their mental
health and mental healthcare experiences as well as their substance use (alcohol,
cannabis, illicit and non-prescription drug use) during the COVID-19 pandemic.
Objectives
Childhood trauma correlates with a greater likelihood of substance use and mental health
implications during adolescence and young adulthood. As noted earlier, the COVID-19
pandemic has also been linked to an uptick of anxiety, depression, and substance use. This
dissertation aims to understand how young adults’ health behaviors, such as substance use and
mental health, are impacted during traumatic times (such as an increase, decrease or by staying
the same) in order to help inform future preventive efforts. In addition, understanding young
adult substance use and mental health and access to mental healthcare services during the
pandemic will be informative in furthering the research on health behaviors. This research may
also potentially bring to light preventive and intervention approaches for other populations with
ACE.

11

FIGURE

Figure 1. Overview of Studies

Aim 1 To examine how COVID-
19 stress is impacting substance
use and mental health in young
adults with different levels of
ACE.

Aim 2 To examine the
subjective mental health and
healthcare experiences of young
adults with ACE during the
COVID-19 pandemic in order to
understand any potential change
in substance use.
2 time points
Pandemic (w11)
& (w12)
Assessing substance
use and mental
health in young
adults with ACE

Interviewed 26 YA
to learn about
substance use,
mental health &
healthcare in young
adults with ACE

12
CHAPTER 2: ASSOCIATIONS OF COVID-19 STRESS WITH MENTAL HEALTH AND
SUBSTANCE USE AMONG YOUNG ADULTS: THE MODERATING ROLE OF
ADVERSE CHILDHOOD EXPERIENCES
ABSTRACT

This study examined the impact of Adverse Childhood Experiences (ACE) and COVID-
19 stress on mental health and substance use among young adults. Participants were 2,393 young
adults in Southern California, primarily female, Hispanic, and socioeconomically living
comfortably, who participated in two waves of a prospective cohort study in 2021 and 2022.
Logistic (for binary outcomes) and linear (for continuous outcomes) regression analyses were
used to assess the main effect of ACE and COVID-19 stress and the interactive associations of
ACE and COVID-19 stress on substance use and mental health symptoms. Results indicated that
most participants (61.3%) had experienced at least one ACE. All levels of ACE (1-3 ACE and 4+
ACE) were significantly associated with anxiety and depression relative to those with 0 ACE,
and 1-3 ACE were significantly associated with alcohol use for coping with COVID-19. Young
adults with 4 or more ACE used cannabis on 1.47 days more than their non-ACE peers. Higher
levels of COVID-19 stress were associated with higher levels of anxiety and depression.
Moreover, per every one-unit increase of COVID-19 stress, young adults were more likely to use
cannabis to cope during the pandemic. The study revealed noteworthy effect modifications
regarding COVID-19 stress and anxiety in individuals with ACE. Specifically, as the levels of
COVID-19 stress escalated, the anticipated levels of anxiety also increased. However, no
significant effect modifications were found for ACE categories and depression, past 30-day
alcohol use, and alcohol or cannabis use as a coping mechanism with COVID-19-related stress.
Both ACE and COVID stress increased the risk of our outcomes, and the effects of COVID
stress were especially strong among people who experienced ACE. Future research should

13
continue to explore the complex relationships among ACE, COVID-19 stress, substance use, and
mental health outcomes.
INTRODUCTION
The COVID-19 pandemic began in March 2020 and was a global event that increased the
risk for problematic substance use
21–23
and mental health problems
2
among young adults due to
social distancing, isolation, and financial and academic stressors.
3
With that said, vulnerable
populations, who were already high risk for maladaptive behaviors have been impacted by the
ongoing pandemic.
24
For young adults in particular, higher rates of substance use and mental
health implications were found during this time.
26,27
During the pandemic, Adverse Childhood
Experiences (ACE) have been linked to higher rates of substance use and mental health
54–59

among young adults. ACE are traumatic events that occur during childhood including
homelessness; physical, sexual or emotional abuse; parental intimate partner violence; household
substance abuse; divorce and familial incarceration.
1,4,5

Previous studies have found associations between ACE and substance use and misuse,
such as alcohol
54
, cannabis, and other drug use.
55–59
Particularly, young adults with higher ACE
scores report higher use of alcohol and cannabis use.
54–59
Also, studies have found that childhood
maltreatment can impact substance use later in life.
54,60–62
Since young adults who experienced
ACE are especially susceptible to maladaptive coping mechanisms, it is crucial to investigate the
links between COVID-19 stressors, mental health, and substance use in this population to better
inform future preventive measures. Individuals who experienced childhood trauma also have an
increased risk of mental health disorders
93
, such as depression
94
and anxiety
95
when compared to
their peers who did not experience ACE. The DSM-5 lists child abuse and neglect as an
identified risk factor for anxiety and depression.
64
There are different speculations for this, such
as childhood trauma impacting emotional regulation.
67

14
When the COVID-19 pandemic began in 2020, substance use increased, and continued to
increase in 2021.
37,113–115
According to the 2022 Monitoring the Future report, cannabis use
among young adults has slightly increased from 2020 to 2021 and has reached an all-time high.
37

Additionally, the report found that alcohol remains the most commonly used substance among
young adults.
37
McPhee and Colleagues
40
found that social isolation had increased binge
drinking and increased solitary drinking behaviors in young adults during the pandemic. Some
studies found that cannabis use increased during the pandemic in young adults
39,47
, with one
study finding that this was due to increased negative emotions, such as stress, depression, and
loneliness.
24
Moreover, young adults report smoking cannabis more frequently when compared
to over other forms of intake during the pandemic.
25

The COVID-19 pandemic also increased levels of anxiety and depression in the overall
global population, especially as the pandemic progressed.
13,83–88
Contributing factors to higher
rates of self-reported mental health problems include lack of social support, history of mental
health disorders, childhood trauma, and lower resilience.
89
Young adults in particular, during the
pandemic, were reporting higher levels of anxiety and depression when compared to other adult
age groups.
92
Furthermore, life stressors may exacerbate underlying and unaddressed mental
health issues such as anxiety and depression, particularly for those who experienced ACE.
COVID-19 has caused significant stress and anxiety for many people around the world,
including young adults, with studies finding that young adults are particularly vulnerable to
COVID-19-related stressors.
114,116
As the pandemic continued to unfold, young adults were
experiencing a variety of stressors, including concerns about their health and the health of loved
ones, financial uncertainty, social isolation, and disruptions to their education and career
plans.
45,92,117
Additionally, social and relational stressors have been found to have the biggest

15
impact on COVID-19 related stressors in young adults when compared to other age groups.
118

Stressful life events, such as a pandemic, may adversely impact young adult substance use and
this has been widely studied in the literature.
119–122

As far as we know, there is limited literature examining the impact of COVID-19 stress
across different waves of data, particularly among young adults ACE, before the dissemination
of COVID-19 vaccines and after the vaccine became widely available for this age group. Since
young adults who experienced ACE are especially susceptible to maladaptive coping
mechanisms, it is crucial to investigate the links between COVID-19 stressors, mental health,
and substance use in this population. Understanding the impact of the pandemic on young adults
who are highly vulnerable, coupled with a history of ACE, is an area of research that is still
being understood. Understanding how different levels of ACE impact these behaviors is also
particularly important in light of the CDC's reporting that individuals who have experienced
higher levels of ACE (i.e., 4 or more ACE) are at greater risk of experiencing poor health
outcomes when compared to those who have experienced fewer ACE (i.e., 1-3 ACEs) or none at
all.
1

Theory
The Transactional Model of Stress and Coping
102
provides a framework to understand
stressful experiences are based on individual perceptions of external stressors. Thus, the theory
posits cognitive appraisal and coping as two sequential stress processes.
103,104
. The response to
and coping of the stressors is contingent upon the intensity of stress, while the intensity of stress
experienced is contingent upon individual and related elements (i.e., young adults who have a
history of trauma). Therefore, this theory was used as a framework for this study, as we aim to

16
examine how COVID-19 stress is impacting substance use and mental health in young adults and
to evaluate the extent to which the association differs by the number of ACE.
Study Aim
This study aims to evaluate the association of COVID-19 stress with the use of and
coping with alcohol and cannabis, and levels of anxiety and depression during the COVID-19
pandemic in young adults, and to evaluate the extent to which the association differs by the
number of ACE.
H1: It is hypothesized that a dose-response relationship exists between ACE and
substance use as well as mental health among young adults. Such that, young adults with 1-3
ACE will exhibit poorer substance use and mental health outcomes compared to those without
any ACE, whereas those with 4 or more ACE will experience even more severe outcomes.
H2: It is hypothesized that young adults that experienced COVID-19 stress will have
increased substance use and mental health problems, controlling for baseline levels.
H3: It is hypothesized that the relationship between ACE and substance use, as well as
mental health problems among young adults, is influenced by the presence of COVID-19 stress.
Specifically, it is proposed that individuals with 1-3 ACE and those with 4 or more ACE will
experience more severe substance use and mental health outcomes.
METHODS

Participants
Data are from individuals who participated in the Happiness and Health (H&H) cohort
and completed two waves of the study – Wave 11 (January 2021-May 2021) and Wave 12
(November 2021-March 2022). The purpose of these two time points is focus on health
behaviors before the COVID-19 vaccine versus after the dissemination of the vaccine. The H&H

17
study is a Los Angeles County, California cohort that began collecting data in 2013, from 10
high schools when participants were in 9
th
grade. The mission of the study is to understand
substance use and mental health trends across the lifespan. The H&H study has a diverse sample
of 57.9% females, 47% Hispanic ethnicity, and current mean age of 21.18 years old (see table 1
demographics). This prospective cohort study initially enrolled 3396 participants, with a
retention of 2207 participants in wave 11, and 2422 participants in wave 12. All original
participants were invited to participate in each wave, and occasionally people who did not
participate in one wave participated in a later wave.
Procedures
Self-report surveys were collected and managed using Research Electronic Data Capture
(REDCap) electronic data capture tools hosted at the University of Southern California in the
Keck School of Medicine, Department of Population and Public Health Sciences. REDCap is a
secure, web-based software platform designed to support data capture for research studies.
Wave 11 data collection (N = 2207) occurred over 5 months from January 2021 to May 2021.
Wave 12 data collection (N=2422) began in November 2021 and ended in March 2022. All data
collection is confidential, and participants provided informed consent. This study was approved
by the University of Southern California Institutional Review Board.
Measures
ACE was measured in wave 11 using the Adverse Childhood Experiences (ACE) scale.
123

The ACE scale has good internal consistency (Cronbach's α=.88) and reliability.
124
The ACE
scale is comprised of ten dichotomous (yes/no) questions that assess childhood trauma
experiences from 0-18 years of age. The 10 ACE items were summed to create an ACE score that
ranged from 0 to 10. The ACE variable was coded categorically
125
as 0 ACE vs. 1-3 ACE vs. 4+

18
ACE. The prompt read, "When you were growing up, during your first 18 years of life," followed
by questions such as "Did a parent or other adult in the household often...?" and "Were your
parents ever separated or divorced?" Table 6 shows the 10 questions.
COVID-19 Stress. A question assessing the stress of the COVID-19 pandemic was also
asked on the H&H wave 11 survey. The question is posed as “Please rate your degree of
concern, worry, and stress towards the following issues in terms of their effect on you
personally. The novel coronavirus (COVID-19): stressed.” The stressed question was answered
in a 5-point Likert scale format “not at all”, “slightly”, “somewhat”, “very” and “extremely.”
This variable was kept as continous.
Substance Use. Questions assessing substance use during the COVID-19 pandemic were
asked on the H&H waves 11 and 12 surveys. Substance use was addressed in different ways
using different variables. For the first variables, response options included checking if the
statement applied to the participant. These questions included the following header: “To cope
with social distancing and isolation are you doing any of the following? (Select all that apply):”
“drinking alcohol” and “using marijuana or cannabis.” Past 30-day substance use was used in the
next model. The survey asked participants: "In the last 30 days, how many days did you use
marijuana (also referred to as pot, weed, hash, reefer, bud, or grass)?" and "In the last 30 days,
how many days did you have one full drink of alcohol (such as a can of beer, glass of wine, wine
cooler, or shot of liquor)?" The response options ranged from "0 days" to "All 30 days," with
intermediate options including "1 or 2 days," "3 to 5 days," "6 to 9 days," "10 to 19 days," "20-29
days." To analyze the past 30-day substance use data, we treated the variables as continuous and
used the midpoint values of each response option: 0 days, 1.5 days, 4 days, 7.5 days, 14.5 days,
24.5 days, and 30 days. In addition, this variable was treated dichotomously, such that if

19
participants said they drank one or more days in the past 30 days, they were coded in the “yes”
category, and if they indicated they did not drink at all in the past 30-days they were coded in the
“no” category. This variable was also recorded such that those who consumed alcohol one or
more days were placed in the “yes” category, and the “no” category was the reference group and
labeled as “1+ days.”
Anxiety. Anxiety was assessed with the Generalized Anxiety Disorder 7-item (GAD-7)
Scale
126
. The GAD scale has good internal consistency (α=0.94), and good reliability and
generalizability of anxiety for the general population.
127
Answer choices included 4 options, 0=
“not at all”, 1= “several days”, 2= “more than half of the days”, 3= “nearly every day.”
Questions included, “Over the past 2 weeks, have you felt bothered by any of these things?”
“feeling nervous, anxious, or on edge?”. All questions can also be found in Table 5. The total
anxiety score was summed, with a range of 0-21 for the responses.
Depression. Depressive symptoms were assessed with the Center for Epidemiological
Studies Depression Scale (CES-D)
128
. The CES-D scale has a Cronbach’s alpha of 0.859 and is
often used in mental health studies because of it is a comprehensive measure of depression for
the general public.
129
Both waves of data used the CES-D-10 version questions. Answer choices
included 4 options, 0= “Rarely or none of the time (less than 1 day)”, 1= “Some or little of the
time (1-2 days)”, 2= “Occasionally or a moderate amount of time (3-4 days)”, 3= “All of the
time (5-7 days).” Questions included: “Below is a list of some of the ways you may have felt or
behaved. Please indicate how often you have felt this way during the past week:” I felt hopeful
about the future, I felt depressed". All questions can also be found in Table 4. The total
depression score was summed with a range of 0-30.

20
Covariates included characteristics collected in wave 11 that are known to be associated
with substance use and mental health, including gender identity (filled in by the participant, was
categorized as “male”, “female”, “other gender identity”), race/ethnicity (coded as White, Black,
Asian, Hispanic, Multi/Other) (individuals who identified as Hispanic were classified under the
Hispanic category, even if they also selected another racial category [e.g., if an individual
identified as Hispanic and also chose a different racial category, they were still classified under
the Hispanic category]). Socioeconomic status (SES) was asked as “Considering your own
income and your income from any other people who help you, how would you describe your
overall personal financial situation”: 1= “live comfortably”, 2= “meet needs with a little left” 3=
“just meet basic expenses” 4= “don't meet basic expenses”. Females, Hispanics and participants
who indicated ‘live comfortably’ are the reference categories as they have the highest number of
participants in each category. The same wave 11 substance use and mental health outcomes were
used to control for the prior wave, to explore the residualized outcome.

STATISTICAL ANALYSIS

Main effects of ACE, COVID-19 Stress
The statistical analyses for the main effects were conducted using SPSS version 28.
130

Generalized linear regression and logistic regression models were used to assess past 30-day
substance use and substance use as a coping mechanism during COVID-19, with ACE as the
predictor variable. Additionally, a generalized linear model was performed using ACE as the
predictor variable and either depression or anxiety as the outcome variable to evaluate mental
health or past 30-day alcohol or cannabis use to evaluate substance use. Logistic regressions
were run for the substance use for coping with COVID-19 variables as the outcome. All models

21
were adjusted for covariates, including wave 11 mental health scores or substance use,
socioeconomic status (SES), gender, and race/ethnicity. For the linear regression models, betas
and 95% confidence intervals were reported, while odds ratios with 95% confidence intervals
were reported for logistic regression models. The analysis was repeated with COVID-19 stress as
the predictor variable. All statistical tests were two-tailed (α=0.05).
Moderation Analysis
Moderation analysis was used to determine whether the association between COVID-19
stress levels and substance use/mental health outcomes differs for individuals by the number of
ACE experienced. Each model was repeated with the addition of a product term between ACE
and the COVID-19 stress variable (ACE*Stress of COVID-19). The COVID-19 stress variable,
was centered prior to the interaction. The categorical covariates included SES, gender and
race/ethnicity and the respective wave 11 outcome. The product term was tested, and the
significant interaction was plotted using Rweb
131
, with shading showing the 95% CI intervals of
the interaction.
Missing data. Given the longitudinal nature of the dataset, missing demographic variables
such as gender and race were obtained from earlier waves and matched up per participant.
Multiple imputation (MI) was used to impute missing data for the other predictors and the
outcomes. It is considered one of the most rigorous methods of handling missing data as it
considers the uncertainty of imputed values.
132
This study used MI Fully Conditional
Specification algorithm in SPSS.
133
MI generates random values based on the conditional
distribution of the missing data. Then the imputed sample is analyzed as if all the observations
were complete. This method is repeated multiple times, with 10 iterations to accommodate the

22
large sample size and variables
133
and then all the results are combined to take into consideration
the uncertainty of the imputed values.
132

RESULTS
Participants (N=2393, Mage 21.84 years old, SD 0.401) were female (57.9%), Hispanic
(47.5%), and lived comfortably (34.2%). Over half of the participants (n=1272, 61.3%)
experienced at least one ACE, with 910 (43.9%) experiencing 1-3 ACE and 362 (17.5%)
experiencing 4+ ACE. Demographics, the mean number of mental health severity (i.e., anxiety
and depression) as well as the mean number of days for substance use (i.e., daily substance use
and substance use for coping during COVID-19) per ACE category can be found in Table 1
below. For past 30-day substance use, participants indicated that they drank alcohol or used
cannabis 4 or less days in the past month.
Main Effects
Substance use – ACE
Substance use as coping during COVID-19. Young adults who reported 1-3 ACE had
1.36 higher odds of using alcohol to cope (AOR=1.36 95% CI=1.01, 1.82, p=0.029), when
compared to their peers who did not experience ACE. We did not observe a higher odd of using
alcohol to cope for young adults with 4+ ACE. Additionally, we also did not observe higher odds
of using cannabis to cope with the COVID-19 pandemic among young adults with 1-3 or 4+
ACE compared to those without ACE (see Table 2).
Past 30-day substance use.
Categorical. We did not find a significant difference in past 30-day alcohol use for young
adults who experienced 1-3 ACE, but we did find that those who experienced 4 or more ACE
used alcohol 1.08 days a month more when compared to those without ACE (B=1.08, 95%
CI=0.29, 2.13, p=0.044). For past 30-day cannabis use we found those who experienced 4+ ACE

23
(B=1.47, 95% CI=0.15, 2.78, p=0.03) used cannabis nearly 1.5 days more when compared to no
ACE (see Table 2).
Dichotomous. For past 30-day alcohol use, young adults who experienced 1-3 ACE were
1.39 times more likely to use alcohol (B=1.39, 95% CI=1.12,1.73), and those who experienced 4
or more ACE were 1.57 times more likely to use alcohol (B=1.57, 95% CI=1.16, 2.11).
However, for the past 30-day cannabis use, young adults with 4 or more ACE were 1.86 times
more likely to use cannabis. A significant association was not found for the past 30-day cannabis
use and young adults who experienced 1-3 ACE when compared to their non-ACE peers.
1+ days of Substance Use. For the past 30-day alcohol use, young adults with 1-3 ACE
and 4 or more ACE were 0.06 times more likely and 0.08 times more likely to use alcohol in the
past 30 days when compared to those without ACE.
Mental health – ACE
Anxiety. We found that young adults who reported 1-3 ACE (B=1.14, 95% CI=0.71, 1.58,
p<0.001) and 4+ ACE (B=1.59, 95% CI=0.924, 2.24, p<0.001) had a significantly higher anxiety
level compared to those without ACE (see Table 2).
Depression. We found that young adults who reported 1-3 ACE had a significant
depression level (B=0.83, 95% CI=0.37, 1.29, p<0.001). Similarly, those with 4 or more ACE
had a significantly higher mean depression level (B=1.76, 95% CI=1.13, 2.38, p<0.001)
compared to those without ACE (see Table 2).
Substance Use – COVID-19 Stress
Substance use as coping during COVID-19. We did not find a correlation between
COVID-19 stress and the use of alcohol to cope with the pandemic. However, we did find that

24
with each unit increase of COVID-19 stress experienced, young adults had higher odds of using
cannabis to cope during the pandemic (AOR=1.11 95% CI=1, 1.21, p=0.033) (see Table 3).
Past 30-day substance use.
Categorical. We did not find a significant difference between the past 30-day alcohol and
cannabis use and COVID-19 stress (see Table 3).
Dichotomous. For each unit increase of COVID-19 stress experienced, young adults had
higher odds of using alcohol (AOR=1.15 95% CI=1.08, 1.24, p<0.001) and cannabis (AOR=1.1
95% CI=1.02, 1.91 p=0.012) to cope.
1+ days of Substance Use. We did not find a correlation between COVID-19 stress and
past 30-day alcohol use. However, for each unit increase in COVID-19 stress experienced, young
adults were 0.05 times more likely to use cannabis in the past 30 days.
Mental Health – COVID-19 Stress
Anxiety. For each unit increase of COVID-19 stress reported, we observed an increase in
anxiety (B= 0.43 95% CI= 0.27, 0.58, p<0.001) (see Table 3).
Depression. For each unit increase of COVID-19 stress, we observed an increase in
depression (B=0.32 95% CI= 0.15, 0.49, p<0.001) (see Table 3).
Interaction of ACE and COVID-19 Stress
Next, we ran the interaction models and found no significant effect modifications in the
relationship between ACE categories and depression, past 30-day alcohol or marijuana use, and
alcohol or cannabis use as a coping mechanism for COVID-19 stress. However, we found a
significant effect modification for anxiety and COVID-19 stress for young adults, such that the
relationship between COVID-19 stress and anxiety experienced in wave 12 varies depending on
the level of ACE that young adults have experienced. In the full sample, higher levels of

25
COVID-19 stress were associated with higher levels of anxiety; however, the strength of this
association varies across levels of ACE. Compared to people who experienced no ACE B=
0.374(95% CI= 0.150, 0.599, p= 0.002), for people who experienced 1-3 ACE B= 0.422(95% CI
= 0.193, 0.650, p>0.001), the effect of stress on anxiety is stronger. Moreover, for people who
experienced more than 4 ACE B= 0.514(95% CI= 0.151, 0.878, 0.007), the effect of stress on
anxiety is even stronger. This suggests that ACE makes the effects of COVID-19 stress more
severe (see Figure 1).
DISCUSSION
This study examined associations of ACE and COVID-19 stress with mental health and
substance use among young adults during the COVID-19 pandemic. Previous research has
shown that ACE has been linked to an increased risk of mental health problems and maladaptive
coping mechanisms including substance use.
1,134,135
Given the stressful nature of the COVID-19
pandemic, it was crucial to examine the impact of the pandemic on young adults who
experienced ACE, who are already at a higher risk for negative health outcomes.
Main Effects & Moderation
Substance Use
For some of the substance use outcomes, it was found that young adults who experienced
ACE differed in their substance use when compared to their non-ACE peers
27
, such that those
with ACE use alcohol to cope during the COVID-19 pandemic. This falls in line with the
literature that young adults with ACE reported an increase in alcohol use during the
pandemic.
23,45,136,137
This also is indicative of young adults with ACE in general as they report
higher substance use outside of pandemic conditions. Moreover, in the past 30-day alcohol and
cannabis use we only saw a significant effect for those with more than 4 ACE, which also falls in
line with past findings outside of pandemic conditions, as higher ACE often leads to poorer

26
health outcomes.
138
When we dichotomized this variable, however, we found that young adults
with 1-3 ACE did have a significant effect of past 30-day alcohol use, which falls in line with the
literature that young adults with ACE are more likely to engage in substance use when compared
to their non-ACE peers.
62
When we analyzed the findings to include only those who had used
alcohol in the past 30 days, for alcohol we found that young adults with any ACE had a
significant correlation to use. However, for cannabis use only young adults with 4 or more ACE
had a significant correlation to past 30-day use. This falls in line with past literature outside of
pandemic conditions, as more ACE often leads to poorer health outcomes.
138

For the COVID-19 stress main effects, we found that COVID-19 stress predicted higher
odds of using cannabis to cope with the COVID-19 pandemic. This falls in line with previous
studies, as young adults reported using more cannabis to cope with stressors during the
pandemic
24,115
. Moreover, in terms of moderation, no significant interactions were found
between COVID-19 stress and the substance use outcomes of the past 30-day alcohol and
cannabis use as well as alcohol and cannabis use as a coping mechanism when examining
differing levels of ACE. This suggests that the impact of COVID-19 stress on substance use
among young adults may not differ significantly between those with a history of ACE and those
without. This can be because young adults, although reporting stress are feeling less isolated
139

due to the lifting of government mandates in wave 12, and consequently have a reduced
motivation to use certain substances such as alcohol within specific contexts, (i.e., daily use, to
cope with COVID-19 pandemic)., A study on young adult pandemic drinking behaviors reported
a decrease in alcohol use during 2021.
113
However, contrary to our findings, other studies have
found an increase in daily alcohol use and alcohol and cannabis use as a coping mechanism for

27
COVID-19.
136,137,140
Thus, it is possible that our COVID-19 stress variable collected early to
mid-2021 did not impact some of the substance use behaviors in late 2021-mid 2022.
When we looked at the past 30-day substance use variable dichotomously, we found that
COVID-19 stress was correlated to past 30-day alcohol and cannabis use.
136,137,140
However,
when we looked at these analyses from 1 or more days of alcohol or cannabis use, we only found
that cannabis use and COVID-19 stress were significantly correlated. This may be due to the fact
that marijuana was used as a coping mechanism during COVID-19 for stress.
13,24,47,136

Mental Health
Compared to their non-ACE peers, young adults who experienced ACE had significantly
higher self-reported anxiety and depression scores, which is in line with other studies on adults
who experienced ACE and mental health outcomes during the COVID-19 pandemic.
141,142
This
indicates that a history of ACE may impact mental health in novel traumatic experiences. The
Transactional Model of Stress and Coping
102
posits that individuals who are re-exposed to
stressors may feel a cumulative effect. On the other hand, some studies have shown that young
adults without a history of ACE also reported higher levels of anxiety and depression during the
pandemic than other age groups. In the main effects of COVID-19 stress, we found increased
rates of anxiety and depression for all young adults in our sample.
26,27,117
The stress associated
with the COVID-19 pandemic included financial disruption (i.e., loss of employment)
92
, lack of
social support
122
, and social and physical distancing
85
during the government-imposed
lockdowns. Thus, other studies have assessed what may impact this association
143
, therefore in
order to further the literature, assessing how the relationship between COVID-19 stress and
mental health differs between levels of ACE was explored.
144

28
In terms of moderation, our findings indicate that the association between COVID-19
stress and anxiety was significantly moderated by levels of ACE, such that as levels of ACE
increased (i.e., 1-3 ACE vs 4 or more ACE), the association was more pronounced. This may be
attributable to the fact that stress, anxiety and past trauma may cumulatively manifest during
present traumatic conditions (i.e., the COVID-19 pandemic). In line with this, a study presented
at the Anxiety and Depression Association of America in 2022 revealed that childhood trauma
affects later-life anxiety by influencing brain inflammation and impacting stress response.
145

Also, Alradhi and colleagues
144
found that stress during COVID-19 moderated the association
between higher ACE and anxiety.
Strengths and Limitations
This study did have some respective strengths and limitations. Strengths include the
relatively large sample size of young adults from Los Angeles County, California, and an
ethnically diverse population with a high retention rate over multiple waves of data. Also, the
two waves of data are valuable in assessing the outcomes of substance use and mental health
during different phases of the COVID-19 pandemic. However, this study is geographically
limited and not representative of all young adults. Additionally, the survey answers are self-
reported and do not serve as a diagnostic criterion for mental health disorders such as anxiety
and depression. Furthermore, given the sensitivity of questions regarding their mental health,
substance use and adverse childhood experiences, there is a probability that some respondents
did not answer honestly, regardless of the confidentiality of the survey.
CONCLUSIONS
This study aimed to identify the effect of ACE, the effect of COVID-19 stress, and the
combined effects of both in relation to how young adults respond to the pandemic by measuring
their substance use and mental health symptoms. These findings could better inform future

29
preventive measures (i.e., interventions before young adulthood) for young adults with a history
of ACE. Many studies have examined potential moderators (i.e., generalized stress, gender, race)
between ACE and mental health and substance use, as this at-risk group has a higher frequency
of anxiety, depression and substance use. The findings of this study have implications for
policymakers, public health professionals and healthcare workers as it highlights the need for
early identification and prevention of ACE and the provision of appropriate mental health
services to young adults, especially during the COVID-19 pandemic and future pandemics.
Additionally, it suggests the need for further research to examine the long-term effects of ACE
on mental health and substance use during and after the pandemic.

30
Table 1. Demographics of Wave 11 and 12
Table 1 Demographics of Waves 11 and 12 N= 2393 0 ACE 1-3 ACE 4+ ACE P value
Gender - wave 11 N(%)
Females 1354(56.5%) 407(19.6%) 547(26.4%) 248(12%) <.001
Males 963(40.2%) 376(18.1%) 332(16.0%) 85(4.1%)
Other Gender Identity 79(3.3%) 19(0.9%) 31(1.5%) 29(1.4%)

Race - wave 11 N(%)
Hispanic 1138(47.5%) 379(18.3%) 402(19.4%) 199(9.6%) <.001
White 385(16.1%) 118(5.7%) 161(7.8%) 59(2.8%)
Black 120(5%) 30(1.4%) 54(2.6%) 15(0.7%)
Asian 438(18.3%) 182(8.8%) 167(8.1%) 45(2.2%)
Multiracial/Other 312(13.0%) 93(4.3%) 126(6.1%) 42(2%)

Socioeconomic Status - wave 11 N(%)
Lives Comfortably 820(39.5%) 396(49.7% 335(37%) 89(24.8%) <.001
Meets needs with little left 500(24.1% 158(19.8%) 223(24.6%) 119(33.1%)
Just meets basic expenses 631(30.4%) 211(26.5%) 297(32.8%) 123(34.3%)
Don't meet basic expenses 111(5.4%) 32(4%) 51(5.6%) 28(7.8%)

Substance use - wave 11 (yes) Mean(SD)
Past 30-day Alcohol Use 6.29(6.71) 3.06(4.52) 3.77(4.8) 3.95(5.49) 0.002
Past 30-day Cannabis Use 4.38(7.03) 2.29(6.34) 3.78(8.46) 3.82(8.01) <.001
Coping with Alcohol 407(19.6%) 128(16%) 182(20%) 97(26.8%) <.001
Coping with Cannabis 404(19.5%) 100(12.5%) 205(22.5%) 99(27.3%) <.001

Substance use - wave 12 (yes) Mean(SD)
Past 30-day Alcohol Use 3.53(4.83) 3.06(4.52) 3.77(4.8) 3.95(5.49) 0.002
Past 30-day Cannabis Use 5.05(7.97) 4.17(6.89) 5.5(8.5) 5.9(8.65) <.001
Coping with Alcohol 356(17.2%) 105(14.2%) 173(20.3%) 78(23.5%) <.001
Coping with Cannabis 321(15.5%) 84(11.3% 165(19.3%) 72(21.7%) <.001

Substance use - wave 11 - past 30 day use No 1.5 days 4 days 7.5 days 14.5 days 24.50 days 30 days
Pat 30-day Alcohol Use 831 501 361 213 136 20 9
Past 30-day Cannabis Use 1492 165 117 58 84 68 88

Substance use - wave 12 - past 30 day use No 1.5 days 4 days 7.5 days 14.5 days 24.50 days 30 days
Pat 30-day Alcohol Use 683 439 367 272 129 19 9
Past 30-day Cannabis Use 1360 185 97 63 69 57 87

31
Mental health - wave 11 Mean(SD)
Anxiety 6.09(5.56) 4.3(4.81) 6.44(5.43) 9.17(5.91) <.001
Depression 9.52(6.24) 7.64(5.47) 9.83(6.19) 12.87(6.44) <.001

Mental Health - wave 12 Mean(SD)
Anxiety
6.58(5.71) 4.65(4.8) 7.17(5.78) 9.37(5.93)
<.001
Depression 11.79(5.2) 10.37(5.18) 12.15(4.93) 14.13(4.96) <.001

ACE - wave 11 N(%)
No ACE 802(38.7%)
1-3 ACE 910(43.9%)
4-6+ ACE 362(17.5%)

32
Main Effects - ACE N=2393

W12 Outcomes B(95% CI)
Anxiety Pvalue
1-3 ACE 1.14(.0.71, 1.58) <.001
4+ ACE 1.59(.924,2.24) <.001
Depression
1-3 ACE 0.83(.37,1.2) <.001
4+ ACE 1.76(1.13,2.38) <.001

30 day Alcohol
1-3 ACE .51('-.11,1.12) 0.103
4+ ACE 1.08(.29,2.13) 0.044
30 day Cannabis
1-3 ACE .78('-.041,1.6) 0.062
4+ ACE 1.47(0.15, 2.78) 0.03
1-3 ACE Past 30 day Alcohol Yes/No
4+ ACE 1.39(1.12,1.73) 0.003
1.57(1.16,2.11) 0.003
Past 30 day Cannabis Yes/No
1-3ACE 1.26(.99,1.61) 0.062
4+ ACE 1.86(1.36,2.53) <.001

Past 30 day Alcohol, 1+ days
1-3ACE .06(.18,.1) <.001
4+ ACE .08(.02,13) <.001
Past 30 day Cannabis, 1+ days
1-3ACE .02('-.01,.06) 0.198
4+ ACE .103(.05,.15) <.001
Alcohol Cope
1-3ACE 1.36(1.01,1.82) 0.029
4+ ACE 1.38(.96,1.99) 0.086
Cannabis Cope

33
1-3ACE 1.34(.95,1.89) 0.092
4+ ACE 1.4(.86,2.06) 0.187

Table 2. Main effects of ACE

34
Table 3. COVID-19 stress main effects

B(95% CI)

Pvalue
Anxiety
.43(.27,.58) <.001
Depression

.33(.15,.49) <.001
Past 30-day Alcohol

.17('-.05,.38) .119
Past 30-day Cannabis
.20(-0.05,0.46) .115
Past 30 day Alcohol Yes/No
1.15(1.08,1.24) <.001
Past 30-day Cannabis Yes/No
1.1(1.02,1.91) .012
Past 30-day Alcohol, 1+ days
.009('-.005,.024) .213
Past 30-day Cannabis, 1+ days
.05('-.002,.1) .002
Alcohol Cope
1.08(.97,1.20) .164
Cannabis Cope
1.11(1.00,1.21) .033

35
Figure 1. Interaction Plot

Note: ACE level 0 is young adults who did not experience any ACE, ACE level 1 is young
adults who experienced 1-3 ACE, and ACE level 2 is young adults who experienced 4 or more
ACE. Shading of the lines is indicative of the 95% CI.

Table 4. CES-D-10 scale
CES-D- 10 Questions asked in W11 & 12
1 I was bothered by things that usually don't bother me.
2 I had trouble keeping my mind on what I was doing.
3 I felt depressed.
4 I felt that everything I did was an effort.
5 I felt hopeful about the future.
6 I felt fearful.
7 My sleep was restless.
8 I was happy.
9 I felt lonely.
10 I could not "get going."
*Items 5 and 8 are reverse coded.

37
Table 5. GAD-7 scale
GAD-7 Questions asked in W11 &12

Over the past 2 weeks, have you felt bothered by any of these
things?
1 Feeling nervous, anxious, or on edge?
2 Not being able to stop or control worrying?
3 Worrying too much about different things?
4 Trouble relaxing?
5 Being so restless that it is hard to sit still?
6 Becoming easily annoyed or irritable?
7 Feeling afraid as if something awful might happen?

38
Table 6. ACE Scale

When you were growing up, during your first 18 years of life:
1. Did a parent or other adult in the household often … Swear at you, insult you, put you down,
or humiliate you? or Act in a way that made you afraid that you might be physically hurt?
Yes No
2. Did a parent or other adult in the household often … Push, grab, slap, or throw something at
you? or Ever hit you so hard that you had marks or were injured?
Yes No
3. Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you
touch their body in a sexual way? or Try to or actually have oral, anal, or vaginal sex with you?
Yes No
4. Did you often feel that … No one in your family loved you or thought you were important
or special? or Your family didn’t look out for each other, feel close to each other, or support
each other?
Yes No
5. Did you often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had
no one to protect you? or Your parents were too drunk or high to take care of you or take you to
the doctor if you needed it?
Yes No
6. Were your parents ever separated or divorced?
Yes No
7. Was your mother or stepmother: Often pushed, grabbed, slapped, or had something thrown
at her? or Sometimes or often kicked, bitten, hit with a fist, or hit with something hard? or Ever
repeatedly hit over at least a few minutes or threatened with a gun or knife?
Yes No
8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
Yes No
9. Was a household member depressed or mentally ill or did a household member
attempt suicide?
Yes No
10. Did a household member go to prison? Yes No

39
CHAPTER 3: “BEING LONELY AND JUST DREADING IN MY THOUGHTS ABOUT
MY CHILDHOOD AND ALL THAT LITERALLY CAME BACK TO ME WHEN I WAS
ALONE” A QUALITATIVE EXAMINATION OF SUBSTANCE USE, MENTAL
HEALTH, AND MENTAL HEALTHCARE BEHAVIORS IN YOUNG ADULTS WITH
ADVERSE CHILDHOOD EXPERIENCES DURING COVID-19
ABSTRACT
Young adults with Adverse Childhood Experiences (ACE), e.g., household dysfunction
and maltreatment) are at high risk for poor health outcomes such as mental health and substance
use disorders. The COVID-19 pandemic imposed numerous external stressors and impacted
access to mental healthcare services for many individuals. This study explores mental health,
substance use and mental healthcare experiences among young adults who experienced ACE
during the COVID-19 pandemic. Young adults (N=26, ages 21-29 years old, 15 males, 9
females, and 2 non-binary) who experienced ACE were recruited online and interviewed via
Zoom to learn about their histories of substance use, anxiety, depression, and mental healthcare
experiences during COVID-19. After transcription, thematic analysis was conducted. Thematic
analyses revealed several factors impacting young adults’ substance use and mental health
behaviors during the pandemic. Young adults with a history of ACE experienced the following:
isolation, grief and loss, financial and employment disruption, problematic interpersonal
relationships that were exacerbated by staying home, and health-related anxiety. Taken together,
these experiences impacted their substance use, mental health and mental healthcare services.
Young adults who experienced ACE indicated that substances helped alleviate feelings of
anxiety and depression. However, young adults who received mental healthcare during the
pandemic reported that such care benefited them in reducing symptomology. Future pandemic
responses should include a focus on mental healthcare for young adults at risk for substance use
and mental health problems.

40
INTRODUCTION

Adverse childhood experiences (ACE) are defined as traumatic events that occur during
childhood, including: homelessness; abuses; parental intimate partner violence; household
substance abuse; divorce, and familial incarceration.
1,4,5
Young adults who experienced ACE are
considered a high-risk population because they are more likely to engage in substance
misuse,
1,146,147
have higher rates of anxiety and depression,
6-8
are more likely to need psychiatric
care,
22,23
and have higher overall healthcare costs,
26
compared to their non-ACE peers. A recent
systematic review

concluded that the strong association between ACE and later mental health
problems calls for better intervention strategies.
134
The COVID-19 pandemic might have
exacerbated mental health challenges among young adults who experienced ACE.
148
Thus
understanding the relationship between mental health, substance use, and mental healthcare for
young adults who experienced ACE during the COVID-19 pandemic is instrumental for this
population.
Stressors such as academic, familial, and societal problems increased worldwide during
the COVID-19 pandemic. The World Health Organization stated that young adult mental health
was most negatively impacted during the pandemic when compared to other age groups, such
that young adults experienced increased stressors and gaps in mental health and substance use
treatment.
149
Despite the rise in telemedicine during the COVID-19 pandemic,
150
young adults
reported a lack of access to mental health services due to financial barriers,
150
lack of health
insurance, and poor treatment effectiveness.
151
This, in turn, may exacerbate underlying
conditions, especially for young adults who have experienced ACE and are predisposed to
mental health disorders and problematic substance use. Understanding substance use behaviors
and mental health implications of young adults who experienced the COVID-19 pandemic has

41
been studied.
11,23,144,152
However, the literature on the impacts of mental healthcare on these
aforementioned behaviors and implications during COVID-19 is limited for young adults who
experienced ACE. Taking this a step further, qualitative interviews are beneficial in
understanding the experiences of individuals with a history of trauma
153
, as well as young adult
substance use and mental health behaviors.
154,155
Exploratory qualitative studies provide a means
for understanding the “how” and “why” in research.
156
Using a combination of both deductive
and inductive approaches
157,158
allows for the creation of a theoretical framework to guide the
research question (deductive) while also enabling the coding process to begin after analyzing the
interview transcripts (inductive). This combined approach is organized and thorough
157
, which
can help us better understand how a new virus, such as COVID-19, can impact behavior.
Adopting a qualitative approach can provide insight into how mental healthcare experiences
influenced the substance use and behaviors of young adults who have experienced ACE and why
these behaviors differed from the pre-pandemic period.
The Transactional Model of Stress and Coping
102
posits that events are experienced as
stressful based on how the individual perceives them, including the individual’s sense of the
intensity of the stressor and their cognitive capacity for responding.
102,144,149,159,160
This theory
suggests that individual’s responses to the pandemic will vary based on their own cognitive
capacities.
104
Thus, young adults with ACE who perceive that they have inadequate resources to
cope with the pandemic may experience relatively high levels of depression and anxiety.
105
To
mitigate the feelings of depression and anxiety, such an individual may be at risk for poor coping
behaviors such as substance use.
105
Conversely, those who believe that they have sufficient
resources to cope with the pandemic may be more likely to exhibit resiliency
161
to substance use
and mental health problems.

42
Current Study
Research on the mental healthcare experiences of young adults who experienced ACE
during the current COVID-19 pandemic is limited. Based on the Transactional Model of Stress
and Coping
102
, the current study investigates how young adults who experienced ACE have been
impacted during the COVID-19 pandemic, focusing on their mental health, mental healthcare
access and utilization, and substance use behaviors. Because young adults who experienced ACE
had an elevated risk for anxiety, depression, substance use, and need for mental healthcare before
the pandemic,
29
and these problems increased worldwide during the pandemic
144,162
, it is critical
to understand the pandemic’s effect on this vulnerable population as there may be residual
aftereffects and the potential for mental healthcare services to ameliorate the pandemic’s
negative effects. This study employs a qualitative approach, utilizing both deductive and
inductive strategies. The theoretical framework of the Transactional Model of Stress and
Coping
102
is used to guide the research aim deductively, while the inductive strategy involves
coding after reading over the interview transcripts.
157,158
The focus of this study is to explore the
experiences of young adults who have a history of ACE during the COVID-19 pandemic, which
was a global traumatic experience. The ultimate objective of this research is to gain insights that
can inform future prevention and treatment interventions for this population, beyond the context
of the pandemic.
METHODS
Participants & Procedures
Using qualitative interviewing, 26 young adults who experienced ACE were interviewed
to learn about their substance use, anxiety, depression, and their subjective mental healthcare
experiences during the COVID-19 pandemic. Participants (ages 21-29 years old) were recruited
using online recruitment strategies including social media advertisements and flyers distributed

43
at organizations that work with substance use and mental health clientele. Interested participants
completed a screener to ensure they qualified for the study. The inclusion criteria included being
within the age range of 21-29, given that we studied substance use behaviors and needed
participants to be of legal age. Also, participants had to have experienced at least one ACE.
Afterwards, eligible participants were sent an informed consent form to sign online and were
invited to participate in a 30-to-45-minute one-on-one interview via Zoom. From January
through April 2022, participants were interviewed to understand their subjective experiences
before and during COVID-19. The number of interviews conducted was selected based on
previous studies until data saturation was achieved.
163,164,165(p20)
All interviews took place via
Zoom and were conducted by the lead author and a co-author with experience conducting
qualitative interviews.
Measures
The interview questions are shown in Supplementary Table 1. Participants first responded
to demographic questions and the ACE questionnaire verbally to confirm their ACE exposure
and build rapport with the interviewer. Next, they responded to semi-structured interview
questions about the effects of their ACE,
166
substance use, mental health, and mental health
experiences before and during the COVID-19 pandemic. These interviews were focused on
understanding (1) any feelings of anxiety or depression that may or may not be about the
pandemic (2) participants’ use of and experiences with mental healthcare and (3) problematic
substance use behaviors during the pandemic and how participants’ substance use related to their
mental health.

Thematic Analyses

44
Interviews were analyzed using thematic analysis
167,168
, which is widely used in health
sciences studies.
169,170
Data compiling
171
was completed, where the interviews were transcribed
using a professional transcription service. Next, dissassembling
171
of the transcriptions took
place, in which they are read line by line to uncover themes, concepts, or ideas that may be
connected.
172
Interview transcripts were read over, corrected for accuracy, and uploaded to
Atlas.ti version 22.
173
Next, data were reassembled
171
where overarching themes were created
based on participant interview data,
170
using inductive coding.
157
This process continued until
themes were saturated and no new themes were identified.
172
A codebook was created allowing
all data analysts to work from the same framework during the coding process. The codebook was
organized by identified themes and their corresponding codes, such as childhood trauma,
substance use, mental health, mental healthcare and fears associated with COVID-19. Coding
was conducted by the lead author and three co-authors. An intra-coder kappa reliability score of
at least 0.85 was used to determine that analysts were in agreement.
174
Next, interpretation
171
was
completed, in which the major themes were identified to understand and discuss the findings.
This included considering the relationship between themes and any global findings between the
coders. Lastly, concluding
171
was completed, in which the research questions are answered and
conclusions and implications are generated.
175
Table 2 shows the themes and their definitions.

Themes Definitions
Mental health during COVID-
19
Participants described their mental well-being during the
COVID-19 pandemic, compared with pre-pandemic
Factors that impacted mental
health
Participants described what factors impacted their mental
health, such as finances, isolation, interpersonal
relationships, lifestyle and living changes and health
anxiety.
Substance use patterns during
COVID-19
Participants described their substance use behaviors during
the COVID-19 pandemic and how it was prior to the
pandemic.

45
Factors that impacted substance
use
Participants described which factors impacted their
substance use, such as finances, isolation, interpersonal
relationships, lifestyle and living changes and mental
health.
Healthcare and coping strategies
for mental health and substance
use during COVID-19
Participants described their unique mental healthcare and
what specific coping mechanisms they used for their mental
health and substance use (i.e., sleep, exercise, gaming).
Table 2. Themes and definitions
RESULTS
Participant Demographics and ACE
Participants’ mean age was 23.51 (SD=2.41); 15 were male, 9 female, and 2 non-binary.
Participants reported a mean of 4.5 ACE, including a mean of 1.81 types of maltreatment and
2.69 types of household dysfunction prior to the age of 18.
Themes
Mental health during COVID-19
All participants reported experiencing mental health symptomology during the COVID-
19 pandemic. Describing their depression, a participant stated, “I ended up sleeping a lot and I
really didn’t have any motivation to do anything. There wasn’t really a point, so I guess that
would be hopelessness” (Participant #13). Similarly, many participants experienced anxiety
frequently during the pandemic, with many experiencing anxieties daily or almost every day. “I
developed kind of a hair-pulling thing,” explained Participant (#2). In fact, nearly all young adult
participants reported an increase in mental health problems during COVID-19.
Factors that impacted mental health
Participants often described being affected by social isolation and loneliness during the
pandemic. Also, participants often described the challenge of having to cancel holiday plans, not
seeing friends or family, and being stuck indoors for long periods of time. One participant
explained how they felt that they no longer had a social life. Another described how their ACE

46
history may have placed them at particular risk of being affected by social isolation and
loneliness during COVID-19: “Being lonely and just dreading in my thoughts about my
childhood and all that literally came back to me when I was alone during COVID” (Participant
#14). In fact, participants often noted that during re-openings and periods when they were able to
see loved ones, their mental health greatly improved. On the other hand, some participants
reported that socializing less and having less to do during the pandemic helped them feel less
anxious, with one noting that socializing via technology seemed to benefit their mental health.
Young adults reported other COVID-19-related interpersonal issues, including break-ups
during the pandemic, challenges they faced living with family members, and difficulty
navigating differences in preferences around social distancing measures: “A couple months in,
when people were starting to get together more, I felt more anxious because I felt pressured to
spend time with people. And I wanted to. But at the same time didn’t think that it was a good
idea. And I did have a lot of anxiety saying no to family members and saying no to my friends,
worrying about how that was gonna affect our relationships” (Participant #26)
Most participants experienced some health-related anxiety during the pandemic, namely
fear of themselves or others catching COVID-19. Health anxiety contributed to the reduction in
social activity for many interviewees, including a participant who described the link in the
following way: “I think the disease affected little things, how we interact with people, and also,
we don’t know if someone is exposed to COVID-19, so it was really hard. It was really hard”
(Participant #3). Some participants were especially worried about their or others’ pre-existing
medical conditions and feared this would put them at risk of poor outcomes if they contracted the
virus.
Participants often specifically noted a fear of themselves or others dying due to the

47
pandemic, and several participants did in fact experience a death or other loss during the
pandemic and identified a link between grief and their mental health difficulties. Additionally,
some participants linked their substance use to experiences of death and loss during the
pandemic. One shared, “Obviously being exposed to so much death, it just – I would go reach for
the drink to erase this; this pain out of my head and out of my memory” (Participant #6).
Although the emergence of vaccines helped assuage fears, many participants had fears about the
vaccines that created more anxiety. Worries about the vaccine included having more severe
symptoms of COVID-19 after receiving the vaccine, the vaccine affecting childbearing abilities,
or even dying due to the vaccine.
Participants often also had financial or employment-related concerns and reported these
too affected their mental health. Participants discussed the effect of frequent job changes, losing
work, and pay cuts that they or their loved ones experienced. A participant who suffered a job
loss stated, “I was depressed because I lost my job. My main source of income during the
pandemic” (Participant #5).
Substance use patterns during COVID-19
Alcohol was the most frequently used substance and was used by nearly all young adult
participants specifically during the pandemic. Many participants reported drinking nearly every
day and/or binge drinking. A participant illustrated the extent of their heavy drinking by saying,
“I was just drinking a lot. I was always drinking. I was putting a little bit of stuff in my coffee in
the morning, but I was not becoming drunk, I just needed it to get through the day. But then at
night I was drinking quite a bit and that probably lasted for like a month, I guess” (Participant
#6). In terms of other substances, over half of the participants reported some cannabis use, and
again many of these participants reported daily or nearly daily use of cannabis during the

48
pandemic. A minority of participants endorsed other illicit substance use or prescription drug
misuse during the pandemic. Considering all substances, nearly all described increases in use
behaviors during COVID-19. In fact, some participants expressed concern that their substance
use was becoming addictive. One, for example, stated, “I would say, during the pandemic, I got
addicted to taking alcohol…I have to smoke marijuana early in the morning once I get out of
bed” (Participant #7).
Factors that impacted substance use
Nearly all participants reported that their use of substances during COVID-19 was in part
an attempt to cope with mental health symptomology, with several participants specifically
noting they used substances to cope with depression and anxiety. Describing how alcohol
seemed to help with their anxiety symptomology, one participant stated, “It’s just, I think, a nice
way to calm down and think about something else, because it kind of slows down thoughts, so
that helps” (Participant #23). Several participants said they used substances to slow their mind
down or relax enough to fall asleep when their mental health symptomology made it difficult to
do so. However, one participant shared that their attempts to self-manage their mental health
symptomology with substances were not effective: “I wanted to add that my use of substances
didn’t, in any way, give me a permanent relief. For that moment, two hours, sometimes 30
minutes, I could feel relief, I could feel free. After which, those same things I tried to run away
from, come again” (Participant #5). Another seemed to feel that the use of substances was
making them feel worse, stating substances impacted their mental health negatively. Describing
the potentially reciprocal links between substance use and mental health, another participant
stated “I’m not sure what happens first; like if the depression is what triggers that or if the
substance use is what triggers the lengthy depression crashes. But they definitely coincide for

49
sure” (Participant #18).
Healthcare and coping strategies for mental health and substance use during COVID-19
Although all participants experienced some degree of mental health symptomology and
many reported problematic substance use during the pandemic, only some participated in some
form of mental healthcare (i.e., therapy or psychiatric care). Of those who participated in mental
healthcare, most felt that doing so benefited them in reducing or preventing their mental health
symptomology, as they often stated that they likely would have fared worse during the pandemic
had they not engaged in treatment. Participants often utilized telehealth during the pandemic, and
many reported that they found telehealth particularly helpful and convenient. Describing how
telehealth lowered barriers, one participant shared, “Having [sessions] be virtual makes it really
easy for me to incorporate it into my day, even if I really don’t wanna do it that day” (Participant
#26).
Service challenges. However, other participants found telehealth challenging, noting
glitching (malfunctioning telehealth software), privacy concerns, and awkwardness. One
participant described feeling self-conscious on group sessions via Zoom, sharing that it made her
nervous. Another participant felt individual sessions with her psychologist via telehealth were
inferior to those she has had in person “because he understands my body language [in person].
So, I feel that meeting him in-person is better” (Participant #7). Notably, nearly some
participants reported they did not have health insurance or could not afford care during the
pandemic. Describing their predicament, one participant stated, “I would like to but it’s just the
fact that the services are pretty expensive for me right now and I just can’t justify the expense”
(Participant #15). One participant who did not have adequate insurance coverage stated that,
instead, her friend group had formed a self-help group to cope with the challenges of the

50
pandemic.
Coping strategies. Participants identified a number of other coping strategies they had
been utilizing during the pandemic. Most frequently, participants spoke of exercise as a way to
feel better, and one of these participants shared that they used exercise as a “healthy distraction
from drinking” (Participant #11). Several participants described their use of mindfulness or self-
compassion skills that they had learned either through therapy or with a mindfulness app, and
some spoke highly of the benefits. Lastly, some participants reported sleeping more than usual as
a way to cope with COVID-related mental health symptomology; one shared, “when I’m
depressed, I just sleep” (Participant #22).
DISCUSSION
This study examined how young adults who experienced ACE fared during the COVID-
19 pandemic by interviewing them about their substance use, mental health, and mental
healthcare during this time. Childhood trauma has been linked to an increased risk of mental
health problems and maladaptive coping mechanisms including substance use.
1,134,135
As the
COVID-19 pandemic was an unprecedented shared experience, it provides a unique opportunity
to study young adults who experienced ACE, who are already at high risk for the aforementioned
problems, during a global traumatic event. Qualitative studies allow an in-depth approach to
understanding the subjective experiences of young adults who experienced ACE. Several
common themes were identified in this analysis, including factors that impacted mental health
and substance use behaviors of young adults who experienced ACE during the pandemic, as well
as mental healthcare and other means of coping during the COVID-19 pandemic. These themes
were data driven that flowed directly form the questions, whereas others were responses that
provided insights beyond the scope of the original question.

51
Overall, most young adults indicated that they experienced depression and/or anxiety
during the COVID-19 pandemic.
35
This aligns with what has been found in the recent COVID-
19-related literature, that young adults who experienced ACE are more susceptible to mental
health complications during traumatic conditions.
23,177–179
Additionally, young adults who did not
experience ACE also indicated higher levels of depression and anxiety during the COVID-19
pandemic when compared to prior to the pandemic
176
, which indicates that young adults in
general were experiencing higher levels of mental health problems during the pandemic. Several
factors impacted mental health for our participants, including loneliness and isolation
180,181
, and
some reported their difficulty was further exacerbated by the effect of previous trauma.
159,182

This indicates that previous trauma can have an impact on future trauma responses. However,
seeing loved ones in-person or talking to them via technology
22
helped alleviate feelings of
loneliness and isolation during the pandemic, which is indicative of counteracting loneliness with
connectedness, even via technology. Future studies should focus on understanding the
relationship of technology and connectivity, especially in young adults with trauma. In line with
the Transactional Model of Stress and Coping
102
we found that having viable resources does
impact the stress response of young adults with a history of ACE during the COVID-19
pandemic.
Additionally, other participants stated that their peer groups and loved ones were not
comforting or understanding if they expressed anxiety about interacting in-person. In line with
this, Chou and colleagues found that social distancing was not widely supported, meaning that
peers did not follow the government-recommended social distancing measures.
183
Young adults
tend to socialize in groups, thus, it is probable that those social distancing measures were not
followed as strictly as needed. Many participants reported other interpersonal issues that arose

52
during the pandemic and due to social distancing measures. For example, the COVID-19
pandemic required many to spend a lot of time with family members they normally do not
cohabitate with and in some cases with whom they experienced relational strain or difficulty
(e.g., college students sometimes had to move back to their family home during campus
lockdowns). Perhaps some of this conflict was because social distancing measures made it
difficult for young adults to socialize outside of their homes
184
, and have independence to live
without restrictions.
Health anxiety was also a common theme in our study, though it was experienced in
differing ways. On the one hand, many of our young adult participants were concerned about
catching the COVID-19 virus or having a loved one contract the virus. Many even reported a
fear of dying due to the COVID-19 virus
116
, which other studies have found to be the case for
young adults who did not experience ACE.
185
It is possible that young adults who experienced
ACE, and have higher rates of anxiety, may also have higher rates of health anxiety as well. In
line with The Transactional Model of Stress and Coping,
102
the way an individual perceives and
evaluates a situation, such as experiencing health anxiety during a pandemic, can determine their
stress response. When it came to the COVID-19 vaccine, some young adults were relieved and
saw it as a solution to their anxiety
45
, but others worried the vaccine would cause severe adverse
reactions such as problems with fertility and even death.
186,187
Bellis and Colleagues reported that
young adults (aged 18-29) had the highest percentage of vaccine hesitancy when compared to
other adult age groups.
160
Fears associated with the vaccine was a finding of our study, which is
in line with other literature on the topic of ACE and vaccine hesitancy behaviors.
188
Future
public health and pandemic responses should focus on interventions to reduce vaccine hesitancy
in vulnerable populations, such as young adults who have experienced ACE.

53
Another factor that impacted mental well-being during the COVID-19 pandemic was
financial stressors.
3
Moreover, finances have greatly impacted many individuals during the
COVID-19 pandemic, in particular young adults.
3,150
This study adds to the literature, by taking a
qualitative approach to understanding the financial stressors that young adults who experienced
ACE were faced with during COVID-19. Considering what is known about our study
population’s susceptibility to maladaptive coping in the face of stress, it is perhaps not surprising
that participants reported that their alcohol and marijuana use increased during the pandemic
when compared to their pre-pandemic consumption. The Transactional Model of Stress and
Coping,
102
which states that increased stress may lead to maladaptive coping mechanisms due to
an individual’s perception and appraisal of threat, provides a framework for why young adults
who experienced ACE may feel an intensified level of stress in traumatic conditions, such as a
pandemic. The stressors of the pandemic led to using substance use as a coping mechanism.
122,189

In particular, some young adults indicated that anxiety and depression were reasons for wanting
to use substances during the pandemic
189
, and some even mentioned that they were unsure of the
order of use, that is if they were alleviating their mental health or using substances first. This
may be due to the fact that substance use and mental health can overlap in young adults,
especially in stressful situations.
Young adults also indicated that they used substances as a means to offset boredom
22
, as
activities were limited during the pandemic. Given that social distancing was imposed for a
while during the pandemic, it is probable that young adults found a means to cope with the
boredom associated with this, by using substances to pass the time. Some participants also
indicated that substance use was a coping mechanism for grief or losses experienced during the
pandemic.
190
Corroborating our finding, Lee and Neimeyer administered the Pandemic Grief

54
Scale and found that adults experiencing relatively high grief and loss were using more
substances, likely as a coping mechanism for pandemic-related grief and loss.
56

Our participants also highlighted changes in healthcare delivery. Namely, many
participants indicated that they utilized telehealth for mental health treatment during the
pandemic.
177,192
Some young adults felt that telehealth was not the same as in-person as the
experience was different for them in the way the therapy resonated with them
193
, although others
found telehealth to be relatively convenient and therefore reduce barriers to obtaining care.
Future pandemic responses should focus efforts on maintaining accessible and innovative mental
healthcare measures, especially for children and adolescents at risk for trauma
194
, prior to their
young adult years. An interesting finding is that young adults who utilized mental healthcare
reported that their substance use and mental health symptoms subsided as they found an outlet
during this time.
193
However, other participants stopped going to therapy altogether, due to
several factors, such as cost, lack of insurance and hesitancy to engage in virtual platforms for
therapy. Some young adults who wanted to seek therapy during this time were unable to do so
because of poor finances and a lack of health insurance.
177
This is yet another example of how
the pandemic highlighted, and perhaps even exacerbated, existing socioeconomic
disadvantages
195
, and also brings to light a lack of access to care during traumatic experiences.
Also, some young adults shared that they discovered new avenues for treatment or self-help,
such as group therapy, mobile mental health applications, and other technology-driven mental
health resources (i.e., peer support zoom calls), again reflecting broader changes in the care
landscape. In line with this, a systematic review and meta-analysis on college students found that
the use of meditation is helpful for alleviating feelings of anxiety and depression.
196

55
Our study did have some strengths and limitations. One strength was that we had a
geographically diverse sample spread across the US. We were also able to focus our sample only
on young adults who had experienced ACE. Our limitations included recall bias, as we asked
young adults to recall their pre-pandemic substance use, mental health and mental healthcare
behaviors. Additionally, social desirability bias is another limitation, because although our study
was confidential, participants may not be inclined to fully share sensitive information.
CONCLUSION
The COVID-19 pandemic is a collective, global trauma. Our findings can inform future
pandemic responses for young adults who have a history of ACE. We found that young adults
who experienced ACE, who are already susceptible to maladaptive coping mechanisms indicated
increased depression, anxiety, and alcohol and marijuana use during this time. Thus, providing
viable resources that are accessible, adaptable to technology and supportive of young adults with
childhood trauma may be important for future directions within the field. Participation in mental
healthcare services was said to help improve substance use and mental health symptomology.
However, a lot of young adults also indicated that they could not access mental healthcare
services due to cost and lack of insurance. Therefore, making mental healthcare more affordable
and accessible can be beneficial for future preventive measures in general and for pandemic
responses. Additionally, future pandemic prevention efforts should include intervening with
mental healthcare during traumatic times.

56

Supplemental S1. Interview Questions
1. Please state your first name - this should be a pseudo name that is different from your
real name for confidentially purposes
2. Please state your city and state
3. Please state your age and gender
4. Are you currently enrolled in college?
5. Are you currently employed (please specify part-time or full-time)?
6. Have you experienced an adverse childhood experience (ACE)? ACE is defined as is a
negative event that occurs before a person reaches 18 years of age. I am going to ask a series
of questions regarding ACE
7. Have you experienced: abuse, which can be emotional, physical, or sexual?
8. Have you experienced: neglect, either physical or emotional?
9. Have you experienced: domestic violence?
10. Have you experienced: substance misuse by a member of the household?
11. Have you experienced: divorce or separation of parents or caregivers?
12. Have you experienced: mental illness of a member of the household?
13. Have you experienced: having a member of the household go to prison?
Now I am going to ask questions regarding your mental health during the COVID-19
pandemic
14. Did you experience prolonged feelings of hopelessness, sadness, and/or lethargy during
the COVID-19 pandemic?
15. Please elaborate if you experienced these feelings before the pandemic as well.
16. How often did you feel ‘depressed’ between March 2020-present?
17. Were there certain points during the current 22-month pandemic when you felt more
depressed? Less depressed?
18. Did you experience prolonged feelings of anxiousness, restlessness, and worry during
the COVID-19 pandemic?
19. Please elaborate if you experienced these feelings before the pandemic as well.
20. How often did you feel ‘anxiety’ between March 2020-present?
21. Were there certain points during the current 22-month pandemic when you felt more
anxious? Less anxious?
Now I am going to ask questions regarding your mental healthcare during the COVID-19
pandemic
22. IF NO SKIP TO #26. During this pandemic have you received mental healthcare
services?
23. Describe your mental healthcare treatment experiences.
24. Did you have health insurance that covered mental healthcare during this time, or did
you have to pay out of pocket?
25. If yes, how did you receive mental healthcare? (Some probes: via telehealth? In-
person? Any other means?)
a. How was this if it was in-person with masks? If virtual via telehealth with the
computer/limited privacy?
26. If you received mental healthcare before the pandemic: how are your current mental
healthcare experiences different than pre-pandemic?

57
Now I am going to ask you questions regarding your substance use during the COVID-19
pandemic
27. Do you use any of the following substances: alcohol?
28. Do you use any of the following substances: marijuana?
29. Do you use any of the following substances: illicit drugs?
30. Do you use any of the following substances: prescription drugs not prescribed to you?
If yes to any of above questions (#27-30), the following questions will be asked (#31-34), if no
to #27-30, then skip to #35:
31. During the pandemic: If you drank alcohol, how often did you drink? How many
drinks in one sitting? Please elaborate in which context (with others? alone?)?
a. How was your alcohol intake before March 2020?
32. During the pandemic: If you smoked or ingested THC, how often did you? How many
mg in one sitting? Please elaborate in what context (with others? alone?)?
a. How was your marijuana intake (THC only) before March 2020?
33. During the pandemic: If you engaged in using illicit drugs, how often did you?
a. How was your drug use from before March 2020?
34. During the pandemic: If you engaged in prescription drug misuse (i.e., consumed
prescription drugs not prescribed to you), how often did you do so? Please elaborate in what
context (with others? alone?)?
a. How was your prescription drug misuse before March 2020?
35. Explain if you ever used substances to alleviate feelings of anxiety (pre and during the
pandemic)?
36. Explain if you ever used substances to alleviate feelings of depression (pre and during
the pandemic)?
37. SKIP to #38 IF NO to #27-30. Describe how the pandemic has influenced your overall
substance use.
38. Please share any trends in your substance use during the pandemic.
a. Please describe how this trend may be correlated with your mental health?
b. Please describe how this trend may be correlated to your mental healthcare that you
may have received?
38. Describe how you may feel more stressed out or more resilient during the pandemic?
39. Explain any fears you have when it comes to the COVID-19 pandemic.
Supplementary Table 1. Interview Questions

58
CHAPTER 4: DISCUSSION

Summary of Findings
The overall goal of this dissertation was to examine associations of ACE and substance
use, mental health and access to mental healthcare among young adults during COVID-19.
Young adults with ACE have a disproportionally greater risk of developing maladaptive coping
mechanisms such as substance use during stressful times, such as a pandemic. This dissertation
addressed the vulnerabilities that lead to maladaptive coping mechanisms, that young adults
faced during the pandemic and whether ACE exacerbated these effects.
Study 1 examined associations of ACE and COVID-19-induced stress with mental health
implications and substance use among young adults during the COVID-19 pandemic. Results
indicated that most participants (61.3%) had experienced at least one ACE. Our findings provide
some evidence of ACE moderating the association between levels of COVID-19 stress and
substance use (past 30-day alcohol and cannabis and using these substances to cope with the
COVID-19 pandemic) and mental health outcomes (anxiety and depression). For the COVID-19
stress main effects, we found that anxiety, depression and cannabis use for COVID-19 coping
increased across per one unit increase of COVID-19 related stress.
For anxiety, a significant moderation was found for young adults with 1-3 and 4 or more
ACE and COVID-19 stress. Given the strong association between anxiety and stress, as found in
previous research
23,144
, this overlap likely accounts for the observed connection between mental
health and COVID-19 related stress in our study. Future pandemic responses should focus on
pandemic related stress potentially impacting maladaptive behaviors and mental health
implications of young adults who have a history of childhood trauma.
194
It is possible that a
cumulative stress response
102
may develop from childhood to young adulthood, thus impacting
these behaviors on a larger scale. In line with this finding, research presented at the Anxiety and

59
Depression Association of America in 2022 found that childhood trauma impacts anxiety and
depression by impacting the inflammation in the brain.
145

Study 2 examined how young adults with ACE fared during the COVID-19 pandemic by
interviewing them about their substance use, mental health, and mental healthcare during this
time. Several common themes transpired in this analysis, including factors that impacted mental
health and substance use behaviors of young adults with ACE during the pandemic and mental
healthcare and other means of coping during the COVID-19 pandemic. In our study, it was
especially notable to find that when comparing their mental health to pre-pandemic conditions,
participants with ACE often reported an increase in both anxiety and depression during the
COVID-19 pandemic.
117,197
Namely, many participants indicated that they utilized telehealth for
mental health treatment during the pandemic.
177,192
Some young adults felt that telehealth was
not the same as in-person as the experience was different for them in the way the therapy
resonated with them
193
, although others found telehealth to be relatively convenient and therefore
reduced barriers to obtaining care. Future pandemic responses should focus efforts on
maintaining accessible and innovative mental healthcare measures, especially for children and
adolescents at risk for trauma.
194

The two studies together inform us on how a mixed-methods approach to research is
crucial to understand young adult behaviors on different levels. The quantitative paper (study 1)
allowed us to focus on associations between ACE and substance use and mental health
outcomes. We were able to compare young adults with low and high ACE, with those who did
not experience ACE. We also evaluated the association of COVID-19 stress with the use of
alcohol and cannabis, and levels of anxiety and depression during the COVID-19 pandemic in
young adults and evaluated the extent to which the association differs by the number of ACE. In

60
our qualitative study (study 2), we were able to gain an in-depth perspective on young adults
with ACE behaviors exclusively, with no comparison. The themes that appeared were in line
with the literature regarding young adults during the COVID-19 pandemic.
180,21,186
However, we
were able to learn more about our young adults with ACE, as they shared their COVID-19 fears,
which aligns with our COVID-19 stress moderator in the quantitative study.
Implications
ACE is associated with substance use and mental health implications among young
adults.
1
The COVID-19 pandemic that began in 2020 increased the risk for these behaviors
2

among young adults due to social distancing, isolation, and financial and academic stressors.
3

Findings from this dissertation have implications for substance use, mental health, mental
healthcare services and stress associated with the COVID-19 pandemic.
Substance Use & Mental Health
Young adults with ACE are especially vulnerable to substance use when compared to
their non-ACE peers.
1,23
Thus, understanding how a traumatic experience, such as the COVID-
19 pandemic would impact young adult substance use was one of the aims of this dissertation.
Focusing on how to mitigate maladaptive coping mechanisms, in an already vulnerable group of
individuals, is an imperative implication of this dissertation. Study 1 found that young adults
with 1-3 ACE had higher odds of alcohol use for coping during the pandemic, and that those
with 4 or more ACE had higher daily use of alcohol and cannabis. Study 1 also found that young
adults with COVID-19 stress had higher odds of using cannabis to cope. Study 2 also found that
some young adults with ACE reported higher substance use to cope with the pandemic, due to
isolation
180
, financial distruption
21
grieving, intrapersonal relationships and health anxiety.
186

Therefore, directing efforts towards campaigns that aim to reduce the use of alcohol and

61
cannabis as a coping mechanism during traumatic periods can be advantageous.
198,199

Additionally, interventions for this already high-risk group would benefit them in times of
trauma. It is possible that the COVID-19 pandemic can create a cumulative stress
102
and impact
later substance use for young adults, especially those with ACE.
Similar to our substance use findings, ACE and COVID-19 stress was associated with
higher depression and anxiety scores in study 1. However, in study 2 almost every participant
indicated depression or anxiety experienced during the pandemic, and some participants realized
that their mental health prior to the pandemic was not as noticeable to them personally. They did
not feel as depressed or anxious before the pandemic as did during the pandemic.
26,30
Our
participants in study 2 indicated that isolation
180
, concerns over finances
21
grieving, intrapersonal
relationships and health anxiety
186
were all reasons behind their increased mental health
symptomology during the pandemic.
Beyond the scope of this dissertation, it would be valuable to investigate the effects of
cumulative stress on individuals with ACE further. This could involve examining specific ACE
and examining gender and racial/ethnic disparities
54-58
in relation to substance use and mental
health behaviors. These interventions could include increased access to mental healthcare and
tailored resources, particularly during stressful times like a pandemic.
Mental Healthcare
In study 1 we did not measure mental healthcare. However, our findings in study 2
indicate that young adults with ACE, who are already vulnerable to maladaptive coping
mechanisms, are at increased risk of depression, anxiety, and substance use during the pandemic.
Although some participants suggested that they appreciate the virtual nature of telehealth
therapy
200
, other participants shared that they did not continue mental health services once the

62
pandemic began.
201
Therefore, it is crucial to provide accessible and technology-adaptable
resources
202
that support young adults with childhood trauma and remove other barriers to
mental healthcare (i.e., cost
202
, access to care
203
, racial/ethnic disparities
89
). However, it should
be noted that perhaps as time goes on telehealth may be ‘normalized’ and future research is
needed to understand the utilization of this healthcare service.
COVID-19 Stress
The COVID-19 pandemic has substantially increased stress and anxiety for people
worldwide, particularly among young adults. According to recent studies, young adults are
especially susceptible to stressors related to COVID-19.
114,116
As the pandemic continued to
unfold, young adults were facing a range of stressors such as concerns about their health and the
health of their loved ones, financial instability, social isolation, and interruptions to their
education and career plans.
45,92,117
This combination of stressors caused significant challenges for
young adults, impacting their mental health and well-being. Given that studies have found an
increase in pandemic-related stressors
117,204,205
, measures have been defined for ‘COVID stress
disorder’.
206

Interventions aimed at addressing stressors and fears related to the pandemic are
particularly relevant for young adults who have experienced ACE, as they may have developed
maladaptive coping mechanisms due to their past trauma.
144,207,208
These interventions, which
include using technological meditation tools
196,209
can help young adults conveniently develop
effective coping strategies and promote resilience in the face of pandemic-related stressors. By
addressing the unique needs of young adults with ACE, these interventions can also contribute to
improving their overall mental health and well-being. Thus, future pandemic responses should
entail providing resources for healthy coping mechanisms for young adults.

63
Future Directions
Study 1 also found that ACE moderated the association between COVID-19 and anxiety,
indicating that more stress-relieving and mental well-being tools should be readily available for
young adults with a history of ACE. Thus, exploring this relationship post-pandemic may be
beneficial to understanding traumas in ‘real time’, especially for those who already have a
history of trauma.
30,52,71,210
The other outcomes of interest (i.e., depression, daily alcohol and
cannabis use, and coping with COVID-19 by using alcohol and cannabis) did not have
significant interaction. Future work should examine if perhaps young adults with ACE used other
mental well-being tools, such as therapy, meditation, exercise and other lifestyle factors
196,211,212
,
to help alleviate stress. Past research has brought to light how trauma can have a lasting impact
on individuals, regardless of if it is in the developmental and formative years of childhood and
adolescence, or if it is in the impressionable years of emerging adulthood.
7,8,213
Given that the
current H&H wave 11 data has an average age of 21 years of age, the individuals in this data set
are currently in their emerging adulthood years, a time that has been found to be quite impactful
to developing maladaptive behaviors in relation to any traumas experienced.
7,213
It would be
interesting to be able to follow these participants in their journey through young adulthood,
navigating the remanent post-pandemic life and exploring the relationship between anxiety and
ACE. The retention of the H&H study has been very high in past years, thus, it is anticipated that
many of the same participants would be surveyed.
Study 2 highlighted that participation in mental healthcare services can help mitigate
mental health and substance use issues, but many young adults reported difficulties accessing
such services due to finances and lack of insurance. Thus, improving the affordability and
accessibility of mental healthcare should be a priority for future pandemic responses.
203

64
Furthermore, it is important to intervene in mental healthcare during traumatic times to prevent
and mitigate the negative effects of such events. Future pandemic prevention efforts should take
into account the mental health needs of the population and provide adequate resources and
support for those who need it, such as individuals with ACE. Thus, future directions should look
at a similar study model of this overall dissertation (e.g., study 1 and 2 together), as it would be
beneficial to examine if young adults (aged less than 30 years of age) who experienced low and
high ACE compared to their non-ACE peers had differences in their substance use and mental
health behaviors “post-pandemic”. This association should look at coping mechanisms as a
moderator, in particular mental healthcare and mental well-being tools (see figures 3 &4 below).
This proposed moderator is inspired by the results found in study 2, which found that young
adults with ACE reported using mental well-being tools to mitigate COVID-19 stressors and
concerns. A future study could perhaps look at three waves of H&H data to conduct moderation
analysis, starting with the first-year “post-pandemic” (if that is the case in 2024), the second-year
“post-pandemic” (2025), and lastly 3 years out of the COVID-19 pandemic (2026). This will
allow us to see the change in behaviors between the 3 waves of data and see if any residual post-
pandemic effects do exist (e.g., trauma from the COVID-19 pandemic). It is hypothesized based
on the preliminary findings of this current dissertation that mental healthcare and well-being
tools will reduce substance use and mental health implications in young adults with both low and

65
high levels of ACE.

Figure 3& 4. Future Moderation Analyses
Additionally, it is a pivotal time for research and science, as a pandemic
of this magnitude has not been experienced in roughly the past 70 years (e.g., Polio), such that
social distancing orders were in place for a very prolonged period of time. The economic
stressors, lifestyle disruptions, political unrest, and mental health implications, all foster an
environment that can harbor and breed problematic substance use behaviors. In young adults, in
particular, those who have a history of ACE, the impact may be different for them than their
peers. The findings from this study could have implications for future research and application to

66
other stressors (i.e., political unrest, bodily autonomy, climate change, gun control, racial
injustices) experienced by young adults during the COVID-19 pandemic, extending beyond the
virus itself.
Strengths & Limitations

Study 1 had some respective strengths and limitations. One strength was the relatively
large sample size of young adults from Los Angeles County, California, as well as the
ethnically diverse population. Additionally, data was gathered over more than one wave of
data. Having the two waves of data for this study was helpful in assessing the residualized
outcome in substance use and mental health during different phases of the COVID-19
pandemic. It should be noted that this study is not representative of all young adults and is
geographically limited. Furthermore, as the surveys rely on self-reporting, they cannot be
considered as indicative of diagnostic criteria. Moreover, given the sensitivity of questions
regarding their mental health, substance use and adverse childhood experiences, there is a
probability that some respondents did not answer honestly, regardless of the confidentiality of
the survey.
Study 2 had some strengths, such as focusing only on young adults with ACE and
engaging in in-depth interviews with them about their pre-pandemic and during-pandemic
substance use, mental health and mental healthcare behaviors. However, some limitations
included the small sample size relative to the quantitative study, and the fact that the sample
sizes do not align, which does not make this dissertation a true “mixed methods” study. Also, we
asked participants to recall their pre-pandemic behaviors, thus it is possible that recall bias exists.
Lastly, although this study was anonymous (e.g., participants used a pseudo-name and turned off
their cameras on Zoom) it is possible due to social desirability bias for participants to not be

67
truthful in their responses due to the sensitivity of the questions asked. Moreover, a strength of
this study is that it was via Zoom, reducing the risk of COVID-19 related concerns, and
providing flexibility for the participants. Mental healthcare was assessed in study 2, but not in
study 1, thus why it is proposed in future directions. Also, COVID-19 fears were asked in study
2, which entailed participants discussing some stressors, but it was not an explicit question in
study 1.
Conclusions
This dissertation provides a strong foundation of assessing the substance use and mental
health behaviors of young adults with ACE during the COVID-19 pandemic. Further data on this
association will likely be beneficial to understanding the impacts of the COVID-19 pandemic on
young adults who have already experienced trauma. In both studies, we found that young adults
with ACE were impacted by the COVID-19 pandemic by engaging in maladaptive coping
behaviors. Young adults in general are already vulnerable to maladaptive coping mechanisms,
given the stressors of emerging adulthood, thus, young adults with ACE are at high risk for
poorer health outcomes in comparison. Therefore, future pandemic responses would be
beneficial in providing resources for young adults with ACE that foster health coping
mechanisms, such as mental healthcare and mental well-being tools. Such interventions have the
potential to reduce maladaptive coping mechanisms during stressful and traumatic times. It is
important to continue this line of research, as the residual effects of traumatic experiences have
been found to last for years (e.g., ACE and later life outcomes). Thus, future research should
examine if young adults (aged less than 30 years of age) who experienced ACE to their non-ACE
peers had differences in their substance use and mental health behaviors “post-pandemic.”

68
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Abstract (if available)

Abstract The overall goal of this dissertation was to examine associations of ACE and substance use, mental health and mental healthcare among young adults during COVID-19. Young adults with ACE have a disproportionally greater risk of developing maladaptive coping mechanisms during stressful times, such as a pandemic. The vulnerabilities that young adults with ACE face, coupled with studying the effects of a pandemic since ACE was identified as a risk factor, were the aim of this dissertation. Study 1 explored ACE and COVID-19 stress on mental health and substance use among young adults. The results of the study indicated that COVID-19 stress may have a significant impact on anxiety levels, particularly in young adults who have experienced varying levels of ACE. As COVID-19 stress levels increased, so did anxiety, and this association was found to be more pronounced in those with a history of ACE. Study 2 took a qualitative approach and thematic analysis of interviews with young adults with ACE during COVID-19 reveals several factors impacting their substance use and mental health behaviors, including isolation, grief, financial and employment disruption, problematic interpersonal relationships, and health-related anxiety. The study highlights the need for future pandemic responses to include a focus on mental well-being for young adults with ACE. That said, future pandemic responses should include giving young adults mental health and substance use resources.

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Creator Pakdaman, Sheila (author)

Core Title The impact of childhood trauma on substance use and mental health during the SARS-CoV-2 pandemic among young adults

School Keck School of Medicine

Degree Doctor of Philosophy

Degree Program Preventive Medicine

Degree Conferral Date 2023-08

Publication Date 06/19/2023

Defense Date 05/11/2023

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag adverse childhood experiences,Alcohol,Anxiety,cannabis,COVID-19,Depression,Mental Health,mental health care,mixed-methods,OAI-PMH Harvest,substance use,Young adults

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Advisor Unger, Jennifer (committee chair), Barrington-Trimis, Jessica (committee member), Clapp, John (committee member), Davis, Jordan (committee member), Steinberg, Jane (committee member)

Creator Email sheila.pakdaman@gmail.com,spakdama@usc.edu

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