Association between adverse childhood experiences, bullying, self-esteem, resilience, social support, caries and oral hygiene in children and adolescents in sub-urban Nigeria

Adverse childhood experiences (ACE) are negative life events that are detrimental to brain development, and are root causes of diseases and mortality [1]. ACE occur before the age of 18 years [1], and include physical, sexual and emotional abuse and neglect, as well as bullying victimization and parental separation. They directly increase the likelihood of a child having poor oral health, including dental caries [2‐4], and are also associated with adult health risks, such as cardiovascular diseases [5], diabetes mellitus [6] and smoking [7] which in turn, are associated with poor oral health in adulthood [8‐10]. ACE further have negative impacts on the neuroendocrine-immune system and host defense mechanism [11] thereby causing high psychological stress [12] that increase the risk for poor oral hygiene and, thereby, caries [13].

Vasiliou et al. [14] developed a conceptual framework from the works of Shankardass [15] and Pearlin et al. [16], to explain the possible link between psychological stress and poor oral health. They suggested that ACE may translate into chronic stress in the absence of promotive assets (resilience, self-esteem) and resources (perceived social support). Chronic stress results in allostatic load, a cumulative physiological impact of chronic stress, that impacts negatively on oral health directly (by increasing inflammatory response which causes periodontal disease [17, 18]) or indirectly (by causing the adoption of unhealthy oral habits such as poor oral maintenance that can result in poor oral hygiene and caries).

Another adverse factor that may have a negative impact on oral health is bully victimization. Bully victimization is defined as the experience of distress or feeling of being controlled by others through aggression and/or power [19]. Good oral health enables children to have a healthy smile, which may be associated with less bully victimization [20]. Multiple studies indicate that poor dental aesthetics [21‐23] and untreated caries [24] increase the risk for bully victimization. Poor oral hygiene causes halitosis, and halitosis is a risk factor for bully victimization [25]. In addition, poor dental aesthetics [26] and caries [27‐29] have negative emotional and social effects on oral health-related quality of life because of their negative impact on self-esteem and self-concept. The history, frequency and consequences of bully victimization also affects oral health related quality of life [30, 31].

Protective factors can mitigate the relationship between ACE and bully victimization and children’s oral health [4, 32] by enhancing one’s ability to use available resources to manage life’s difficulties and maintain one’s health [33, 34]. One of these protective factors is high self-esteem [35]. Improving self-esteem was found to be effective for the management of children with cleft lip and palate [36]. Other individual factors that protect against the negative impact of adverse life events are one’s resilience [37] and access to support [38]. Resilience - an individual’s trait-like ability to demonstrate stable level of functioning despite adversity – acts as a buffer that facilitates positive outcomes despite exposure to adverse life events [39]. Social support also acts as a buffer against the stress that results from adverse life events by enhancing cognitive and emotional processing of the stressful event in a manner that is psychologically adaptive [40].

There is a scarcity of studies determining the relationship between children’s adverse experiences, bullying victimization, protective psychosocial factors and oral health for African populations, despite the identified relationship between these factors [41] and the importance of culture and context in moderating these relationships [42‐44]. Individuals pull on external and internal resources to help them manage, cope with, or resolve tensions in health-promoting ways that reduce stress [33, 34]. Culture influences how individuals deal with tensions and how they identify resources to manage stresses [34]. Africans may be more collectivist-oriented than populations in the Global North who may value individualism and liberalism to a greater extent [45, 46].

This study was conducted in a suburban community in Nigeria, West Africa. This is a collectivist community where the rights and interests of individuals are subordinate to the good of the community. It is a community that holds traditional patriarchal beliefs and strong religious and extended family ties [47]. The study determined the relationship between ACE and exposure to bully victimization and oral health status accounting for factors that help overcome the negative effects of these risk factors. Specifically, the study explored the association between oral diseases (caries, caries complications and poor oral hygiene), ACE, bully victimization and promotive assets (resilience, self-esteem) and resources (perceived social support) [48] in schoolchildren in Ile-Ife, Nigeria.

The data of 1001 (66.6%) of the 1502 collected data with complete information was extracted. Of these, 549 (54.8%) were girls, 962 (96.1%) aged 11–16-year-olds, and 586 (58.5%) children were from middle socio-economic status. Eighty-one (8.1%) children had poor oral hygiene.

Fifty-nine (3.9%) children had caries. The dmft ranged from 0 to 4, with nearly all (99.4%) having 0 dmft. The DMFT ranged from 0 to 6, with most having 0 (94.5%) DMFT. Of the children with caries, 6 (10.2%) had complications. The pufa score was 0 while the PUFA score ranged from 1 to 3. No child with high socioeconomic status had caries complications.

ACE score ranged from 0 to 10 with a median (IQR) score of 1 (3). Also, 679 (67.8%) had one or more ACE. The childhood bully victimization score ranged from 0 to 16 with a median (IQR) score of 1 (5). Also, 619 (62.1%) had been bullied one or more times. The self-esteem score ranged from 3 to 31 with a median (IQR) score of 22 (5). The perceived social support score ranged from 3 to 81 with a with a median (IQR) score of 64 (34). The resilience score ranged from 8 to 50 with a mean (SD) score of 31 (9).

Table 1 highlights the association between age, sex, socioeconomic status and the prevalence and severity of caries, caries complications and oral hygiene status. There was no significant association between sex (p = 0.86), socioeconomic status (p = 0.36) and age (p = 0.72) and the prevalence of caries; nor was there a significant association between sex (p = 0.51), socioeconomic status (p = 0.19) and age (p = 1.00) and caries severity. In addition, there was no significant association between sex (p = 0.39), socioeconomic status (p = 0.15) and age (p = 1.00) and caries complications; nor was there a significant association between age (p = 0.07), and sex (p = 0.11) and oral hygiene status. However, there was an association between socioeconomic status and oral hygiene; a greater percentage of children with good oral hygiene than those with fair or poor oral hygiene were from low socioeconomic status (P = 0.02).

.

Table 2 shows the associations between the explanatory and outcome variables for the study in bivariate analysis. There were no significant differences in ACE score between children with and without caries (p = 0.74); with low and high caries severity (p = 0.43), with and without caries complications (p = 0.60); and with good, fair and poor oral hygiene (p = 0.45).

There were no significant associations between childhood bully victimization score and the proportion of children with and without caries (p = 0.37), with low and high caries severity (p = 0.63), with and without caries complications (p = 0.11), and with good, fair and poor oral hygiene (p = 0.17).

There were also no significant associations between self-esteem score and the proportion of children with low and high caries severity (p = 0.95), with and without caries complications (p = 0.97), and with good, fair and poor oral hygiene (p = 0.13). There was however, a significant difference in self-esteem score of children with and without caries (p = 0.03): the median (IQR) self-esteem score of children with caries was lower than the median (IQR) of children without caries (21(5) vs 22 (5). See Table 2.

There were no significant associations between the social support score and the proportion of children with and without caries (p = 0.08), children with low and high caries severity (p = 0.63), with and without caries complications (p = 0.65); and with good, fair and poor oral hygiene (p = 0.50). See Table 2.

There were no significant associations between resilience score and the proportion of children with and without caries (p = 0.55), children with low and high caries severity (p = 0.70), with and without caries complications (p = 0.09); and with good, fair and poor oral hygiene (p = 0.18). See Table 2.

Table 3 shows the factors associated with poor oral hygiene after logistic regression analysis. While in the adjusted model, higher self-esteem was associated with better oral hygiene, none of the psychosocial factors had significant association. The higher the self-esteem score, the higher the odds of having poor oral hygiene (AOR: 1.09; 95% CI: 1.01–1.17; p = 0.03). In addition, sex and age were associated with poor oral hygiene in the adjusted models. Males had higher odds of having poor oral hygiene than did females (AOR: 1.78; 95% CI: 1.10–2.88; p = 0.02). Also, 12–16-year-old children had significantly higher odds of having poor oral hygiene than 6–11-year-old children in the adjusted model (AOR: 0.21; 95% CI: 0.12–0.35; p < 0.001).

Table 4 shows the factors associated with caries after the logistic regression analysis. In the unadjusted model, none of the psychosocial factors was significantly associated with caries. When the model was adjusted, two psychosocial factors became significantly associated with caries: self-esteem and perceived social support. The higher the self-esteem score, the lower was the odds of having caries (AOR: 0.91; 95% CI: 0.85–0.98; p = 0.02), and the higher the perceived social support, the lower the odds of having caries (AOR: 0.98; 95% CI: 0.97–1.00; p = 0.02).

Table 5 shows the factors associated with caries complications. None of the psychosocial factors was associated with caries complications in the unadjusted and unadjusted models. However, the socioeconomic status was significantly associated with caries complications in the adjusted model: The odds of having caries complication was lower for children with middle socio-economic status than for children with low socioeconomic status (AOR: 0.02; 95% CI: 0.00–0.06; p = 0.02). No child with high socioeconomic status had caries complications.

This is the first study conducted in Nigeria that queried if ACE and bully victimization are associated with oral diseases in children and adolescents, and how children and adolescents’ psychological assets and resources are associated with oral diseases. The study findings indicate that though there was no association between presence of caries, caries complication, poor oral hygiene, ACE and bullying, there was an association between presence of caries, self-esteem and social support, and an association between poor oral hygiene and self-esteem. Resilience was not associated with the presence of caries, caries complication and poor oral hygiene. The study was conducted in a community with low caries prevalence confirming previous research [71] and thus, the results may be useful in helping to identify sub-populations with high caries risk who may benefit from strategies to reduce caries risk and ameliorate caries complication [72].

One of the strengths of this study is its large number of participants and the use of instruments that had been validated to measure the various constructs for the study population. In addition, the measure of ACE captures a wide range of possible events. Data was generated through a household survey making the findings representative of the study population. The study also contextualized the interplay between oral health and psychosocial profile in a population of children and adolescents using measures that have not been widely studied.

The study however, is cross-sectional and thus limited in its ability to determine the causality of the associations between psychosocial factors and oral health. The study population was recruited from one of the 774 local government areas of Nigeria thus making the study not representative of all of Nigeria. The sample is also not representative of all children and youths as the participants are in-school with context that differs from that of out-of-school children and adolescents. In addition, although the type of school [73] and body images and size [74] could result in bullying, we did not include this in the data analysis: data on type of school was not available in the primary data. Nonetheless, the study generated several hypotheses that can lead to further research on the inter-relationship between psychosocial factors, culture and oral health.

The study results indicate that the psychosocial factors interact in various ways with oral health problems in children. While the prevalence of caries was lower in children with lower self-esteem and those with higher social support, none of these factors were associated with caries complications. Lower self-esteem was also associated with higher prevalence of poor oral hygiene. All these associations, however, were weak with small effect sizes as indicated by the values of the odds ratios. This is new information on the possible effect of psychosocial factors on oral health though the pathways for the observed association is not clear. Children and adolescents with high perceived social support – in this case, emotional support [75‐77] – may have positive outlook on life and may take less risk with their oral health by indulging less with alcohol consumption, tobacco smoking or use of psychoactive substances [78], which reduces the risk for caries [79]. The link between low self-esteem and low prevalence of caries is however, less clear and needs further studies. The association between low self-esteem and poor oral hygiene is plausible but the pathway in this study could not be deciphered –low self-esteem may have impacted negatively on oral hygiene practices, resulting in poor oral hygiene [80, 81], and/or conversely, poor oral hygiene may have resulted in the low self-esteem. Studies on self-esteem and prevalence of caries and poor oral hygiene are needed.

The prevalence of bully victimization was high when compared with reports from other countries. For example, the prevalence of adolescents reporting bully victimization ranged from 14.2–38.9% in Brazil [82‐84], to 26% in 40 resource-rich countries [44], 32% in United Kingdom [85], and 47% in Jordan [86]. The prevalence of ACE was also high when compared with the prevalence in other countries - 25% in Hungary [87], 46.3% in the United States of America [88], and 46.4% in the United Kingdom [89]. It was however comparable to the prevalence of 68.2% in Germany [90].

Despite the high prevalence of ACE and bully victimization in this study, they were not significantly associated with caries, caries complications and poor oral hygiene, unlike the associations reported in previous studies [2, 20‐23]. There may be several reasons for this. First, it may be too early to detect the impact of ACE and bully victimization on oral health. Adversities in childhood have a dose-response relationship with health problems [91]. In young children and adolescents, the mean number of bully victimization and adverse events is low. Also, adversities in childhood have impact on later-life development [92], so the study may be looking for the impact of ACE too early in the life-time trajectory of events as some define ACE as adverse events that occur in the first 18 years of life [93]. Its impact on the risk for caries and poor oral hygiene may therefore, be less detectable in persons younger than 18 years of age. However, previous studies have investigated and identified the impact of bully victimization on the risk for caries in adolescents younger than 18 years [24, 84]. Studying ACE and bully victimization before age 18 years allows for accurate recollection of events, reduce the risk of recall bias and thereby enables contemporaneous rather than retrospective data collection [94].

Second, stress from ACE and bully victimization may be attenuated by culture. While children who are exposed to stressors from ACE and bully victimization may develop internalizing (anxiety and depression) and externalizing (delinquency and violence against peers) symptoms [95‐97], not all children develop these symptoms: these symptoms are moderated by resilience and access to social support [98]. It is also possible that access to social support changes the effects that ACE and bully victimization may have had on oral health. Also, the collectivism culture of the ethnic group of the study population – the Yorubas [99] – may moderate the perception of stress from ACE and bully victimization. Ngo and Le [98] reported that collectivism dampened the impact of some stressors by enabling individuals to marshal and rely on support and resources from others. Social support, which is usually highly available in collective societies, may ameliorate the impact of negative life events. However, when the individual’s self-esteem is affected negatively by these life events, the negative impact of ACE and bully victimization on the risk of caries may be stronger.

Third, the relatively high prevalence of ACE and bully victimization observed in the study population might have imparted a norm status to them. If these phenomena are common, there is less variation among participants in the chances of experiencing them and consequently they cannot explain differences in oral health outcomes [100]. This complex inter-relationship between psychosocial factors and oral diseases needs further study.

The relationship between psychosocial factors and oral diseases is complex: While self-esteem and perceived social support had a protective effect on the risk of caries, they were not protective against poor oral hygiene. In all cases, the associations indicated weak effects. ACE and bully victimization were not associated with caries, caries complications, or poor oral hygiene. The possible effect of culture in moderating these relationships needs to be explored.