Adverse childhood experiences (ACEs) are stressful or traumatic events faced by individuals that could have a pervasive impact throughout the developmental stages of their lives through psychological and physiological mechanisms, particularly when the consequences are neglected [1]. ACE can have profound effects on individuals of all ages [2,3]. These experiences may culminate in disrupted development of brain areas that are stress-sensitive [4,5], which are reflected in behavioral alterations.

For example, individuals with ACEs may face challenges with emotion regulation, thereby leading to diverse negative consequences such as difficulties with interpersonal relationships, alcohol, and smoking habits [6,7]. Overall, these events are associated with obesity, depression, suicide, anxiety, heart attack, chronic health problems, chronic obstructive pulmonary disease, asthma, stroke, cancer, and unemployment [8,9]. Apart from emotion regulation, ACE survivors’ experience deficits in several domains of executive functions [10], which impact their well-being and psychological health [11]. Evidence suggests that individuals with ACEs, particularly children and young adults, are disadvantaged in terms of coping with increased stress relative to their peers without such bad experiences [12]. Since young adults are still experiencing biological and psychosocial development, the consequential impacts of ACE can be profound during adolescence and young adulthood [12].

Mental health problems are common among children and adults, which are predominantly presented as depression or anxiety and are characterized by frequent comorbidities [13]. Studies have demonstrated that ACEs represent an important predictor of emotional problems [14]. Previous research has documented several underlying events for the association between emotional problems and early ACEs among young children and adults [13,14]. For instance, individuals with a history of early ACEs were more accurate in recognizing threatening stimuli [15], constituting an adaptive response in harmful conditions. Nevertheless, it can heighten the risk of mental health disorders over time [16]. While individuals with ACEs are more likely to adopt maladaptive emotional regulation skills such as disengagement, expressive suppression, and rumination, they are less likely to perform successful activities such as cognitive appraisal [15], thereby leading to early emotional anomalies [16].

Specifically, ACEs also constitute a significant barrier to an individual’s capacity for resilience. Resilience depicts the resources, capability, and processes available to a system or an individual to adapt successfully in the face of challenges or adversities [17-19]. Resilience encompasses the factors that facilitate positive adaptation and navigation toward resources to sustain well-being in the context of adversity [16]. Therefore, researchers have developed an interest in resilience intervention as a potential approach to addressing the negative impacts of ACEs [19]. For instance, cognitive behavioral therapy (CBT) has been used in resilience interventions in ameliorating health problems, particularly among adults with a history of ACEs [19-21]. Hence, building resilience in individuals with adversity in the context of psychological intervention offers a new approach to managing individuals with ACEs.

ACEs refer to neglect, abuse, and dysfunctional households that may be deleterious to a person’s health and well-being. Research conducted in Malaysia has depicted an increasing frequency of child abuse and neglect cases, which are typical examples of ACEs that may impact negatively on physical and mental health [22]. ACEs also contribute to the growing health care expenditure, as the health consequences of ACEs reportedly accounted for 2% of the gross domestic product [23].

Nevertheless, information on the prevalence and negative impacts of ACEs among children and adults in Asia, specifically Malaysia, is scarce due to limited research. A recent study revealed a high prevalence of various ACEs among university students in northeast Malaysia, with a report of emotional abuse, emotional neglect, physical abuse, and sexual abuse occurring in 30.2%, 29.2%, 28.7% and 9.1% of the studied population [22]. High-risk behaviors (HRBs), particularly physical inactivity and community violence were recorded among 39.3% and 54.5% of the students, respectively [22].

Apart from HRBs, depression has been identified as a consistent outcome of ACEs among young adults in Malaysia [24,25]. Young individuals from Shah Alam, Malaysia, exhibited a high level of depression and ostracism, which was associated with ACEs. Early psychological mistreatment such as parental neglect of a child’s needs can lead to poor mental well-being [25], externalizing and internalizing problems, as well as anxious and avoidant attachment styles, making it challenging for children to develop a sense of belonging and feeling ostracized [26,27]. Therefore, early life traumatic events and ignorance appear to have strong influences on psychological well-being among this vulnerable population.

Besides the younger population, older adults in Malaysia have also been shown to be affected by ACEs, which may ultimately transit into elder abuse [28]. Furthermore, the risk of elder abuse increased with the cumulative number of ACEs. The results depict how early life adversities play an important role in older adults’ victimization. Recognizing the possibility that vulnerability to maltreatment can persist throughout the life course of elderly individuals is critical when attempting to address the problem through emotional and social support.

Resilience is considered to be pertinent in the association between emotional problems and ACEs. Studies have depicted that resilience is a protective factor that can propel an individual to successfully address adverse experiences [29]. Thus, resilience is regarded as playing a protective role in the relationship between emotional disorders and ACE [29-31].

ACEs constitute a public health crisis that requires a wide range of interventions due to their high prevalence and impact on health disparities [31,32]. Resilience interventions are typical examples of CBT that are effective in ameliorating mental health disorders faced by individuals with ACEs [15]. According to Iniguez and Stankowski [33], ACE research has yielded strong evidence to support claims that “resilience resources and well-timed interventions to promote resilience can ameliorate the negative effects of ACEs” [33].

Chandler et al [21] demonstrated the feasibility and efficacy of an empower resilience intervention to enhance resilience and health behaviors among young adults with a history of ACEs. By using a 2-arm pre-post repeated measures design, young adults in the intervention group recorded significantly higher scores for building strengths, creating support connections, and reframing resilience. Meanwhile, a face self-help app designed by Brodbeck et al [34] and based on cognitive-behavioral principles, is currently being tested for its efficacy in promoting resilience and well-being in emerging adults with a history of ACE. MacIsaac et al [35] also evaluated the effects of an innovative, smartphone app-based resilience intervention on first-year university students’ self-regulatory skills (ie, emotion regulation and executive functioning), and the mediating role of emotion regulation. After 4 weeks of using the app, students’ emotion regulation and depressive symptoms improved significantly, with a faster rate of change in emotion regulation among those with more ACEs. Thus, evidence suggests that app-based resilience intervention can assist young adults with ACE by improving their emotion regulation skills and mitigating depression.

Systematic review findings depict that most interventions for addressing ACEs focused on psychological interventions and mental health outcomes, and cognitive-behavioral therapy has been consistently found to be effective in mitigating the negative impacts of abuse [36]. On the other hand, findings from interventions involving psychological therapies, specific support such as parent training, and broad support interventions are generally inconclusive despite some promising results [36]. In summary, significant gaps exist in the available evidence on interventions for ACEs, with most research focusing on individual psychological effects while neglecting the social pathways which may indirectly influence the negative impacts of ACEs. Several areas such as social relationships, life circumstances and health behaviors are examples of several negative impacts of ACEs that are still under investigation in most intervention research [34-36].

Building upon the global view on ACE research and resilience-building interventions, the Malaysian context must be taken into account in order to develop an effective intervention to address the problem of ACEs among children and young adults. Literature findings from the studies conducted in Malaysia have shown that ACE is a multifactorial problem that requires a multidimensional approach, rather than focusing on one individual aspect [22,23]. Such an approach is well-described in the multisystemic model of resilience developed by Ungar [8], highlighting the capacity of biopsychosocial and social-ecological systems to support external and internal conditions for well-being, as well as improving diverse populations’ quality of life. Thus, resilience encompasses the process whereby individuals harness the resources that are necessary for them to function optimally and seek resources to be provided using meaningful approaches, either contextually or culturally [8].

Interventions that emphasize individual change without considering the environmental domain may yield short-term benefits [37]. Hence, intervention should have a dual focus, encompassing personal and environmental change. For instance, a child’s resilience is a product of both their capacity to cope effectively under stress and the capacity of their physical and social environments to facilitate positive development. Under conditions of normal stress, individual ruggedness may be sufficient to support well-being; nevertheless, resources become more important and required as the individual experiences greater barriers to functioning. These 2 broad aspects form the foundation of the multisystemic perspective of resilience “R2,” which was coined to affirm the need to mitigate both the rugged qualities of individuals and their access to resources) [38].

Research has shown that individuals with more internal capacities such as problem-solving, self-regulation, and positive future orientation are more likely to harness opportunities for relationships and exploit such opportunities for academic or financial success [39,40]. Likewise, higher levels of motivation to execute life tasks and being more optimistic were observed among individuals with better access to external resources [41,42]. These findings reflect the dynamicity of resilience, whereby individuals interact with the world around them to make the best use of available resources despite exposure to adversity or atypical stress.

As highlighted in the reviewed resilience-building interventions for ACEs, while some target the public and common adversities like job burnout [43] and stress [44], others are aimed at specific groups, such as chronically diseased individuals [45], employees returning to work [46], and health care workers [47]. These interventions are delivered using diverse methods, ranging from phone apps to web-based tools or printed manuals, and duration may be as short as single-day workshops to weekly or monthly sessions. However, a recent meta-analysis revealed that such interventions have a small to moderate effect on improving resilience [44,47]. Existing resilience interventions also differ in terms of the targeted protective factors, such as self-efficacy, problem-solving skills, and cognitive flexibility, with most focusing on rugged factors. Only a few interventions consider resources that are external to individuals with ACEs [48]. Accumulated evidence suggests little to no data on interventions that explicitly target both coping strategies and ways of creating better-resourced environments around individuals with ACEs.

Hence, this study will modify and implement an R2 resilience program based on a resilience-building intervention designed with the principles of implementation science [38]. The multisystem aspect of the intervention allows it to focus on multiple systems for the individual’s change process and adaptation process around life circumstances. It is a curriculum-based approach that integrates all the well-researched factors and presents equal emphasis on the surrounding environments to the individual [8,38]. Thereafter, the factors and aspects can be modified and implemented into the resilience-building intervention accordingly. This study aims to explore the effects of the resilience-building intervention on mental health, stress, resilience, and resource finding among individuals affected with ACEs in Malaysia.

This is a 2-armed, single-blinded, randomized controlled trial (RCT) that will be conducted among Malaysian youths with ACEs at the Department of Clinical and Health Psychology, National University of Malaysia. Briefly, the intervention group includes an evidence-based curriculum and components such as emotion regulation, active coping and goal setting, cognitive flexibility, mindfulness-based stress reduction, social support, self-exploration, resources and navigation, and finally, spirituality and religion. Participants in the control group will not receive any form of intervention. The main outcome of this study is resilience among youths with ACE while the secondary outcomes include coping, psychological well-being, quality of life, subjective stress, perceived stress, personal resources, and adult resilience. These variables will be evaluated at baseline and postintervention. Intention-to-treat analysis will also be performed. This clinical trial has been registered with the Australia New Zealand Clinical Trials Registry (trial Id: ACTRN12622000604707).

All data management and statistical analysis will be conducted using SPSS (version 26; IBM Corp). Data management will be performed by screening for missing data and checking for potential outliers. Descriptive statistics will be used to assess the data normality and to summarize the pre and postintervention scores for each group at different periods. Mean and SDs will be provided for normally distributed data, followed by mixed ANOVA with repeated measures to compare the pre and postintervention mean scores between and within the groups.

The assumptions of ANOVA include randomly collected and normally distributed data, sufficient sample size, homogeneity of variances, and absence of violation and outliers. Levene’s test will be applied to test the homogeneity of variance. Mixed ANOVA benefits RCT design as it allows testing for 2 groups across 2-time points. Mixed ANOVA analysis aims to handle response outcomes conducted on the same experimental unit at a different time or under different conditions [57]. The differential effects of the intervention components will be tested with interactions between the component and time. These analyses will model random slopes and intercepts for participants, explore the fixed effects of the condition, and test the repeated measures over time. This type of analysis is advantageous by accounting for missing values through the maximum likelihood estimation method [57]. Effect sizes will be computed based on Cohen d.

In addition, the intention-to-treat analysis will be applied to analyze the participants according to their assigned groups. This analysis includes all participants and ignores noncompliance, protocol deviation, and withdrawal. The intention-to-treat analysis is a complete trial strategy for the design, execution, and analysis of RCT, focusing on the consolidated standard of reporting trial guidelines. Thus, the number of participants in each assigned group will be analyzed by the intention-to-treat principle.

As for missing data, drop-out in this study refers to participants who withdraw actively from the intervention post randomization. All cases of dropouts will be considered in the intent-to-treat samples since they have been randomized and included in the analysis. The extent and pattern of missing data will be assessed, and depending on the results, missing values will be replaced by using multiple imputations. The impact of the imputation of missing values will be further explored by conducting sensitivity analyses.

Ethical approval was obtained from the Research Ethics Board at the National University of Malaysia (UKM PPI/111/8/JEP-2021-894; January 28, 2021). Detailed information on the intervention and recruitment process is provided in the next sections.

ACEs are relatively common, trigger substantial suffering and are well-documented as a risk factor for diverse physical and mental health conditions throughout life. While primary prevention is pertinent in reducing ACE, the deleterious short and long-term consequences of ACE can be mitigated by selective prevention.

This study adopted the multisystemic approach to resilience “R2,” which recognizes the importance of rugged qualities and access to resources among individuals affected by ACEs. As discussed earlier, the multisystemic model of resilience emphasizes 2 broad aspects, encompassing personal and environmental change [37]. We considered these 2 aspects as pertinent in addressing the consequences of ACEs among young adults in Malaysia, aligning with recommendations from previous studies to approach the problem in a multidimensional manner [8,38]. This study will be the first attempt to adopt an evidence-informed intervention for resilience-building among Malaysians with ACEs. In addition, this research is among the few interventions that explicitly entail both coping strategies and creating better-resourced environments around individuals affected by ACEs.

It is anticipated that the resilience-building intervention will have moderate to strong effects by ameliorating mental health, and stress, and improving participants’ resilience and resource finding compared with those in the control group. These expected findings are consistent with the report by Chandler et al [21], whereby a resilience intervention centered around 4 main components (ie, active coping, building strength, cognitive flexibility, and social support) was effective in mitigating the adverse effects of ACEs.

Our intervention is structured into 5 sessions, focusing on self-exploration and social support, coping techniques and coping skills, resource finding, spirituality, and resilience-building. These components are expected to enhance participants’ internal capacities such as self-regulation and problem-solving, thereby harnessing opportunities to achieve success in life [39]. By educating them on how to identify and gain better access to external resources, they will be motivated to accomplish life tasks and be more optimistic [42]. These events will assist in building resilience, facilitating participants’ interaction with the world around them, and using available resources effectively regardless of being exposed to adversities.

This intervention aims to focus on vital resilience components which are emotion regulation, active coping and goal setting, cognitive flexibility, physical health, mindfulness-based stress reduction, social support, self-exploration, resources and navigation, financial planning, and spirituality and religion. One of the weaknesses of this intervention is that these components will be monitored by informal assessment such as observation, tracking, and recap to ensure participants have learned and acquired the tools and knowledge. It is also difficult to ensure participants from the control group will not receive any form of therapy during the whole duration of the intervention. Hence, the therapist has to check in with the group from time to time to ensure their well-being is taken care of. If needed, the therapist will conduct a post-group counselling session with an individual who is distressed by the intervention. Given that the participants were selected from a pool of individuals obtaining a specific level of ACEs, the findings might not be generalized to the entire population of people with ACEs in the country.

This is the first full clinical trial study investigating resilience-building intervention for youths with ACEs in Malaysia. There are limited studies evaluating the effectiveness of resilience-building interventions combining mental health and physiological responses as outcome measures in Malaysia. Thus, this study conceptualizes resilience from a biopsychosocial-ecological perspective and adapts resilience-building intervention in the Malaysian context. This study aims to develop resilience-building intervention modules specifically for Malaysia, focusing on the process of adapting the modules and modifications according to the Malaysian culture. This will be one of the first studies to provide evidence in the context of RCTs for resilience-building intervention combining self-report and physiological measures (ie, saliva and heart blood pressure) among individuals with ACEs. The findings will assist relevant authorities in the health and policy sectors to develop effective strategies for addressing the negative impacts of ACEs on the vulnerable population in Malaysia.