Abstract / Summary
Abstract Background Adverse childhood experiences are associated with depressive symptoms, but the processes underlying this association remain insufficiently understood among nursing students. This study examined the association between adverse childhood experiences and depressive symptoms, serial indirect associations through family communication and perceived stress, and whether self-efficacy moderated the association between perceived stress and depressive symptoms. Methods This secondary cross-sectional analysis used data from 932 nursing students aged 18–35 years from 196 universities identified in a nationwide multicenter survey in China. Adverse childhood experiences, family communication, perceived stress, depressive symptoms, and self-efficacy were assessed using self-report scales. Covariate-adjusted serial mediation and exploratory moderated mediation models were estimated. University-level clustering was addressed using cluster-robust inference, and indirect associations were evaluated using 5,000 university-level cluster-bootstrap resamples. Results Greater exposure to adverse childhood experiences was associated with poorer family communication, higher perceived stress, and more severe depressive symptoms. The total indirect association was 0.343 (95% confidence interval 0.171 to 0.599). The specific indirect association through perceived stress was 0.294 (95% confidence interval 0.116 to 0.553), and the serial indirect association through family communication and perceived stress was 0.086 (95% confidence interval 0.040 to 0.138). The indirect association through family communication alone was not supported. The perceived stress-by-self-efficacy interaction was statistically supported (unstandardized coefficient 0.053, P = 0.014), with the stress–depressive symptom association slightly stronger at higher self-efficacy; however, the incremental explanatory contribution was small (change in explained variance = 0.010). Conclusions Perceived stress was the principal indirect pathway linking adverse childhood experiences with depressive symptoms, while family communication contributed through stress-related processes. Trauma-informed, non-stigmatizing student support may benefit from prioritizing stress assessment and management while considering family interaction contexts. The small and unexpected moderation finding requires cautious interpretation and longitudinal replication.