Associations between adverse childhood experiences, depression, and empathy among Thai medical students: implications for trauma-informed medical education

Adverse childhood experiences (ACEs) can influence emotional development and long-term mental health. Empathy, a core professional competency in medical education, may be shaped not only by training but also by early life adversity and current psychological distress. However, evidence specifically examining the association between ACEs and empathy among medical students in Southeast Asia remains limited. This study aimed to examine the association between ACEs and empathy among Thai medical students. We also examined whether depressive symptoms were independently related to empathy after adjusting for ACE exposure and other covariates. A cross-sectional analytical study was conducted between April and July 2025 among first- to sixth-year medical students at a Faculty of Medicine and two affiliated medical education centers in Southern Thailand. A total of 540 students (response rate 77.1%) completed anonymous self-administered questionnaires, including demographic characteristics, the Thai ACE questionnaire, the Toronto Empathy Questionnaire (TEQ), and the Patient Health Questionnaire-9 (PHQ-9). Empathy was analyzed as a continuous outcome using multiple linear regression, with logistic regression using TEQ < 45 as the cutoff performed as a sensitivity analysis. Among 540 participants, 54.4% reported at least one ACE. The mean TEQ score was 45.6 (SD = 6.6). In multivariable linear regression, exposure to 1–2 ACEs (β = -1.75, p = 0.003) and depressive symptoms (β = -0.33, p < 0.001) were independently associated with lower empathy scores. In contrast, current life stress showed a modest but statistically significant positive association with empathy (β = 1.47, p = 0.024). Sensitivity analyses using logistic regression yielded consistent findings. After adjustment for covariates, academic stage (pre-clinical vs. clinical) was not significantly associated with empathy. ACEs are common among Thai medical students and are independently associated with lower empathy scores. Depressive symptoms were also linked to reduced empathy, whereas current life stress showed a modest but statistically significant positive association, a finding that warrants further investigation. These findings suggest that empathic development during medical training is influenced not only by curricular experiences but also by students’ early life experiences and psychological well-being. Integrating trauma-informed and mental health-responsive approaches into medical education may help support both student well-being and empathic clinical practice.