When universal is not enough: the moderating effects of universal mental health services and targeted support for students with adverse childhood experiences

School-based mental health services are widely available in China. However, current services focus more on universal services and lack specificity, which may weaken the possibility of students exposed to adverse childhood experiences (ACEs) benefiting from them. Yet large-scale empirical evidence on this gap remains scarce, limiting understanding of how these services are associated with mental health outcomes in this vulnerable population. This study aimed to examine the association between the quality of multi-level school mental health services, as perceived by students, and their mental health, with particular attention to the moderating role of ACE exposure. This cross-sectional study analyzed data from a national school-based survey of 84,866 students (mean age = 15.90, SD = 1.62) across 374 Chinese secondary schools. ACEs, including abuse, household dysfunction and neglect, were measured. Satisfaction with school-based universal mental health services and students’ perceived effectiveness of school-based targeted psychological support were measured. Depression, self-injury behaviors, subjective well-being and self-esteem were measured as mental health outcomes. Analyses used generalized linear mixed models with interaction effects between ACE exposure and satisfaction or perceived effectiveness. All ACE domains and cumulative ACEs were associated with poorer mental health, whereas satisfaction of universal services and perceived effectiveness of targeted support were associated with better mental health. However, these associations were significantly weakened among adolescents exposed to abuse or household dysfunction—but not among those exposed to neglect—with largely similar patterns across the two adversity types for both positive and negative mental health outcomes. In addition to these shared attenuations, the perceived effectiveness showed weaker associations between depression and self-esteem in the abuse-exposed group (depression: AOR: 1.06, 95% CI: 1.01–1.11, p = 0.012; self-esteem: AOR: 0.93, 95% CI: 0.88–0.98, p = 0.004). Adolescents exposed to multiple domains of ACEs showed weaker associations between school support and mental health outcomes. Given that students exposed to ACEs face significantly elevated risks for mental health problems, their psychological well-being cannot be overlooked. These findings suggest that enhancing professional capacity and providing more targeted support may be particularly critical and urgent for this vulnerable group.