Life course health consequences and associated annual costs of adverse childhood experiences across Europe and North America: a systematic review and meta-analysis

Bellis, Mark A; Hughes, Karen; Ford, Kat; Ramos Rodriguez, Gabriela; Sethi, Dinesh; Passmore, Jonathon

doi:10.1016/s2468-2667(19)30145-8

Cited by 1,032Child Abuse and TraumaChild Welfare and AdoptionIntimate Partner and Family Violence

Life course health consequences and associated annual costs of adverse childhood experiences across Europe and North America: a systematic review and meta-analysis

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Bellis, Mark A, Hughes, Karen, Ford, Kat, Ramos Rodriguez, Gabriela, Sethi, Dinesh, Passmore, Jonathon·2019·The Lancet Public Health

DOI 10.1016/s2468-2667(19)30145-8PMC PMC7098477

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Abstract

BACKGROUND: An increasing number of studies are identifying associations between adverse childhood experiences (ACEs) and ill health throughout the life course. We aimed to calculate the proportions of major risk factors for and causes of ill health that are attributable to one or multiple types of ACE and the associated financial costs. METHODS: In this systematic review and meta-analysis, we searched for studies in which risk data in individuals with ACEs were compared with these data in those without ACEs. We searched six electronic databases (MEDLINE, CINAHL, PsycINFO, Applied Social Sciences Index and Abstracts, Criminal Justice Databases, and the Education Resources Information Center) for quantitative studies published between Jan 1, 1990, and July 11, 2018, that reported risks of health-related behaviours and causes of ill health in adults that were associated with cumulative measures of ACEs (ie, number of ACEs). We included studies in adults in populations that did not have a high risk of ACEs, that had sample sizes of at least 1000 people, and that provided ACE prevalence data. We calculated the pooled RR for risk factors (harmful alcohol use, illicit drug use, smoking, and obesity) and causes of ill health (cancer, diabetes, cardiovascular disease, respiratory disease, anxiety, and depression) associated with ACEs. RRs were used to estimate the population-attributable fractions (PAFs) of risk attributable to ACEs and the disability-adjusted life-years (DALYs) and financial costs associated with ACEs. This study was prospectively registered in PROSPERO (CRD42018090356). FINDINGS: Of 4387 unique articles found following our initial search, after review of the titles (and abstracts, when the title was relevant), we assessed 880 (20%) full-text articles. We considered 221 (25%) full-text articles for inclusion, of which 23 (10%) articles met all selection criteria for our meta-analysis. We found a pooled prevalence of 23·5% of individuals (95% CI 18·7-28·5) with one ACE and 18·7% (14·7-23·2) with two or more ACEs in Europe (from ten studies) and of 23·4% of individuals (22·0-24·8) with one ACE and 35·0% (31·6-38·4) with two or more ACEs in north America (from nine studies). Illicit drug use had the highest PAFs associated with ACEs of all the risk factors assessed in both regions (34·1% in Europe; 41·1% in north America). In both regions, PAFs of causes of ill health were highest for mental illness outcomes: ACEs were attributed to about 30% of cases of anxiety and 40% of cases of depression in north America and more than a quarter of both conditions in Europe. Costs of cardiovascular disease attributable to ACEs were substantially higher than for most other causes of ill health because of higher DALYs for this condition. Total annual costs attributable to ACEs were estimated to be US$581 billion in Europe and $748 billion in north America. More than 75% of these costs arose in individuals with two or more ACEs. INTERPRETATION: Millions of adults across Europe and north America live with a legacy of ACEs. Our findings suggest that a 10% reduction in ACE prevalence could equate to annual savings of 3 million DALYs or $105 billion. Programmes to prevent ACEs and moderate their effects are available. Rebalancing expenditure towards ensuring safe and nurturing childhoods would be economically beneficial and relieve pressures on health-care systems. FUNDING: World Health Organization Regional Office for Europe.

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Burden of Mental Disorders and Suicide Attributable to Childhood Maltreatment
Grummitt, L. R., Baldwin, J. R., Lafoa’i, J., Keyes, K. M., & Barrett, E. L. (2024) · JAMA Psychiatry · doi:10.1001/jamapsychiatry.2024.0804 · Cited by 131 · see citing works
Type and dose-response effect of adverse childhood experiences in predicting depression: A systematic review and meta-analysis
Tan, M., & Mao, P. (2023) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2023.106091 · Cited by 130 · see citing works
Adverse childhood experiences and related outcomes among adults experiencing homelessness: a systematic review and meta-analysis
Liu, M., Luong, L., Lachaud, J., Edalati, H., Reeves, A., & Hwang, S. W. (2021) · The Lancet Public Health · doi:10.1016/s2468-2667(21)00189-4 · Cited by 125 · see citing works
The burden of disease attributable to indoor air pollutants in China from 2000 to 2017
Liu, N., Liu, W., Deng, F., Liu, Y., Gao, X., Fang, L., Chen, Z., Tang, H., Hong, S., Pan, M., et al. (2023) · The Lancet Planetary Health · doi:10.1016/s2542-5196(23)00215-2 · Cited by 121 · see citing works
Adverse and Protective Childhood Experiences and Parenting Attitudes: the Role of Cumulative Protection in Understanding Resilience
Morris, A. S., Hays-Grudo, J., Zapata, M. I., Treat, A. E., & Kerr, K. L. (2021) · Adversity and Resilience Science · doi:10.1007/s42844-021-00036-8 · Cited by 116 · see citing works
Adverse childhood experiences (ACEs) relate to blunted cardiovascular and cortisol reactivity to acute laboratory stress: A systematic review and meta-analysis
Brindle, R. C., Pearson, A., & Ginty, A. T. (2022) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2022.104530 · Cited by 112 · see citing works
The longitudinal influences of adverse childhood experiences and positive childhood experiences at family, school, and neighborhood on adolescent depression and anxiety
Wang, D., Jiang, Q., Yang, Z., & Choi, J. (2021) · Journal of Affective Disorders · doi:10.1016/j.jad.2021.05.108 · Cited by 114 · see citing works
Health effects associated with exposure to intimate partner violence against women and childhood sexual abuse: a Burden of Proof study
Spencer, C. N., Khalil, M., Herbert, M. E., Aravkin, A. Y., Arrieta, A., Baeza, M. J., Bustreo, F., Cagney, J., Calderon-Anyosa, R. J. C., Carr, S., et al. (2023) · Nature Medicine · doi:10.1038/s41591-023-02629-5 · Cited by 112 · see citing works
Intergenerational Transmission of Parental Adverse Childhood Experiences and Children’s Outcomes: A Scoping Review
Zhang, L., Mersky, J. P., Gruber, A. M., & Kim, J. (2022) · Trauma Violence & Abuse · doi:10.1177/15248380221126186 · Cited by 106 · see citing works
Positive childhood experiences can moderate the impact of adverse childhood experiences on adolescent depression and anxiety: Results from a cross-sectional survey
Qu, G., Ma, S., Liu, H., Han, T., Zhang, H., Ding, X., Sun, L., Qin, Q., Chen, M., & Sun, Y. (2022) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2022.105511 · Cited by 103 · see citing works
Adverse childhood experience is associated with an increased risk of reporting chronic pain in adulthood: a stystematic review and meta-analysis
Bussières, A., Hancock, M. J., Elklit, A., Ferreira, M. L., Ferreira, P. H., Stone, L. S., Wideman, T. H., Boruff, J. T., Zoubi, F. A., Chaudhry, F., et al. (2023) · European Journal of Psychotraumatology · doi:10.1080/20008066.2023.2284025 · Cited by 94 · see citing works
“ACEs are estimated to result in 37.5 million disability-adjusted life years globally and carry an estimated ﬁ nancial cost of $1.3 trillion per annum across North America and Europe, with over 75% of these costs arising in individuals reporting two or more ACEs (Bellis et al., 2019).”
Influential
A review of mental health disparities during COVID-19: Evidence, mechanisms, and policy recommendations for promoting societal resilience
Parenteau, A. M., Boyer, C. J., Campos, L., Carranza, A. F., Deer, L. K., Hartman, D. T., Bidwell, J. T., & Hostinar, C. E. (2022) · Development and Psychopathology · doi:10.1017/s0954579422000499 · Cited by 93 · see citing works
“These outcomes, in turn, are associated with decreased productivity and earlier mortality, which have been shown to have negative economic consequences at the societal level (Bellis et al., 2019; Metzler et al., 2017).”
Background
Adverse Childhood Events and Health Biomarkers: A Systematic Review
Soares, S., Rocha, V., Kelly‐Irving, M., Stringhini, S., & Fraga, S. J. D. S. (2021) · Frontiers in Public Health · doi:10.3389/fpubh.2021.649825 · Cited by 91 · see citing works
The Influence of Adverse Childhood Experiences in Pain Management: Mechanisms, Processes, and Trauma-Informed Care
Tidmarsh, L. V., Harrison, R. N., Ravindran, D., Matthews, S. L., & Finlay, K. A. (2022) · Frontiers in Pain Research · doi:10.3389/fpain.2022.923866 · Cited by 89 · see citing works
“A growing body of literature demonstrates harmful effects of ACEs exposure on increasing the likelihood of chronic pain (16, 17) and disability (11) in adulthood.”
Background
Aerobic fitness and response variability in preadolescent children performing a cognitive control task.
Wu, C.-T., Pontifex, M. B., Raine, L. B., Chaddock, L., Voss, M. W., Kramer, A. F., & Hillman, C. H. (2011) · Neuropsychology · doi:10.1037/a0022167 · Cited by 88 · see citing works
Economic Burden of Health Conditions Associated With Adverse Childhood Experiences Among US Adults
Peterson, C., Aslam, M. V., Niolon, P. H., Bacon, S., Bellis, M. A., Mercy, J. A., & Florence, C. (2023) · JAMA Network Open · doi:10.1001/jamanetworkopen.2023.46323 · Cited by 91 · see citing works
Self-citation
Screening for Adverse Childhood Experiences (ACEs) in Primary Care
Campbell, T. L. (2020) · JAMA · doi:10.1001/jama.2020.4365 · Cited by 87 · see citing works
Health and financial burden of adverse childhood experiences in England and Wales: a combined primary data study of five surveys
Hughes, K., Ford, K., Kadel, R., Sharp, C., & Bellis, M. (2020) · BMJ Open · doi:10.1136/bmjopen-2019-036374 · Cited by 75 · see citing works
Self-citation
Adverse childhood experiences: A scoping review of measures and methods
Karatekin, C., Mason, S. M., Riegelman, A., Bakker, C., Hunt, S., Gresham, B. L., Corcoran, F., & Barnes, A. J. (2022) · Children and Youth Services Review · doi:10.1016/j.childyouth.2022.106425 · Cited by 78 · see citing works
Childhood Experiences and Psychological Distress: Can Benevolent Childhood Experiences Counteract the Negative Effects of Adverse Childhood Experiences?
Hou, H., Zhang, C., Tang, J., Wang, J., Xu, J., Zhou, Q., Yan, W., Gao, X., & Wang, W. (2022) · Frontiers in Psychology · doi:10.3389/fpsyg.2022.800871 · Cited by 78 · see citing works
Intergenerational transmission of parent adverse childhood experiences to child outcomes: A systematic review and meta-analysis
Racine, N. M., Deneault, A., Thiemann, R. F., Turgeon, J., Zhu, J., Cooke, J. E., & Madigan, S. L. (2023) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2023.106479 · Cited by 82 · see citing works
Adverse childhood experiences and depressive symptoms in later life: Longitudinal mediation effects of inflammation
Iob, E., Lacey, R. E., & Steptoe, A. (2020) · Brain Behavior and Immunity · doi:10.1016/j.bbi.2020.07.045 · Cited by 69 · see citing works
“ACEs are extremely common across several countries (Bellis et al., 2014; Merrick et al., 2018), and are major psychosocial risk factors for depression, as well as for other mental and physical disorders (Hughes, 2017; Bellis, 2019).”
Background
Validity and reliability of the 10-Item Adverse Childhood Experiences Questionnaire (ACE-10) among adolescents in the child welfare system
Oláh, B., Fekete, Z., Szabó, I. K., & Kovács-Tóth, B. (2023) · Frontiers in Public Health · doi:10.3389/fpubh.2023.1258798 · Cited by 74 · see citing works
The Roadmap for Resilience: The California Surgeon General's Report on Adverse Childhood Experiences, Toxic Stress, and Health
Bhushan, D., Kotz, K. J., McCall, J., Wirtz, S., Gilgoff, R., Dube, S. R., Powers, C., Olson-Morgan, J., Galeste, M., Patterson, K., et al. (2020) · doi:10.48019/peam8812 · Cited by 71 · see citing works
The interaction of adverse childhood experiences and gender as risk factors for depression and anxiety disorders in US adults: a cross-sectional study
Whitaker, R. C., Dearth-Wesley, T., Herman, A. N., Block, A. E., Holderness, M. H., Waring, N. A., & Oakes, J. (2021) · BMC Public Health · doi:10.1186/s12889-021-12058-z · Cited by 65 · see citing works
“Acting on that evidence in both prevention and treatment may help reduce the large burden of depression and anxiety among females that is attributable to ACEs [43].”
Background
The association between exposure to childhood maltreatment and the subsequent development of functional somatic and visceral pain syndromes
Chandan, J. S., Keerthy, D., Zemedikun, D. T., Okoth, K., Gokhale, K. M., Raza, K., Bandyopadhyay, S., Taylor, J. S., & Nirantharakumar, K. (2020) · EClinicalMedicine · doi:10.1016/j.eclinm.2020.100392 · Cited by 64 · see citing works
The evolving neurobiology of early-life stress
Birnie, M. T., & Baram, T. Z. (2025) · Neuron · doi:10.1016/j.neuron.2025.02.016 · Cited by 65 · see citing works
“4,5 10 In 2019, the annual economic burden of early-life stress was estimated as $748 billion 11 and the estimate for 2023, following the COVID-19 pandemic, has been (cid:1) $14 trillion.”
Integrating and synthesizing adversity and resilience knowledge and action: The ICARE model.
Hays-Grudo, J., Morris, A. S., Beasley, L. O., Ciciolla, L. M., Shreffler, K. M., & Croff, J. M. (2021) · American Psychologist · doi:10.1037/amp0000766 · Cited by 65 · see citing works
The association of adverse childhood experiences and its subtypes with adulthood sleep problems: A systematic review and meta-analysis of cohort studies
Yu, H., Liu, X., Yang, H., Chen, R., & He, Q. (2022) · Sleep Medicine · doi:10.1016/j.sleep.2022.06.006 · Cited by 65 · see citing works
Associations between adverse childhood experiences and substance use: A meta-analysis
Zhu, J., Racine, N. M., Devereux, C., Hodgins, D. C., & Madigan, S. L. (2023) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2023.106431 · Cited by 63 · see citing works
Poor Individual Risk Classification From Adverse Childhood Experiences Screening
Meehan, A. J., Baldwin, J. R., Lewis, S. J., MacLeod, J. G., & Danese, A. (2021) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2021.08.008 · Cited by 60 · see citing works
“, parental incarceration, mental illness, substance use), are consistently associated with elevated risk for physical and mental health conditions.(1,2) Given the global ubiquity of violence against children and broader family adversity, various regional, national, and international health bodies have advocated for ro…”
Background
An Umbrella Review of the Links Between Adverse Childhood Experiences and Substance Misuse: What, Why, and Where Do We Go from Here?
Grummitt, L., Barrett, E., Kelly, E., & Newton, N. (2022) · Substance Abuse and Rehabilitation · doi:10.2147/sar.s341818 · Cited by 45 · see citing works
“As shown, meta-analytic estimates demonstrate an increased pooled risk associated with just one ACE for harmful alcohol use, illicit drug use, and smoking.(22,25,26,34) The strength of this association increases for those experiencing more than one ACE,(22,25,26,34) which sadly represents the majority of children who…”
BackgroundMethod
Population-attributable risk of adverse childhood experiences for high suicide risk, psychiatric admissions, and recurrent depression, in depressed outpatients
Gloger, S., Martínez, P., Behn, A. J., Chacón, M. V., Cottin, M., de Medina, D. D., & Vöhringer, P. A. (2021) · European Journal of Psychotraumatology · doi:10.1080/20008198.2021.1874600 · Cited by 58 · see citing works
“A recently published meta-analysis by Bellis et al. (2019) and a report from the Centers for Disease Control and Prevention (Merrick et al., 2017) have highlighted the important contribution of ACEs to depressive disorders in general, with PARs of 40 and 44.1%, respectively.”
BackgroundMethodResultInfluential
Prevalence of Adverse Childhood Experiences in sub-Saharan Africa: A multicountry analysis of the Violence Against Children and Youth Surveys (VACS)
Amene, E. W., Annor, F., Gilbert, L. K., McOwen, J., Augusto, Â. D. R., Manuel, P., Nobah, M. T. V. N., & Massetti, G. M. (2023) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2023.106353 · Cited by 60 · see citing works
“The association between ACEs and poor health outcomes throughout the lifespan have been well documented (Bellis et al., 2019; Boullier & Blair, 2018; Felitti et al., 1998; Hughes et al., 2021).”
Background
Psychometric properties of the Adverse Childhood Experiences Questionnaire 10 item version (ACE-10) among Hungarian adolescents
Kovács-Tóth, B., Oláh, B., Szabó, I. K., & Fekete, Z. (2023) · Frontiers in Psychology · doi:10.3389/fpsyg.2023.1161620 · Cited by 56 · see citing works
“org (abuse, neglect, household dysfunction) contribute to the development of various mental and somatic disorders that span into or develop in adulthood (Felitti et al., 1998; Hughes et al., 2017; Bellis et al., 2019).”
BackgroundResult
Resilience and Adverse Childhood Experiences: Associations With Poor Mental Health Among Homeless Adults
Liu, M., Mejía-Lancheros, C., Lachaud, J., Nisenbaum, R. A., Stergiopoulos, V., & Hwang, S. W. (2020) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2019.12.017 · Cited by 57 · see citing works
Child maltreatment and incident mental disorders in middle and older ages: a retrospective UK Biobank cohort study
Macpherson, J. M., Gray, S. R., Ip, P., McCallum, M., Hanlon, P., Welsh, P. I., Chan, K. L., Mair, F. S., Celis-Morales, C. A., Minnis, H., et al. (2021) · The Lancet Regional Health - Europe · doi:10.1016/j.lanepe.2021.100224 · Cited by 56 · see citing works
“Adverse childhood experiences (ACEs) are a global problem affecting 42% of children or adolescents in Europe and 58% in North America [1].”
Background
What Oncologists Should Know About Treating Sexual and Gender Minority Patients With Cancer
Quinn, G. P., Alpert, A. B., Sutter, M. E., & Schabath, M. B. (2020) · JCO Oncology Practice · doi:10.1200/op.20.00036 · Cited by 56 · see citing works
Child protection training for professionals to improve reporting of child abuse and neglect
Walsh, K., Eggins, E., Hine, L., Mathews, B., Kenny, M. C., Howard, S., Ayling, N. J., Dallaston, E., Pink, E., & Vagenas, D. (2022) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd011775.pub2 · Cited by 65 · see citing works
Association between childhood maltreatment and the prevalence and complexity of multimorbidity: A cross-sectional analysis of 157,357 UK Biobank participants
Hanlon, P., McCallum, M., Jani, B., McQueenie, R., Lee, D., & Mair, F. S. (2020) · Journal of Comorbidity · doi:10.1177/2235042x10944344 · Cited by 54 · see citing works
Adverse childhood experiences, daytime salivary cortisol, and depressive symptoms in early adulthood: a longitudinal genetically informed twin study
Iob, E., Baldwin, J. R., Plomin, R. J., & Steptoe, A. (2021) · Translational Psychiatry · doi:10.1038/s41398-021-01538-w · Cited by 53 · see citing works
Positive psychological well‐being and cardiovascular disease: Exploring mechanistic and developmental pathways
Boehm, J. K. (2021) · Social and Personality Psychology Compass · doi:10.1111/spc3.12599 · Cited by 56 · see citing works
“This parallels interest in adverse childhood experiences (Appleton, Holdsworth, et al., 2017; Bellis et al., 2019; Hughes et al., 2017) but asks not whether traumatic life experiences are detrimental to health, but rather whether protective factors such as well‐being can promote health.”
Background
Exploration of trends in the incidence and prevalence of childhood maltreatment and domestic abuse recording in UK primary care: a retrospective cohort study using ‘the health improvement network’ database
Chandan, J. S., Gokhale, K. M., Bradbury‐Jones, C., Nirantharakumar, K., Bandyopadhyay, S., & Taylor, J. S. (2020) · BMJ Open · doi:10.1136/bmjopen-2020-036949 · Cited by 51 · see citing works
Targets for intervention to prevent substance use in young people exposed to childhood adversity: A systematic review
Grummitt, L., Kelly, E., Barrett, E., Keyes, K., & Newton, N. (2021) · PLOS ONE · doi:10.1371/journal.pone.0252815 · Cited by 51 · see citing works
“This reflects a substantially increased risk of harmful substance use [2,3] and substance use disorder [4] for children exposed to childhood adversity, compared to their non-exposed peers.”
Background
Increased cardiometabolic and mortality risk following childhood maltreatment in the United Kingdom
Chandan, J. S., Okoth, K., Gokhale, K. M., Bandyopadhyay, S., Taylor, J., & Nirantharakumar, K. (2020) · Journal of the American Heart Association · doi:10.1161/jaha.119.015855 · Cited by 48 · see citing works
Articulating the Trauma‐Informed Theory of Individual Health Behavior
Marks, C., Pearson, J., Zúñiga, M. L., Martin, N. K., Werb, D., & Smith, L. R. (2021) · Stress and Health · doi:10.1002/smi.3068 · Cited by 50 · see citing works
Adverse Childhood Experiences and Criminal Justice Contact in Adulthood: ACEs and Adult Criminal Justice Contact.
Testa, A., Jackson, D. B., Ganson, K., & Nagata, J. M. (2021) · Academic pediatrics · doi:10.1016/j.acap.2021.10.011 · Cited by 39 · see citing works
Examining the Effectiveness of Circle of Security Parenting (COS-P): A Multi-Site Non-Randomized Study with Waitlist Control
Maxwell, A.-M., McMahon, C., Huber, A., Reay, R. E., Hawkins, E., & Barnett, B. (2021) · Journal of Child and Family Studies · doi:10.1007/s10826-021-01932-4 · Cited by 49 · see citing works
The impact of traumatic childhood experiences on interoception: disregarding one’s own body
Schmitz, M., Back, S. N., Seitz, K. I., Harbrecht, N. K., Streckert, L., Schulz, A., Herpertz, S. C., & Bertsch, K. (2023) · Borderline Personality Disorder and Emotion Dysregulation · doi:10.1186/s40479-023-00212-5 · Cited by 58 · see citing works
“The groups did not differ in heart rate (H[3] = 0.”
Background
Associations of Adverse Childhood Experiences with Frailty in Older Adults: A Cross-Sectional Analysis of Data from the Canadian Longitudinal Study on Aging
Mian, O., Anderson, L. N., Belsky, D. W., González, A., Ma, J., Sloboda, D. M., Bowdish, D. M. E., & Verschoor, C. P. (2021) · Gerontology · doi:10.1159/000520327 · Cited by 47 · see citing works
Association between adverse childhood experiences and premenstrual disorders: a cross-sectional analysis of 11,973 women
Yang, Q., Thordardottir, E. B., Hauksdóttir, A., Aspelund, T., Jakobsdóttir, J., Halldorsdottir, T., Tómasson, G., Rúnarsdóttir, H., Daníelsdóttir, H. B., Bertone‐Johnson, E. R., et al. (2022) · BMC Medicine · doi:10.1186/s12916-022-02275-7 · Cited by 52 · see citing works
“S2 and then divided into the categories of 0, 1, 2, 3, ≥4 ACEs, as commonly done in previous studies [27].”
Method
Applying an evolutionary mismatch framework to understand disease susceptibility
Lea, A. J., Clark, A. G., Dahl, A., Devinsky, O., García, A. R., Golden, C. D. W., Kamau, J., Kraft, T. S., Lim, Y. A. L., Martins, D. J., et al. (2023) · PLoS Biology · doi:10.1371/journal.pbio.3002311 · Cited by 54 · see citing works
Adverse Childhood Experiences (ACEs)
British Psychological Society (2021) · The Child & Family Clinical Psychology Review · doi:10.53841/bpscypf.2021.1.7.28 · Cited by 50 · see citing works
Neighborhood Poverty and Adverse Childhood Experiences over the First 15 Years of Life
Maguire-Jack, K., Font, S. A., Dillard, R., Dvalishvili, D., & Barnhart, S. (2021) · International Journal on Child Maltreatment Research Policy and Practice · doi:10.1007/s42448-021-00072-y
Role of thwarted belongingness, perceived burdensomeness and psychological distress in the association between adverse childhood experiences and suicidal ideation in college students
Bhargav, M., & Swords, L. (2022) · BJPsych Open · doi:10.1192/bjo.2021.1087 · Cited by 45 · see citing works
Psychometric evaluation of an Adverse Childhood Experiences (ACEs) measurement tool: an equitable assessment or reinforcing biases?
Mei, X.-H., Li, J., Li, Z.-S., Huang, S., Li, L.-L., Huang, Y., & Liu, J. (2022) · Health & Justice · doi:10.1186/s40352-022-00198-2 · Cited by 46 · see citing works
“…been found to be associated with increased physical and mental illness through the engagement of healthrisk behaviors (Baldwin et al., 2021a; Centers for Disease Control and Prevention, 2022; Hughes et al., 2021), and has been linked to $748 billion in related health costs (Bellis et al., 2019).”
Background
Adverse childhood experiences and risk of diabetes: A systematic review and meta-analysis
Zhu, S., Shan, S., Liu, W., Li, S., Hou, L., Huang, X., Liu, Y., Yi, Q., Sun, W., Tang, K., et al. (2022) · Journal of Global Health · doi:10.7189/jogh.12.04082 · Cited by 50 · see citing works
Intergenerational transmission of health inequalities: towards a life course approach to socioeconomic inequalities in health – a review
Houweling, T. A. J., & Grünberger, I. (2024) · Journal of Epidemiology & Community Health · doi:10.1136/jech-2022-220162 · Cited by 46 · see citing works
“68”
The Australian Child Maltreatment Study (ACMS): protocol for a national survey of the prevalence of child abuse and neglect, associated mental disorders and physical health problems, and burden of disease
Mathews, B., Pacella, R., Dunne, M. P., Scott, J. G., David Finkelhor, B., Meinck, F., Higgins, D. J., Erskine, H. E., Thomas, H. J., Haslam, D. M., et al. (2021) · BMJ Open · doi:10.1136/bmjopen-2020-047074 · Cited by 46 · see citing works
Testing Deprivation and Threat: A Preregistered Network Analysis of the Dimensions of Early Adversity
Carozza, S., Holmes, J., & Astle, D. E. (2022) · Psychological Science · doi:10.1177/09567976221101045 · Cited by 44 · see citing works
Preventing Adverse Childhood Experiences: The Role of Etiological, Evaluation, and Implementation Research
Matjasko, J. L., Herbst, J. H., & Estefan, L. F. (2022) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2021.10.024 · Cited by 45 · see citing works
Adverse Childhood Experiences and Their Impact on Sleep in Adults
Vadukapuram, R., Shah, K. H., Ashraf, S., Srinivas, S., Elshokiry, A. B., Trivedi, C. G., Mansuri, Z., & Jain, S. B. (2022) · The Journal of Nervous and Mental Disease · doi:10.1097/nmd.0000000000001480 · Cited by 42 · see citing works
“Approximately 30% of adult anxiety cases and 40% of adult depression are ACE linked (Bellis et al., 2019).”
Background
Comparing relationships between single types of adverse childhood experiences and health-related outcomes: a combined primary data study of eight cross-sectional surveys in England and Wales
Bellis, M., Hughes, K., Cresswell, K., & Ford, K. (2023) · BMJ Open · doi:10.1136/bmjopen-2023-072916 · Cited by 40 · see citing works
Self-citation
Adverse childhood experience and adult persistent pain and disability: protocol for a systematic review and meta-analysis
Bussières, A., Hartvigsen, J., Ferreira, M. L., Ferreira, P. H., Hancock, M. J., Stone, L. S., Wideman, T. H., Boruff, J., & Elklit, A. (2020) · Systematic Reviews · doi:10.1186/s13643-020-01474-8 · Cited by 40 · see citing works
The association between adverse childhood experiences and young adult outcomes: A scoping study
Park, E., Lee, J., & Han, J. (2021) · Children and Youth Services Review · doi:10.1016/j.childyouth.2020.105916 · Cited by 41 · see citing works
Association Between Adverse Childhood Experiences and Academic Performance Among Children and Adolescents: A Global Meta-Analysis
Qu, G., Shu, L., Liu, H., Ma, S., Han, T., Zhang, H., Huang, C., Wang, J., Yang, L., & Sun, Y. (2024) · Trauma Violence & Abuse · doi:10.1177/15248380241246758 · Cited by 40 · see citing works
“To date, the impact of ACEs on human physical and psychological health development and even life-course morbidity and early mortality has aroused much concern worldwide (Bellis et al., 2019; Campbell et al., 2016; Hughes et al., 2017; Nelson et al., 2020).”
Measurement of Adverse Childhood Experiences: It Matters
Reidy, D. E., Niolon, P. H., Estefan, L. F., Kearns, M. C., D’Inverno, A. S., Marker, C. D., & Merrick, M. T. (2021) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2021.05.043 · Cited by 40 · see citing works
Associations between adverse childhood experiences, attitudes towards COVID-19 restrictions and vaccine hesitancy: a cross-sectional study
Bellis, M. A., Hughes, K. E., Ford, K., Madden, H. C. E., Glendinning, F., & Wood, S. K. (2022) · BMJ Open · doi:10.1136/bmjopen-2021-053915 · Cited by 41 · see citing works
Self-citation
Prevalence of child maltreatment in India and its association with gender, urbanisation and policy: a rapid review and meta-analysis protocol
Fernandes, G., Fernandes, M., Vaidya, N., Souza, P. D., Plotnikova, E., Geddes, R., Holla, B., Sharma, E., Benegal, V., & Choudhry, V. (2021) · BMJ Open · doi:10.1136/bmjopen-2020-044983 · Cited by 42 · see citing works
Annual Research Review: Mapping the multifaceted approaches and impacts of adverse childhood experiences – an umbrella review of meta‐analyses
Kim, B., & Royle, M. L. (2024) · Journal of Child Psychology and Psychiatry · doi:10.1111/jcpp.14022 · Cited by 41 · see citing works
The social value of investing in public health across the life course: a systematic scoping review
Ashton, K., Schröder‐Bäck, P., Clemens, T., Dyakova, M., Stielke, A., & Bellis, M. A. (2020) · BMC Public Health · doi:10.1186/s12889-020-08685-7 · Cited by 39 · see citing works
“For example, it has been estimated that investing in breastfeeding has a clear positive return on investment across the life course [23].”
BackgroundSelf-citation
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Portwood, S. G., Lawler, M. J., & Roberts, M. C. (2021) · American Psychologist · doi:10.1037/amp0000809 · Cited by 39 · see citing works
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de Maat, D. A., Schuurmans, I. K., Jongerling, J., Metcalf, S. A., Lucassen, N., Franken, I. H. A., Prinzie, P., & Jansen, P. W. (2021) · Child Development · doi:10.1111/cdev.13663 · Cited by 40 · see citing works
“For instance, children exposed to negative life events or parental psychopathology are at increased risk for subsequent emotional and behavioral difficulties (Bellis et al., 2019; Goodman et al., 2011).”
A Scoping Review of Trauma-Informed Curricula for Primary Care Providers
Gundacker, C., Barreto, T. W., & Phillips, J. P. (2021) · Family Medicine · doi:10.22454/fammed.2021.500263 · Cited by 39 · see citing works
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Zhou, Y., Mika Kivimaki, B., Holt‐Lunstad, J., Yan, L. L., Zhang, Y., Wang, H. Z., Wang, S., & Xu, X. (2025) · EClinicalMedicine · doi:10.1016/j.eclinm.2025.103225 · Cited by 38 · see citing works
“42,47 The strengths of our study included the use of harmonised data from three nationally representative cohorts, a large pooled sample size, and the measurement of a broad range of childhood and adulthood stressful life events, which enable a comprehensive assessment of the associations with…”
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“Background Adverse childhood experiences (ACEs), defined as potentially traumatic abuse, neglect, and household challenges during childhood and adolescence, can have detrimental effects on health and wellbeing [1].”
Background
Air Purifier Intervention to Remove Indoor PM 2.5 in Urban China: A Cost-Effectiveness and Health Inequality Impact Study
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PW 0661 Estimating the financial costs of adverse childhood experiences (ACES) in europe
Bellis, M. A., Hughes, K. E., Wood, S. K., Rodriguez, G., & Sethi, D. D. (2018) · Abstracts · doi:10.1136/injuryprevention-2018-safety.282 · Cited by 1 · see citing works
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Hughes, K. E., Ford, K., Bellis, M. A., Quigg, Z., & Hopkins, J. C. (2026) · BMJ Open · doi:10.1136/bmjopen-2026-124416
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Economic Burden of Health Conditions Associated With Adverse Childhood Experiences Among US Adults
Peterson, C., Aslam, M. V., Niolon, P. H., Bacon, S., Bellis, M. A., Mercy, J. A., & Florence, C. (2023) · JAMA Network Open · doi:10.1001/jamanetworkopen.2023.46323 · Cited by 91 · see citing works
Self-citation

Authors: Bellis, M. A., Hughes, K., Ford, K., Ramos Rodriguez, G., Sethi, D., & Passmore, J.
Affiliations: Bangor University (GB)
World Health Organization Regional Office for Europe (DK)
Corresponding author: Bellis, Mark A
ORCID: Bellis, Mark A
Hughes, Karen
Ford, Kat
Venue: The Lancet Public Health
Publisher: Elsevier BV
Published: 2019-10
Volume: 4
Issue: 10
Pages: e517-e528
ISSN: 2468-2667 (ISSN-L)
DOI: 10.1016/s2468-2667(19)30145-8
PMC: PMC7098477
OpenAlex: W2971937136
Cited by: 1,032
References: 51
Citations by year: 2026: 132 · 2025: 178 · 2024: 216 · 2023: 161 · 2022: 167 · 2021: 118 · 2020: 57 · 2019: 2
FWCI: 13.65
Type: journal article
Language: en
Open access: gold
doi.org
Licence: cc-by
www.elsevier.com/tdm/userlicense/1.0/ (tdm)
www.elsevier.com/legal/tdmrep-license (tdm)
creativecommons.org/licenses/by/4.0/ (vor)
Locations: The Lancet Public Health (publishedVersion, cc-by)
PubMed Central (publishedVersion, cc-by)
PubMed (publishedVersion)
Bangor University Research Portal (Bangor University) (publishedVersion, other-oa)
Liverpool John Moores University (acceptedVersion)
DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
Topics: Social Sciences › Psychology › Clinical Psychology › Child Abuse and Trauma
Social Sciences › Safety Research › Child Welfare and Adoption
Social Sciences › Health › Intimate Partner and Family Violence
Keywords: adverse childhood experiences, life course health, population attributable fraction, disability-adjusted life years, health care costs, alcohol consumption, illicit drug use, smoking, obesity, cancer, diabetes mellitus, cardiovascular disease, respiratory diseases, anxiety, depression, health disparities
MeSH terms: Adult Survivors of Child Adverse Events, Adverse Childhood Experiences, Costs and Cost Analysis, Europe, Health Status, Humans, North America

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Life course health consequences and associated annual costs of adverse childhood experiences across Europe and North America: a systematic review and meta-analysis

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