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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
Open accessAbstract
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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“47 48 This alone may help avert further financial crises but reducing ACEs would also potentially leave populations more resilient to crises that arise from other causes.”
BackgroundSelf-citationComprehensiveness of State Insurance Laws and Perceived Access to Pediatric Mental Health Care
Foster, A. A., Hoffmann, J. A., Douglas, M. D., Monuteaux, M. C., Douglas, K., Benevides, T. W., Hudgins, J. D., & Stewart, A. M. (2024) · JAMA Network Open · doi:10.1001/jamanetworkopen.2024.26402 · Cited by 5
Adverse Childhood Experiences and Adult Household Firearm Ownership
Testa, A. M., Fu, K., Jackson, D. B., Semenza, D. C., & McKay, S. (2024) · JAMA Network Open · doi:10.1001/jamanetworkopen.2024.28027 · Cited by 5
Huang, Y. Y., Zhang, W. S., Jiang, C. Q., Zhu, F., Jin, Y. L., Yeung, S. L. A., Wang, J., Cheng, K. K., Lam, T. H., & Xu, L. (2024) · European Psychiatry · doi:10.1192/j.eurpsy.2024.1760 · Cited by 5
“Our findings in a setting with social development patterning very different from Western populations are consistent with previous studies mostly from Western countries showing that childhood adversities were associated with late-life depressive symptoms with dose-response patterns [5, 30 – 32].”
ResultIannaccone, P. M., Ryznar, R. J., & Winkle, L. J. V. (2024) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph21111522 · Cited by 6
“Moreover, adults exposed to more than one ACE (e.g., child abuse and inter-parental violence) develop health-threatening behaviors, such as drug abuse, as well as anxiety, cancer, and diabetes more often than their unexposed counterparts [15].”
InfluentialBigler, M. E., Schuurmans, I. K., Zhu, Y., Siddique, N., Hoffman, N., Koen, N., Zar, H. J., Stein, D. J., Cecil, C. A. M., & Dunn, E. C. (2025) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2025.107315 · Cited by 5
Risk and Protective Factors for Treatment Dropout in a Child Maltreatment Population
Eirich, R., Racine, N. M., Garfinkel, D. A., Dimitropoulos, G., & Madigan, S. L. (2020) · Adversity and Resilience Science · doi:10.1007/s42844-020-00011-9 · Cited by 5
Illustrating a novel methodology and paradigm applied to Emergency Department research
Binnie, V., Brocque, R. M. L., Jessup, M., & Johnston, A. N. B. (2021) · Journal of Advanced Nursing · doi:10.1111/jan.15017 · Cited by 5
Beasley, T. E., McDaniel, K. L., Oshiro, W. M., MOSER, V. C., MacMillan, D. K., & Herr, D. W. (2021) · Neurotoxicology and Teratology · doi:10.1016/j.ntt.2021.107061 · Cited by 5
Human Females as a Dispersal-Egalitarian Species: A Hypothesis about Women and Status
Benenson, J. F. (2022) · Adaptive Human Behavior and Physiology · doi:10.1007/s40750-022-00191-x · Cited by 5
“Children of higher SES mothers in Western cultures also experience fewer adverse childhood experiences, such as maltreatment and interparental violence and familial substance abuse, which predict poorer adult outcomes (Bellis et al., 2019).”
BackgroundBisagno, E., Cadamuro, A., Dierickx, S., Mosleh, D. B., Groenen, A., Linde‐Ozola, Z., Kandāte, A., Varga‐Sabján, D., Morva, D., Noémi, L., et al. (2023) · Children · doi:10.3390/children10050858 · Cited by 5
“Each year, approximately one in four children and adolescents are exposed to child abuse and trauma or one or more adverse childhood experiences (ACEs) [1,2] (Figure 1).”
BackgroundAre childhood factors predictive of adult health literacy? A longitudinal birth cohort analysis
Solis‐Trapala, I., Campbell, P., Lacey, R. J., Rowlands, G., Dunn, K. M., & Protheroe, J. (2023) · SSM - Population Health · doi:10.1016/j.ssmph.2023.101426 · Cited by 6
Szalas, N., & Bryńska, A. (2023) · Psychiatria i Psychologia Kliniczna · doi:10.15557/pipk.2023.0007 · Cited by 5
Hosang, G. M., Havers, L., Shuai, R., Fonagy, P., Fazel, M. S., Morgan, C., Karamanos, A., Fancourt, D. E., McCrone, P., Smuk, M., et al. (2023) · PLoS ONE · doi:10.1371/journal.pone.0289438 · Cited by 4
“Youth adversity is a robust risk factor for later mental and physical health problems [9, 10].”
BackgroundTrinh, H. H., Nguyen, T. T., Nguyen, T. Q., Ngo, N. T., Nguyen, S. T., Nguyen, C. V., Mac, T. D., & Nguyen, H. T. (2025) · Psychiatry Investigation · doi:10.30773/pi.2025.0068 · Cited by 4
Adverse childhood experiences and adult psychopathology: A latent class analysis approach
Mildred-Short, G., & Tashjian, S. M. (2025) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2025.107672 · Cited by 6
Wang, D., Wang, W., Liao, Y., Zhang, H., Lu, Y., Liu, H., Zhang, Y., Yuan, L., Wu, M., Gao, Y. H., et al. (2025) · European Archives of Psychiatry and Clinical Neuroscience · doi:10.1007/s00406-025-02124-7 · Cited by 4
Muzi, S., Rogier, G., & Pace, C. S. (2025) · Current Psychology · doi:10.1007/s12144-025-08250-8 · Cited by 4
Wang, F., & Ma, X. (2025) · BMC Psychiatry · doi:10.1186/s12888-025-07179-3 · Cited by 5
“Contemporary adversity research predominantly operationalizes this through the cumulative risk model [34–36], which posits that psychological maladjustment escalates with each additional ACEs exposure due to stress accumulation [34, 36].”
Childhood Maltreatment and Its Long-Term Psychosocial Outcomes: An Umbrella Review of Meta-Analyses
Zhang, L., Hu, L., Chau, P. H., Wu, C., Taylor, J. S., & Choi, E. P. H. (2025) · Trauma Violence & Abuse · doi:10.1177/15248380251388134 · Cited by 8
Çiçek, İ. (2025) · Journal of Interpersonal Violence · doi:10.1177/08862605251399674 · Cited by 4
Adverse Childhood Experiences Predict Diurnal Cortisol Throughout Gestation
Panisch, L. S., Murphy, H. R., Wu, Q., Brunner, J., Duberstein, Z. T., Arnold, M. S., Best, M., Barrett, E. S., Miller, R. K., Qiu, X., et al. (2023) · Psychosomatic Medicine · doi:10.1097/psy.0000000000001218 · Cited by 6
Testa, A. M., Jacobs, B., Zhang, L., Jackson, D. B., Ganson, K. T., & Nagata, J. M. (2023) · BMC Pregnancy and Childbirth · doi:10.1186/s12884-023-05925-7 · Cited by 4
“…on ACEs demonstrates that they are highly powerful, with exposure to ACEs increasing the chance of poor outcomes later in life, including negative physical and mental health [11, 12], diminished employment prospects [13], barriers to health care utilization [14], and premature mortality [15].”
BackgroundSurviving the Storm: Exploring Lives Through Personal Stories of Childhood Trauma
Kashyap, K., Panda, S., & Bhuyan, B. (2024) · Indian Journal of Psychological Medicine · doi:10.1177/02537176241228032 · Cited by 4
Sullivan, A. D. W., Rancher, C. E., & Moreland, A. D. (2024) · Early Childhood Education Journal · doi:10.1007/s10643-024-01638-4 · Cited by 6
“This finding aligns with the sparse literature on teachers (e.g., Hubel et al., 2020, Rancher & Moreland, 2023; Whitaker et al., 2013) and the better-established literature on general samples of adults (e.g., Bellis et al., 2019; Brindle et al., 2022; Hughes et al., 2017; Poole et al., 2018).”
Ross, D., McCallum, N., Truuvert, A. K., Butt, A., Behdinan, T., Rojas, D., Soklaridis, S., & Vigod, S. N. (2024) · Journal of Mental Health · doi:10.1080/09638237.2024.2332797 · Cited by 4
“…a 2003 report to the Law Commission of Canada estimated the annual socioeconomic cost of child abuse to be over 15 billion dollars, in terms of health care, social services, education, judicial system, employment, and personal costs (Bellis et al., 2019; Bowlus et al., 2003; Graziani et al., 2022).”
Willoughby, K., Atallah, S., Arbeau, K., Pearce, J., Ketelaars, T., & Pierre, J. S. (2024) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph21111441 · Cited by 5
Adverse childhood experiences and cardiometabolic biomarkers: A causal analysis
He, F., Zhang, H., Zheng, G., Zhou, B., Fang, Z., Zhu, H., Dong, Y., & Hao, G. (2025) · Journal of Affective Disorders · doi:10.1016/j.jad.2025.04.039 · Cited by 5
Yin, M., Chen, Z., Wáng, Q., Tang, S., Huang, C., & Huang, X. (2025) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2025.107573 · Cited by 4
Metadata
- 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
- Venue
- The Lancet Public Health
- Publisher
- Elsevier BV
- Published
- 2019-10
- Volume
- 4
- Issue
- 10
- Pages
- e517-e528
- ISSN
- 2468-2667 (ISSN-L)
- 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
- 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 › Sociology and Political Science › 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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