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

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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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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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Figure 1 Study selection flowchart ACE=adverse childhood experience. *Did not meet study requirements.CC BY · PubMed Central

Figure 2 Sensitivity analyses of combined ACE-attributable DALYs and costs relating to risk factors and causes of ill health (A) ACE-attributable DALYs. (B) ACE-attributable costs. DALYs for risk factors (harmful alcohol use, illicit drug use, smoking, and obesity) exclude those attributed to causes of ill health (anxiety, depression, cancer, cardiovascular disease, diabetes, and respiratory disease). PAF=population-attributable fraction.CC BY · PubMed Central

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“Our findings are also consistent with prior research implicating ACEs in the etiology of mood and somatic depressive symptomatology, as well as of anxiety disorders.”
Influential
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“ACE are linked to a range of childhood and adult psychiatric disorders and medical conditions across the lifespan (Bellis et al., 2019).”
Background
The reward positivity mediates the association between adverse childhood experiences and anhedonia in young adults with drug-naïve major depressive disorder.
Bao, C.-Q., Zhang, Q.-Y., Zou, H.-W., He, C., Yan, R., Hua, L., Lu, Q., & Yao, Z. (2024) · Biological Psychiatry: Cognitive Neuroscience and Neuroimaging · doi:10.1016/j.bpsc.2024.08.014 · Cited by 6
Prevalence of Functional Difficulty Among School-Aged Children and Effect on School Enrolment in Rural Southern India: A Cross-Sectional Analysis
Chandy, B. R., Davey, C., Oswald, W. E., Kaliappan, S. P., Aruldas, K., Banks, L. M., Jasper, S., Nagarajan, G., Galagan, S. R., Kennedy, D. S., et al. (2024) · Journal of Epidemiology and Global Health · doi:10.1007/s44197-024-00293-7 · Cited by 3
Bidirectional relationships between childhood adversities and psychosocial outcomes: A cross-lagged panel study from childhood to adolescence
Hales, G. K., Debowska, A., Rowe, R., Boduszek, D., & Levita, L. (2024) · Development and Psychopathology · doi:10.1017/s0954579424001470 · Cited by 3
Prevalence, subtypes, and risk factors of adverse childhood experiences among Chinese residents: a multicenter cross-sectional study
Chen, Y., Lu, Y., Wen, X., Zhou, T., & Ke, X. (2024) · Frontiers in Public Health · doi:10.3389/fpubh.2024.1453517 · Cited by 4
Lagged effects of childhood depressive symptoms on adult epigenetic aging
Han, L. K. M., Aghajani, M., Penninx, B. W. J. H., Copeland, W., Åberg, K. A., & van den Oord, E. J. C. G. (2024) · Psychological Medicine · doi:10.1017/s0033291724001570 · Cited by 4
“For example, the initial impact of trauma may magnify over time due to subsequent increases in health-risk behaviors such as smoking, substance use, and high-risk activities (Bellis et al., 2019; Hughes et al., 2017) that then over time accelerate epigenetic aging.”
Background
Typological and cumulative approaches to risk and adversity in Child and Adolescent Mental Health Services (CAMHS): Retrospective cohort analysis in South London
Coughlan, B., Marshall, N., Woolgar, M., Mannes, J., Erkiert, P., Humphrey, A., Smith, J., Drayak, T., Crozier‐Roche, F., Morgan, T., et al. (2024) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2024.152568 · Cited by 3
Childhood Maltreatment and Borderline Personality Disorder
Salavati, M., & Selby, E. A. (2024) · Springer eBooks · doi:10.1007/978-3-031-75503-3_4 · Cited by 3
From Childhood Adversity to Psychological Distress: The Mediating Role of Difficulties in Emotion Regulation and the Moderating Role of Acute Stress and Mentalising Skills
Hanetz‐Gamliel, K., & Dollberg, D. G. (2025) · Stress and Health · doi:10.1002/smi.70025 · Cited by 5
Propensity to childhood anxiety and depression due to exposure to adversity: A multidimensional construct
dos Santos, A. C. G., da Silva, A. B., Libório, M. P., Nobre, C. N., Mannan, H., & D’Ângelo, M. F. S. V. (2025) · PLoS ONE · doi:10.1371/journal.pone.0326239 · Cited by 3
“Given the high prevalence of adverse childhood experiences and the growing evidence of their contribution to most classes of mental disorders [16], adverse childhood experiences are strategic targets for prevention [24].”
Associations between patterns of adverse childhood experiences and adult chronic conditions: A population-based study
Guo, N., Luk, T. T., Zhao, S. Z., & Weng, X. (2025) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2025.107628 · Cited by 3
Ethical Implications of AI‐Driven Chatbots in Domestic Violence Support
Mielismäki, H., & Husso, M. (2025) · Social Inclusion · doi:10.17645/si.9998 · Cited by 3
“It may significantly damage the mental and physical health of victim‐survivors of DV (Bellis et al., 2019; Ellsberg et al., 2015; Miller & McCaw, 2019; Stubbs & Szoeke, 2022).”
How should trauma discussions be approached in maternity care? Perspectives from a qualitative study with women, voluntary sector representatives and healthcare providers in the UK
Cull, J., Thomson, G., Downe, S. M., Fine, M., & Topalidou, A. (2025) · BMJ Open · doi:10.1136/bmjopen-2024-097815 · Cited by 3
Preferences for disclosing adverse childhood experiences for children and adults with cystic fibrosis
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Factors associated with back pain in children aged 6 to 12 years of age, an eight months prospective study
Henriot-Jéhel, C., Lemire, J., Teulier, C., Bussières, A., & Lardon, A. (2022) · Scientific Reports · doi:10.1038/s41598-021-04060-7 · Cited by 3
Experiences of Trauma and DNA Methylation Profiles among African American Mothers and Children
Barcelona, V., Huang, Y.-F., Caceres, B. A., Newhall, K. P., Hui, Q., Cerdeña, J., Crusto, C. A., Sun, Y. V., & Taylor, J. Y. (2022) · International Journal of Molecular Sciences · doi:10.3390/ijms23168951 · Cited by 4
“Potentially traumatic experiences over the life course are common and have a strong, cumulative impact on adult health [1].”
Background
Interventions to change parental parenting behaviour to reduce unintentional childhood injury: a randomised controlled trial
Kawahara, T., Doi, S. K., Isumi, A., Ochi, M., & Fujiwara, T. (2022) · Injury Prevention · doi:10.1136/ip-2022-044721 · Cited by 3
Positive Development and Parenting in the Face of Adversity: A Survey of Emerging Adults
Chainey, C., Burke, K., & Haynes, M. A. (2022) · Adversity and Resilience Science · doi:10.1007/s42844-022-00082-w · Cited by 3
The moment is now: Strengthening communities and families for the future of our nation
Rostad, W. L., Ports, K. A., Merrick, M. T., & Hughes, L. (2022) · Children and Youth Services Review · doi:10.1016/j.childyouth.2022.106745 · Cited by 3
“…between CAN and longer-term health consequences, including changes in physiological development; physical and mental health problems; engagement in health risk behaviors such as smoking and substance use; and premature death (Anda et al., 2006; Bellis et al., 2019; Merrick et al., 2019).”
Background
1000 Days: The “WeCare Generation” Program—The Ultimate Model for Improving Human Mental Health and Economics: The Study Protocol
Uccellini, O., Benlodi, A., Caroppo, E., Cena, L., Esposito, G., Fernández, I., Ghazanfar, M., Imbasciati, A., Longo, F., Mazza, M., et al. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph192416741 · Cited by 3
“ACEs have in Europe and in Italy a prevalence of about 20% [13].”
Background
Community food insecurity predicts child maltreatment report rates across Illinois zip codes, 2011–2018
Kim, H., Gundersen, C., & Windsor, L. C. (2023) · Annals of Epidemiology · doi:10.1016/j.annepidem.2023.01.008 · Cited by 3
Assessment of the Association between Adverse Childhood Experiences and Self-Esteem in a Sample of Teenage Students in Nigeria
Ossai, O. V. (2023) · International Journal of Home Economics Hospitality and Allied Research · doi:10.57012/ijhhr.v2n1.004 · Cited by 3
“In 2014 and 2015, approximately 1 billion children worldwide suffered from ACEs (Bellis, 2019).”
Background
Exposure to household dysfunction at childhood and later number of teeth among older Japanese adults: A life course study from the Japan Gerontological Evaluation Study
Abbas, H., Takeuchi, K., Kiuchi, S., Kondo, K., & Osaka, K. (2023) · Journal of Public Health Dentistry · doi:10.1111/jphd.12582 · Cited by 3
Early Life Adversity as a Risk Factor for Alcohol Use Disorder
Schwandt, M. L. (2023) · Springer eBooks · doi:10.1007/978-3-031-32483-3_34 · Cited by 3
Adverse Childhood Experiences and Cardiovascular Disease Risks: Implications for North Carolina and the Need for an Upstream Approach
Hege, A. (2024) · North Carolina Medical Journal · doi:10.18043/001c.91428 · Cited by 3
“In sum, it has been estimated that the United States spends nearly three-quarters of a billion dollars annually to address the health burdens associated with ACEs, and cardiovascular disease is overwhelmingly the primary culprit due to disability-adjusted life years (DALYs) [5].”
The Association Between a Neighborhood Adverse Childhood Experiences Index and Body Mass Index Among New York City Youth
Schroeder, K., Dumenci, L., Day, S. E., Konty, K., Noll, J. G., Henry, K., Suglia, S. F., Wheeler, D. C., Argenio, K. L., & Sarwer, D. B. (2024) · Childhood Obesity · doi:10.1089/chi.2024.0215 · Cited by 3
History of childhood maltreatment associated with hospitalization or death due to COVID-19: a cohort study
Wang, Y., Ge, F., Aspelund, T., Ask, H., Hauksdóttir, A., Hu, K., Jakobsdóttir, J., Zoëga, H., Shen, Q., Whalley, H. C., et al. (2024) · BMC Medicine · doi:10.1186/s12916-024-03399-8 · Cited by 6
“…adulthood [10], more likely to have suboptimal health behaviours (e.g. smoking) [20] and immune function [21], and to be at higher risk of obesity [12], cardiovascular disease [22], psychiatric disorders [11], and other chronic diseases in adulthood [13], all of which are associated with severe…”
BackgroundInfluential
Online Delivery of Interprofessional Adverse Childhood Experiences Training to Rural Providers: Usability Study
Kapp, J. M., Dicke, R., & Quinn, K. J. (2024) · JMIR Pediatrics and Parenting · doi:10.2196/56722 · Cited by 3
“Illicit drug use had the highest population-attributable fractions associated with ACEs, and population-attributable fractions 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 [14].”
Background
Healthy Communities for Youth: A Cost Analysis of a Community-Level Program to Prevent Youth Violence
Pan, Z., Chapman, D. A., Sullivan, T. N., Bishop, D. L., & Kimmel, A. D. (2024) · Prevention Science · doi:10.1007/s11121-024-01729-z · Cited by 3
“Collectively, these events result in an economic burden of more than $487 billion (Bellis et al., 2019), suggesting potential investment returns both in the short-term and over generations.”
Background
Cross-sectional study on the impact of adverse childhood experiences on psychological distress in patients with an implantable cardioverter-defibrillator
Dörner, M., von Känel, R., Pazhenkottil, A. P., Altwegg, R., König, N., Nager, L., Attanasio, V., Guth, L., Zirngast, S., Menzi, A., et al. (2025) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2024.112033 · Cited by 3
Prospective association of adverse childhood experiences and social support with all-cause mortality among young adults in the USA
Thapa, K., Shen, Y., Cordero, J. F., Vall, E. A., & Rajbhandari‐Thapa, J. (2025) · Journal of Epidemiology & Community Health · doi:10.1136/jech-2024-223342 · Cited by 3
“…analysed separately, we found that school support was directly associated with reduced mortality independent of ACEs and other social support sources, and ACEs were significantly associated with greater mortality risk among those who had poor family support (online supplemental eTables 3 and 4).”
Adverse Childhood Experiences in Youth: Trauma-Informed Assessment, Diagnosis, and Management
Kameg, B., & Fradkin, D. (2020) · The Journal for Nurse Practitioners · doi:10.1016/j.nurpra.2020.04.026 · Cited by 3
Perceptions of a short animated film on adverse childhood experiences: a mixed methods evaluation
Ford, K., Bellis, M. A., Isherwood, K. R., & Hughes, K. E. (2021) · BMJ Open · doi:10.1136/bmjopen-2021-050398 · Cited by 3
Self-citation
Using adverse childhood experiences to explore the usefulness of community health needs assessments to monitor complex determinants of health at the local level
Daily, S. M., Dyer, A., Lilly, C. L., Sarkees, E. A., & Bias, T. K. (2021) · Evaluation and Program Planning · doi:10.1016/j.evalprogplan.2021.102044 · Cited by 3
Prevalence and factors associated with adverse early childhood experiences: a population-based study in Ceará, Brazil
Martins, M. I. S., Rocha, H. A. L., Leite, Á. J. M., Rocha, S. G. M. O., Araújo, D. A. B. S., Machado, M. M. T., Campos, J. S., Sampaio, E. G. M., Silva, A. C. E., & Correia, L. L. (2022) · Revista Brasileira de Epidemiologia · doi:10.1590/1980-549720220035 · Cited by 3
Effects of cross-fostering experience on emotion in adolescent Kunming mice
Zhu, Y., Wang, Y., Wang, Y., Feng, Y., Wang, Q., Wang, Q., Tian, Y., Tai, F., & Jia, R. (2023) · Behaviour · doi:10.1163/1568539x-bja10200 · Cited by 3
Exploring Interrelatedness of Adverse Childhood Experiences in Infancy and Toddlerhood: Using Latent Class Approaches to Examine Developmental Outcomes
McKelvey, L. M., Zhang, D., Whiteside-Mansell, L., & Selig, J. P. (2022) · Adversity and Resilience Science · doi:10.1007/s42844-022-00066-w · Cited by 3
Development and initial validation of a short form of the Memories of Home and Family Scale
Redican, E., Rawers, C., McElroy, E., Hyland, P., Karatzias, T., Ben‐Ezra, M., & Shevlin, M. E. (2023) · Adversity and Resilience Science · doi:10.1007/s42844-023-00097-x · Cited by 3
A Stage 1 Pilot Cohort Exploring the Use of EMDR Therapy as a Video-Conference Psychotherapy During Covid-19 – A Proof of Concept Study Utilising a Virtual Blind 2 Therapist ProtocolPreprint
Farrell, D., Fadeeva, A., Zat, Z., Knibbs, L., Miller, P. W., Barron, I., Matthess, H., Mattheß, C., Gazit, N., & Kiernan, M. (2021) · Research Square · doi:10.21203/rs.3.rs-886940/v1
Feasibility of a Parent-led Stepped Care Trauma-focused Cognitive Behavioural Therapy for Children: a Mixed Methods Pilot Trial ProtocolPreprint
Skjærvø, I., Martinsen, M., Næss, A., Jensen, T. K., Fagermoen, E. M., Skagemo, C. U., Dyrdal, G. M., Knutsen, M., Michaelsen, K., Nymoen, R. C., et al. (2022) · Research Square · doi:10.21203/rs.3.rs-1253190/v1 · Cited by 3
“Every year, a substantial number of children are exposed to violence or other potentially traumatizing events (1, 2).”
Background
A Novel Strategy for Increasing Utilization of Earned Income Tax Credits and Reducing Adverse Childhood Experiences: The EITC Access Project
Maguire‐Jack, K., Solomon, A., Greenberg, S., Chang, O. D., Coggins, H., Schuster-Wachsberger, E., & Hinton, J. (2022) · International Journal on Child Maltreatment Research Policy and Practice · doi:10.1007/s42448-022-00119-8 · Cited by 2
Adolescents with developmental traumas in therapy in a child and adolescent mental health service, outpatient unit: experiences of daily living and expectations for therapy – a qualitative study
Olstad, K., Sørensen, T., Lien, L., & Danbolt, L. J. (2023) · Frontiers in Psychology · doi:10.3389/fpsyg.2023.946394 · Cited by 2
“In research or clinical contexts, there is a clear correlation between violent childhood experiences and mental and physical health problems, daily functioning, and social relationships (Hughes et al., 2017; Bellis et al., 2019; Rueness et al., 2020; Birkeland et al., 2021).”
Background
Impact of adverse childhood experiences on life expectancy with depression in the U.K. population: The mitigating role of educational attainment
Du, Y., Luo, Y., Ren, Z., Zheng, X., & Liu, J. (2023) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2023.106383 · Cited by 2
Modèles descriptifs de l’adversité vécue durant l’enfance (Adverse Childhood Experiences) et implications pour la recherche : état des lieux et perspectives
Tarquinio, C., Trousselard, M., Rotonda, C., & Tarquinio, C. (2023) · Annales Médico-psychologiques revue psychiatrique · doi:10.1016/j.amp.2023.06.008 · Cited by 3
Exploring dimensions of childhood adversity as predictors of psychological adjustment among adolescents involved in the child welfare system: A latent profile analysis
Tomlinson, C. A., McDonald, S. E., Brown, S. M., & Shin, S. H. (2023) · Children and Youth Services Review · doi:10.1016/j.childyouth.2023.107242 · Cited by 2
Adverse childhood experiences, individual‐level risk and protective factors, and recent drug use in a community sample of Nigerian women
Agwogie, M. O., Kliewer, W. L., & Ibrahim, M. B. (2024) · Journal of Traumatic Stress · doi:10.1002/jts.23043 · Cited by 2
Exploring clinicians’ knowledge and attitudes toward the care needs of complex adult users of an Emergency Department: A descriptive mixed methods study
Binnie, V., & Johnston, A. N. B. (2024) · International Emergency Nursing · doi:10.1016/j.ienj.2024.101481 · Cited by 2
A Comparison of Intimate Partner Violence Victimization and Perpetration, Adverse Childhood Experiences, and Mental Health Among Men in Same-Gender and Different-Gender Relationships
Ricks, J. M., Liebhard, B. M., Dush, C. M. K., Manning, W. D., & LoVette, A. (2024) · Partner Abuse · doi:10.1891/pa-2023-0040 · Cited by 3
Adverse Childhood Experiences Module Nonresponse: Behavioral Risk Factor Surveillance System, 2019 and 2021
Besera, G., Annor, F., Swedo, E. A., Aslam, M. V., & Massetti, G. M. (2024) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2024.08.001 · Cited by 2

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 › 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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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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