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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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“Since then, this study has been replicated many times around the world with comparable results (Bellis et al., 2019; Pace et al., 2022; Petruccelli et al., 2019; Samia et al., 2020; Subramaniam et al., 2020; Thomas et al., 2020).”
InfluentialMarshall, E. A., Belisle, L. A., & Miller, H. A. (2025) · Victims & Offenders · doi:10.1080/15564886.2025.2527334
“…of (see Baglivio et al., 2014; Haahr-Pedersen et al., 2020) – has found strong links between ACEs and adverse mental and psychological health outcomes later in life, including but not limited to problematic substance use, anxiety, personality disorders, and suicidality (see Bellis et al., 2019).”
İşcanoğlu, Z., Erden-Başaran, Ö., & Poehlmann, J. (2025) · International Journal of Offender Therapy and Comparative Criminology · doi:10.1177/0306624x251357620
“While early exposure to physical violence is not uncommon in the general population (Bellis et al., 2019), it is notably more prevalent among incarcerated women, with one in two reporting such experiences (Jones et al., 2020).”
Desogus, S., & Russell, K. (2025) · International Journal of Social Psychiatry · doi:10.1177/00207640251353819
“This measure was chosen as it has been widely used in previous research and, therefore, provides the opportunity for this work to contribute to a cumulative evidence base on the consequences of experiencing ACEs (Bellis et al., 2019).”
Zara, S., Ullrich, I. C., Leveling, A. M., Saretzki, F. G. G., Schmitz, J., Eckhard, M., Kruse, J., & Kampling, H. (2025) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2025.1608601
Majlesi, N., Mohammadkhani, S., Hasani, J., & Moghadasin, M. (2025) · Adversity and Resilience Science · doi:10.1007/s42844-025-00180-5
Phillips, B., O’Toole, C., Phillips, S. M., & McGilloway, S. (2025) · Irish Educational Studies · doi:10.1080/03323315.2025.2546962
Wiggins, L. D., DiGuiseppi, C. G., Overwyk, K. J., Barger, B. D., Dichter, G. S., Durkin, M. S., Hightshoe, K., Moody, E. J., Nadler, C. B., Powell, P. S., et al. (2025) · Journal of Developmental & Behavioral Pediatrics · doi:10.1097/dbp.0000000000001414
Stout, M. E., Li, C., & Smith, R. J. (2025) · Stress and Health · doi:10.1002/smi.70101
Liu, N., Huang, C., Yin, Y., Dai, X., Pei, J., Liu, J.-J., Zhao, Z., Zhang, Y., Larson, T. V., Seto, E., et al. (2025) · medRxiv · doi:10.1101/2025.08.25.25333590
Noronha, T. G., Knorst, J. K., Rauber, E. D., Emmanuelli, B., Ardenghi, T. M., & Tomazoni, F. (2025) · Quality of Life Research · doi:10.1007/s11136-025-04034-6
“Investigating these associations is essential for understanding the cumulative impact of early adversity on oral health across the life course [7].”
Bürgin, D., Nishimi, K. M., Clemens, V., Meier, M., Unternäehrer, E., Gurri, L., Bruttin, E., Rohleder, N., Klauser, P., Dwir, D., et al. (2025) · Brain Behavior & Immunity - Health · doi:10.1016/j.bbih.2025.101098
“Indeed, exposure to ELS including childhood adversity, maltreatment, trauma, abuse, or neglect increases risk for adverse health outcomes across the entire lifetime (Bellis et al., 2019; Bürgin et al., 2021; McCrory et al., 2017; McLaughlin, 2016; McLaughlin et al., 2020).”
Kleiner, A. C., Semlali, I., Stanley, N., & Romain-Glassey, N. (2025) · Children and Youth Services Review · doi:10.1016/j.childyouth.2025.108580 · Cited by 3
Turgeon, J., Racine, N. M., McDonald, S., Tough, S., & Madigan, S. L. (2025) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2025.107722
Gurri, L., Beck, K., d’Huart, D., Seker, S., Leiting, M., Boonmann, C., Jenkel, N., Fegert, J. M., Clemens, V., Schmeck, K., et al. (2025) · Kindheit und Entwicklung · doi:10.1026/0942-5403/a000493
Hyland, M. T., Crabb, K. E., & Amarneh, D. Y. (2025) · Journal of Modern Foreign Psychology · doi:10.17759/jmfp.2025140307
Yu, P., Zhang, H., Zhang, X., Zeng, P., Chu, Z., & Wang, K. (2025) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2025.1560961
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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