How Much Adult Ill Health Stems From Adverse Childhood Experiences?

Adverse childhood experiences — violence against a child, or witnessing traumatic events at home such as intimate partner violence, mental illness or substance misuse — can have deep and lasting effects on health and life. They can trigger toxic stress that alters gene expression, brain connections and immune and organ function, and undermine healthy ways of coping. They are linked to alcohol and drug use disorders, suicide, mental illness, heart disease and other chronic illness, risky behavior, and lower education, employment and income; at least five of the 10 leading causes of death have been associated with them. Anyone can be exposed, but historical, social and economic conditions make them more common for some families.

They are also preventable. Trials of preschool enrichment and early childhood home visiting have cut rates of child abuse and neglect by 48%–52%. This CDC Vital Signs report estimated how much adult ill health might be avoided if adverse childhood experiences were prevented.

The data

Twenty-seven states added adverse childhood experience questions to the Behavioral Risk Factor Surveillance System, a telephone survey of adults, in 2015–2017. Two used different questions and were left out, leaving 25 states and 144,017 respondents. Eleven questions covered eight kinds of experience before age 18:

• abuse: physical, emotional and sexual;
• household challenges: a household member's substance misuse, incarceration or mental illness, parental divorce, and witnessing intimate partner violence.

Respondents were grouped by how many kinds they reported — none, one, two or three, or four or more — and the researchers estimated, after adjusting for age, sex and race/ethnicity, how many cases of each outcome might be prevented if those experiences were reduced or eliminated.

How common

• 60.9% of adults reported at least one kind of adverse childhood experience, and 15.6% — nearly one in six — four or more.
• Women, American Indian/Alaska Native and Black adults, and the "other" racial/ethnic group were more likely than men and white adults to report four or more.
• Younger adults, especially those aged 18–34, reported more than older adults. That may reflect differences between generations in exposure, willingness to disclose or memory — or earlier deaths among people with more adverse experiences.

Links to adult health

Compared with adults who reported none, those with four or more kinds had higher adjusted odds of:

What prevention could avoid

Preventing all adverse childhood experiences could potentially reduce:

The largest gains came in every case from the group with four or more kinds of experience. For coronary heart disease, the leading cause of death in the United States, the reduction would mean about 1.1 million fewer cases in the 25 states. Applied to national estimates for 2017, up to 1.9 million cases of coronary heart disease, 2.5 million of overweight or obesity, 1.5 million of not finishing high school and 21 million of depression might have been avoided. Earlier research also connects these experiences to substance use and suicide, making prevention part of addressing the opioid overdose crisis.

How to prevent them

The foundation is safe, stable, nurturing relationships and environments for every child and family. CDC's evidence-based approach has six strategies:

1. Strengthen economic supports for families, such as earned income tax credits and family-friendly work policies.
2. Promote social norms that protect against violence and adversity, through public campaigns supporting positive parenting and bystander approaches to healthy relationships.
3. Ensure a strong start with home visiting, high-quality child care and preschool enrichment.
4. Teach skills for handling stress, emotions and everyday challenges — social-emotional learning, healthy relationship programs and parenting programs.
5. Connect young people to caring adults and activities through mentoring and after-school programs.
6. Lessen harms through primary care that screens for and addresses these experiences, victim-centered services and trauma-informed care.

These strategies have been linked to better school achievement and less depression, suicidal behavior, arrest and incarceration, and substance use. Communities can also work on the stresses of under-resourced neighborhoods and the historical and ongoing trauma of systemic racism and generational poverty, and helping young adults — who are starting families — can break the cycle across generations.

Limitations

Self-reports may undercount adverse experiences; cross-sectional data cannot prove cause; the 25 states may not represent others; the survey did not measure severity, frequency or duration, or compare specific types; it could not adjust for factors such as childhood family income; and its brief module captures only some kinds of childhood adversity. State response rates ranged from 30.6% to 59.0%.

If you or someone you know is thinking about suicide, call or text 988 to reach the 988 Suicide & Crisis Lifeline in the United States.

Sources

• Merrick MT, Ford DC, Ports KA, et al. "Vital Signs: Estimated Proportion of Adult Health Problems Attributable to Adverse Childhood Experiences and Implications for Prevention — 25 States, 2015–2017." MMWR 68(44). CDC.