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To what degree does childhood adversity contribute to preventable causes of morbidity and mortality in the US?
In this systematic review including 19 meta-analyses with a total of 20 654 832 participants, exposure to childhood adversity accounted for approximately 439 072 deaths annually across various health outcomes, with the largest contributions to deaths related to heart disease (219 470), cancer (82 888), and chronic lower respiratory disease (66 702). More than 1 in 3 suicide attempts were attributable to childhood adversity.
Results of this systematic review suggest that childhood adversity is a major contributing factor to early mortality; reduction of adversity exposure and early intervention on intermediate pathways that contribute to disease outcomes may promote health and longevity at the population level.
Childhood adversity (CA) is a powerful determinant of long-term physical and mental health that is associated with elevated risk for chronic disease and psychopathology. However, the degree to which CA contributes to mortality as a preventable driver of ill-health and death is unknown.
To estimate the contribution of CA to health behaviors, including smoking and sedentary behavior, as well as the annual mortality attributable to CA in the US through influences on leading causes of death (eg, cardiovascular disease).
For this systematic review, the PsycINFO and MEDLINE databases were searched on November 15, 2019. The databases were searched for publications from inception (1806 for PsycINFO, 1946 for MEDLINE) to November 15, 2019. Meta-analyses of the associations between CA and morbidity outcomes were included. The population attributable fraction (PAF) was calculated from these associations along with the estimated US prevalence of CA. The PAF was then applied to the number of annual deaths associated with each cause of death to estimate the number of deaths that are attributable to CA. Additionally, the PAF was applied to the incidence of health behaviors to derive the number of cases attributable to CA. Exposure to 1 or more experiences of adversity before the age of 18 years was analyzed, including abuse, neglect, family violence, and economic adversity.
A total of 19 meta-analyses with 20 654 832 participants were reviewed. Childhood adversity accounted for approximately 439 072 deaths annually in the US, or 15% of the total US mortality in 2019 (2 854 838 deaths), through associations with leading causes of death (including heart disease, cancer, and suicide). In addition, CA was associated with millions of cases of unhealthy behaviors and disease markers, including more than 22 million cases of sexually transmitted infections, 21 million cases of illicit drug use, 19 million cases of elevated inflammation, and more than 10 million cases each of smoking and physical inactivity. The greatest proportion of outcomes attributable to CA were for suicide attempts and sexually transmitted infections, for which adversity accounted for up to 38% and 33%, respectively.
Conclusions and Relevance
The results of this systematic review suggest that CA is a leading contributor to morbidity and mortality in the US and may be considered a preventable determinant of mortality. The prevention of CA and the intervention on pathways that link these experiences to elevated disease risk should be considered a critical public health priority.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Accepted for Publication: May 10, 2021.
Published Online: October 4, 2021. doi:10.1001/jamapediatrics.2021.2320
Corresponding Author: Lucinda Rachel Grummitt, BA, National Health and Medical Research Council Centre of Research Excellence in PREMISE, The Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Jane Foss Russell Building, Level 6, Sydney, NSW 2006, Australia (email@example.com).
Author Contributions: Ms Grummitt and Mr Kreski had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Kreski, Keyes, McLaughlin.
Acquisition, analysis, or interpretation of data: Grummitt, Kreski, Kim, Platt.
Drafting of the manuscript: Grummitt, Kreski, Kim.
Critical revision of the manuscript for important intellectual content: Kreski, Platt, Keyes, McLaughlin.
Statistical analysis: Grummitt, Kreski, Platt, Keyes.
Administrative, technical, or material support: Keyes, McLaughlin.
Supervision: Keyes, McLaughlin.
Conflict of Interest Disclosures: Dr Keyes reported receiving personal fees from National Prescription Opioid Litigation K and testifying as an expert witness in litigation against opioid manufacturers and other defendants outside the submitted work. No other disclosures were reported.
Funding/Support: The current study was funded by grants R01-MH103291, R01-MH106482, and R37-MH119194 from the National Institute of Mental Health (Dr McLaughlin).
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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