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Association of Childhood Adversity With Morbidity and Mortality in US AdultsA Systematic Review

Educational Objective
To estimate the contribution of childhood adversity (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).
1 Credit CME
Key Points

Question  To what degree does childhood adversity contribute to preventable causes of morbidity and mortality in the US?

Findings  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.

Meaning  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.


Importance  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.

Objective  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).

Evidence Review  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.

Findings  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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Article Information

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 (lucinda.grummitt@sydney.edu.au).

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.

Centers for Disease Control and Prevention. National Center for Health Statistics mortality data on CDC WONDER. Accessed April 23, 2020. https://wonder.cdc.gov/mcd.html
McGinnis  JM , Foege  WH .  Actual causes of death in the United States.   JAMA. 1993;270(18):2207-2212. doi:10.1001/jama.1993.03510180077038 PubMedGoogle ScholarCrossref
Mokdad  AH , Marks  JS , Stroup  DF , Gerberding  JL .  Actual causes of death in the United States, 2000.   JAMA. 2004;291(10):1238-1245. doi:10.1001/jama.291.10.1238 PubMedGoogle ScholarCrossref
Galea  S , Tracy  M , Hoggatt  KJ , Dimaggio  C , Karpati  A .  Estimated deaths attributable to social factors in the United States.   Am J Public Health. 2011;101(8):1456-1465. doi:10.2105/AJPH.2010.300086 PubMedGoogle ScholarCrossref
Galea  S .  An argument for a consequentialist epidemiology.   Am J Epidemiol. 2013;178(8):1185-1191. doi:10.1093/aje/kwt172 PubMedGoogle ScholarCrossref
Keyes  K , Galea  S .  What matters most: quantifying an epidemiology of consequence.   Ann Epidemiol. 2015;25(5):305-311. doi:10.1016/j.annepidem.2015.01.016 PubMedGoogle ScholarCrossref
McLaughlin  KA , Sheridan  MA , Lambert  HK .  Childhood adversity and neural development: deprivation and threat as distinct dimensions of early experience.   Neurosci Biobehav Rev. 2014;47:578-591. doi:10.1016/j.neubiorev.2014.10.012 PubMedGoogle ScholarCrossref
McLaughlin  KA , Greif Green  J , Gruber  MJ , Sampson  NA , Zaslavsky  AM , Kessler  RC .  Childhood adversities and first onset of psychiatric disorders in a national sample of US adolescents.   Arch Gen Psychiatry. 2012;69(11):1151-1160. doi:10.1001/archgenpsychiatry.2011.2277 PubMedGoogle ScholarCrossref
Green  JG , McLaughlin  KA , Berglund  PA ,  et al.  Childhood adversities and adult psychiatric disorders in the national comorbidity survey replication I: associations with first onset of DSM-IV disorders.   Arch Gen Psychiatry. 2010;67(2):113-123. doi:10.1001/archgenpsychiatry.2009.186 PubMedGoogle ScholarCrossref
Kessler  RC , McLaughlin  KA , Green  JG ,  et al.  Childhood adversities and adult psychopathology in the WHO World Mental Health Surveys.   Br J Psychiatry. 2010;197(5):378-385. doi:10.1192/bjp.bp.110.080499 PubMedGoogle ScholarCrossref
Dong  M , Giles  WH , Felitti  VJ ,  et al.  Insights into causal pathways for ischemic heart disease: adverse childhood experiences study.   Circulation. 2004;110(13):1761-1766. doi:10.1161/01.CIR.0000143074.54995.7F PubMedGoogle ScholarCrossref
Felitti  VJ , Anda  RF , Nordenberg  D ,  et al.  Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. the Adverse Childhood Experiences (ACE) Study.   Am J Prev Med. 1998;14(4):245-258. doi:10.1016/S0749-3797(98)00017-8 PubMedGoogle ScholarCrossref
Kalmakis  KA , Chandler  GE .  Health consequences of adverse childhood experiences: a systematic review.   J Am Assoc Nurse Pract. 2015;27(8):457-465. doi:10.1002/2327-6924.12215 PubMedGoogle ScholarCrossref
Brown  DW , Anda  RF , Tiemeier  H ,  et al.  Adverse childhood experiences and the risk of premature mortality.   Am J Prev Med. 2009;37(5):389-396. doi:10.1016/j.amepre.2009.06.021 PubMedGoogle ScholarCrossref
Chen  E , Turiano  NA , Mroczek  DK , Miller  GE .  Association of reports of childhood abuse and all-cause mortality rates in women.   JAMA Psychiatry. 2016;73(9):920-927. doi:10.1001/jamapsychiatry.2016.1786 PubMedGoogle ScholarCrossref
Puterman  E , Weiss  J , Hives  BA ,  et al.  Predicting mortality from 57 economic, behavioral, social, and psychological factors.   Proc Natl Acad Sci U S A. 2020;117(28):16273-16282. doi:10.1073/pnas.1918455117 PubMedGoogle ScholarCrossref
Kontis  V , Bennett  JE , Mathers  CD , Li  G , Foreman  K , Ezzati  M .  Future life expectancy in 35 industrialised countries: projections with a Bayesian model ensemble.   Lancet. 2017;389(10076):1323-1335. doi:10.1016/S0140-6736(16)32381-9 PubMedGoogle ScholarCrossref
McLaughlin  KA , DeCross  SN , Jovanovic  T , Tottenham  N .  Mechanisms linking childhood adversity with psychopathology: learning as an intervention target.   Behav Res Ther. 2019;118:101-109. doi:10.1016/j.brat.2019.04.008 PubMedGoogle ScholarCrossref
Kessler  RC . National comorbidity survey: adolescent supplement (NCS-A), 2001-2004 (ICPSR 28581). Accessed April 2, 2020. https://www.icpsr.umich.edu/web/HMCA/studies/28581
Kelsey  JL , Whittemore  AS , Evans  AS , Thompson  WD .  Methods in Observational Epidemiology (Monographs in Epidemiology and Biostatistics). 2nd ed. Oxford University Press; 1996.
Levin  ML .  The occurrence of lung cancer in man.   Acta Unio Int Contra Cancrum. 1953;9(3):531-541.PubMedGoogle Scholar
Northridge  ME .  Public health methods—attributable risk as a link between causality and public health action.   Am J Public Health. 1995;85(9):1202-1204. doi:10.2105/AJPH.85.9.1202 PubMedGoogle ScholarCrossref
Rockhill  B , Newman  B , Weinberg  C .  Use and misuse of population attributable fractions.   Am J Public Health. 1998;88(1):15-19. doi:10.2105/AJPH.88.1.15 PubMedGoogle ScholarCrossref
Centers for Disease Control and Prevention. Current cigarette smoking among adults in the United States. Accessed April 24, 2020. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm
Substance Abuse and Mental Health Services Administration. Key Substance Use and Mental Health Indicators in the United States: Results from the 2017 National Survey on Drug Use and Health. US Department of Health and Human Services; 2019.
Centers for Disease Control and Prevention. Table 57. participation in leisure-time aerobic and muscle-strengthening activities that meet the federal 2008 Physical Activity Guidelines for Americans among adults aged 18 and over, by selected characteristics: United States, selected years 1998–2018. National Center for Health Statistics; 2017.
Substance Abuse and Mental Health Services Administration. Results from the 2019 National Survey on Drug Use and Health: detailed tables. US Department of Health and Human Services; 2020.
Kreisel  KM , Spicknall  IH , Gargano  JW ,  et al.  Sexually transmitted infections among US women and men: prevalence and incidence estimates, 2018.   Sex Transm Dis. 2021;48(4):208-214. doi:10.1097/OLQ.0000000000001355 PubMedGoogle ScholarCrossref
Hales  CM , Carroll  MD , Fryar  CD , Ogden,CL. Prevalence of obesity and severe obesity among adults: United States, 2017–2018. NCHS Data Brief. 2020;(360):1-8. Medline:32487284.
Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey. Accessed April 30, 2020. https://www.cdc.gov/nchs/nhanes/index.htm
Moore  JX , Chaudhary  N , Akinyemiju  T .  Metabolic syndrome prevalence by race/ethnicity and sex in the United States, National Health and Nutrition Examination Survey, 1988-2012.   Prev Chronic Dis. 2017;14:E24. doi:10.5888/pcd14.160287 PubMedGoogle Scholar
Bellis  MA , Hughes  K , Ford  K , Ramos Rodriguez  G , Sethi  D , Passmore  J .  Life course health consequences and associated annual costs of adverse childhood experiences across Europe and North America: a systematic review and meta-analysis.   Lancet Public Health. 2019;4(10):e517-e528. doi:10.1016/S2468-2667(19)30145-8PubMedGoogle ScholarCrossref
Petruccelli  K , Davis  J , Berman  T .  Adverse childhood experiences and associated health outcomes: A systematic review and meta-analysis.   Child Abuse Negl. 2019;97:104127. doi:10.1016/j.chiabu.2019.104127PubMedGoogle Scholar
Hughes  K , Bellis  MA , Hardcastle  KA ,  et al.  The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis.   Lancet Public Health. 2017;2(8):e356-e366. doi:10.1016/S2468-2667(17)30118-4PubMedGoogle ScholarCrossref
Norman  RE , Byambaa  M , De  R , Butchart  A , Scott  J , Vos  T .  The long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis.   PLoS Med. 2012;9(11):e1001349. doi:10.1371/journal.pmed.1001349PubMedGoogle Scholar
Jakubowski  KP , Cundiff  JM , Matthews  KA .  Cumulative childhood adversity and adult cardiometabolic disease: A meta-analysis.   Health Psychol. 2018;37(8):701-715. doi:10.1037/hea0000637PubMedGoogle ScholarCrossref
Kuhlman  KR , Horn  SR , Chiang  JJ , Bower  JE .  Early life adversity exposure and circulating markers of inflammation in children and adolescents: A systematic review and meta-analysis.   Brain Behav Immun. 2020;86:30-42. doi:10.1016/j.bbi.2019.04.028PubMedGoogle ScholarCrossref
Baumeister  D , Akhtar  R , Ciufolini  S , Pariante  CM , Mondelli  V .  Childhood trauma and adulthood inflammation: a meta-analysis of peripheral C-reactive protein, interleukin-6 and tumour necrosis factor-α.   Mol Psychiatry. 2016;21(5):642-649. doi:10.1038/mp.2015.67PubMedGoogle ScholarCrossref
Wiss  DA , Brewerton  TD .  Adverse childhood experiences and adult obesity: a systematic review of plausible mechanisms and meta-analysis of cross-sectional studies.   Physiol Behav. 2020;223:112964. doi:10.1016/j.physbeh.2020.112964PubMedGoogle Scholar
Danese  A , Tan  M .  Childhood maltreatment and obesity: systematic review and meta-analysis.   Mol Psychiatry. 2014;19(5):544-554. doi:10.1038/mp.2013.54PubMedGoogle ScholarCrossref
Hemmingsson  E , Johansson  K , Reynisdottir  S .  Effects of childhood abuse on adult obesity: a systematic review and meta-analysis.   Obes Rev. 2014;15(11):882-893. doi:10.1111/obr.12216PubMedGoogle ScholarCrossref
Solmi  M , Köhler  CA , Stubbs  B ,  et al.  Environmental risk factors and nonpharmacological and nonsurgical interventions for obesity: An umbrella review of meta-analyses of cohort studies and randomized controlled trials.   Eur J Clin Invest. 2018;48(12):e12982. doi:10.1111/eci.12982PubMedGoogle Scholar
Wang  Y , Wu  B , Yang  H , Song  X .  The effect of childhood abuse on the risk of adult obesity.   Ann Clin Psychiatry. 2015;27(3):175-184.PubMedGoogle Scholar
Irish  L , Kobayashi  I , Delahanty  DL .  Long-term physical health consequences of childhood sexual abuse: a meta-analytic review.   J Pediatr Psychol. 2010;35(5):450-461. doi:10.1093/jpepsy/jsp118PubMedGoogle ScholarCrossref
Huang  H , Yan  P , Shan  Z ,  et al.  Adverse childhood experiences and risk of type 2 diabetes: A systematic review and meta-analysis.   Metabolism. 2015;64(11):1408-1418. doi:10.1016/j.metabol.2015.08.019PubMedGoogle ScholarCrossref
Angelakis  I , Gillespie  EL , Panagioti  M .  Childhood maltreatment and adult suicidality: a comprehensive systematic review with meta-analysis.   Psychol Med. 2019;49(7):1057-1078. doi:10.1017/S0033291718003823PubMedGoogle ScholarCrossref
Castellví  P , Miranda-Mendizábal  A , Parés-Badell  O ,  et al.  Exposure to violence, a risk for suicide in youths and young adults. A meta-analysis of longitudinal studies.   Acta Psychiatr Scand. 2017;135(3):195-211. doi:10.1111/acps.12679PubMedGoogle ScholarCrossref
Zatti  C , Rosa  V , Barros  A ,  et al.  Childhood trauma and suicide attempt: A meta-analysis of longitudinal studies from the last decade.   Psychiatry Res. 2017;256:353-358. doi:10.1016/j.psychres.2017.06.082PubMedGoogle ScholarCrossref
Devries  KM , Mak  JY , Child  JC ,  et al.  Childhood sexual abuse and suicidal behavior: a meta-analysis.   Pediatrics. 2014;133(5):e1331-e1344. doi:10.1542/peds.2013-2166PubMedGoogle ScholarCrossref
Ng  QX , Yong  BZJ , Ho  CYX , Lim  DY , Yeo  W-S .  Early life sexual abuse is associated with increased suicide attempts: An update meta-analysis.   J Psychiatr Res. 2018;99:129-141. doi:10.1016/j.jpsychires.2018.02.001PubMedGoogle ScholarCrossref
Bellis  MA , Hughes  K , Leckenby  N , Hardcastle  KA , Perkins  C , Lowey  H .  Measuring mortality and the burden of adult disease associated with adverse childhood experiences in England: a national survey.   J Public Health (Oxf). 2015;37(3):445-454. doi:10.1093/pubmed/fdu065 PubMedGoogle ScholarCrossref
Anda  RF , Felitti  VJ , Bremner  JD ,  et al.  The enduring effects of abuse and related adverse experiences in childhood. a convergence of evidence from neurobiology and epidemiology.   Eur Arch Psychiatry Clin Neurosci. 2006;256(3):174-186. doi:10.1007/s00406-005-0624-4 PubMedGoogle ScholarCrossref
Hughes  K , Ford  K , Kadel  R , Sharp  CA , Bellis  MA .  Health and financial burden of adverse childhood experiences in England and Wales: a combined primary data study of five surveys.   BMJ Open. 2020;10(6):e036374-e036374. doi:10.1136/bmjopen-2019-036374 PubMedGoogle ScholarCrossref
Medsafe. 2017 National health expenditures highlights. February 13, 2019. Accessed July 1, 2020. https://www.medsafe.com/blog/compliance-topics/2017-national-health-expenditures-highlights
Dubowitz  H , Feigelman  S , Lane  W , Kim  J .  Pediatric primary care to help prevent child maltreatment: the Safe Environment for Every Kid (SEEK) Model.   Pediatrics. 2009;123(3):858-864. doi:10.1542/peds.2008-1376 PubMedGoogle ScholarCrossref
Garner  AS , Shonkoff  JP ; Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; Section on Developmental and Behavioral Pediatrics.  Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health.   Pediatrics. 2012;129(1):e224-e231. doi:10.1542/peds.2011-2662 PubMedGoogle Scholar
Daelmans  B , Darmstadt  GL , Lombardi  J ,  et al; Lancet Early Childhood Development Series Steering Committee.  Early childhood development: the foundation of sustainable development.   Lancet. 2017;389(10064):9-11. doi:10.1016/S0140-6736(16)31659-2 PubMedGoogle ScholarCrossref
Olds  DL , Eckenrode  J , Henderson  CR  Jr ,  et al.  Long-term effects of home visitation on maternal life course and child abuse and neglect. fifteen-year follow-up of a randomized trial.   JAMA. 1997;278(8):637-643. doi:10.1001/jama.1997.03550080047038 PubMedGoogle ScholarCrossref
Olds  DL , Henderson  CR  Jr , Chamberlin  R , Tatelbaum  R .  Preventing child abuse and neglect: a randomized trial of nurse home visitation.   Pediatrics. 1986;78(1):65-78.PubMedGoogle Scholar
Prevent Child Abuse America. 2020 Federal policy agenda. Accessed August 10, 2020. https://preventchildabuse.org/resources/2020-federal-policy-agenda/
The Children’s Defense Fund. The state of America’s children 2020. Accessed August 10, 2020. https://www.childrensdefense.org/the-state-of-americas-children-2020/
Martin M, Erney R, Citrin A, Reeves R. 20 Years of TANF: Opportunities to better support families facing multiple barriers. Accessed June 17, 2021. https://cssp.org/wp-content/uploads/2018/08/TANF-at-20.pdf
Dubowitz  H .  The Safe Environment for Every Kid (SEEK) Model: helping promote children’s health, development, and safety: SEEK offers a practical model for enhancing pediatric primary care.   Child Abuse Negl. 2014;38(11):1725-1733. doi:10.1016/j.chiabu.2014.07.011 PubMedGoogle ScholarCrossref
McLaughlin  KA , Weissman  D , Bitrán  D .  Childhood adversity and neural development: a systematic review.   Annu Rev Dev Psychol. 2019;1(1):277-312. doi:10.1146/annurev-devpsych-121318-084950 PubMedGoogle ScholarCrossref
Berens  AE , Jensen  SKG , Nelson  CA  III .  Biological embedding of childhood adversity: from physiological mechanisms to clinical implications.   BMC Med. 2017;15(1):135. doi:10.1186/s12916-017-0895-4 PubMedGoogle ScholarCrossref
Colich  NL , Rosen  ML , Williams  ES , McLaughlin  KA .  Biological aging in childhood and adolescence following experiences of threat and deprivation: a systematic review and meta-analysis.   Psychol Bull. 2020;146(9):721-764. doi:10.1037/bul0000270 PubMedGoogle ScholarCrossref
Hardcastle  K , Bellis  MA , Ford  K , Hughes  K , Garner  J , Ramos Rodriguez  G .  Measuring the relationships between adverse childhood experiences and educational and employment success in England and Wales: findings from a retrospective study.   Public Health. 2018;165:106-116. doi:10.1016/j.puhe.2018.09.014 PubMedGoogle ScholarCrossref
Jimenez  ME , Wade  R  Jr , Lin  Y , Morrow  LM , Reichman  NE .  Adverse experiences in early childhood and kindergarten outcomes.   Pediatrics. 2016;137(2):e20151839. doi:10.1542/peds.2015-1839 PubMedGoogle Scholar
Miller  AB , Sheridan  MA , Hanson  JL ,  et al.  Dimensions of deprivation and threat, psychopathology, and potential mediators: a multi-year longitudinal analysis.   J Abnorm Psychol. 2018;127(2):160-170. doi:10.1037/abn0000331 PubMedGoogle ScholarCrossref
Andersen  SL , Teicher  MH .  Desperately driven and no brakes: developmental stress exposure and subsequent risk for substance abuse.   Neurosci Biobehav Rev. 2009;33(4):516-524. doi:10.1016/j.neubiorev.2008.09.009 PubMedGoogle ScholarCrossref
Edalati  H , Krank  MD .  Childhood maltreatment and development of substance use disorders: a review and a model of cognitive pathways.   Trauma Violence Abuse. 2016;17(5):454-467. doi:10.1177/1524838015584370 PubMedGoogle ScholarCrossref
Keyes  KM , Eaton  NR , Krueger  RF ,  et al.  Childhood maltreatment and the structure of common psychiatric disorders.   Br J Psychiatry. 2012;200(2):107-115. doi:10.1192/bjp.bp.111.093062 PubMedGoogle ScholarCrossref
Edwards  VJ , Holden  GW , Felitti  VJ , Anda  RF .  Relationship between multiple forms of childhood maltreatment and adult mental health in community respondents: results from the adverse childhood experiences study.   Am J Psychiatry. 2003;160(8):1453-1460. doi:10.1176/appi.ajp.160.8.1453 PubMedGoogle ScholarCrossref
Purewal Boparai  SK , Au  V , Koita  K ,  et al.  Ameliorating the biological impacts of childhood adversity: a review of intervention programs.   Child Abuse Negl. 2018;81:82-105. doi:10.1016/j.chiabu.2018.04.014 PubMedGoogle ScholarCrossref
Berkowitz  SJ , Stover  CS , Marans  SR .  The child and family traumatic stress intervention: secondary prevention for youth at risk of developing PTSD.   J Child Psychol Psychiatry. 2011;52(6):676-685. doi:10.1111/j.1469-7610.2010.02321.x PubMedGoogle ScholarCrossref
Cohen  JA , Mannarino  AP , Murray  LK , Igelman  R .  Psychosocial interventions for maltreated and violence-exposed children.   J Soc Issues. 2006;62(4):737-766. doi:10.1111/j.1540-4560.2006.00485.x Google ScholarCrossref
Shrier  I , Pang  M .  Confounding, effect modification, and the odds ratio: common misinterpretations.   J Clin Epidemiol. 2015;68(4):470-474. doi:10.1016/j.jclinepi.2014.12.012 PubMedGoogle ScholarCrossref
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