Association of Childhood Adversity With Morbidity and Mortality in US Adults: A Systematic Review

Abstract

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.

Figure 1.. Population Attributable Fractions of Unhealthy Behaviors, Disease Markers, and Disease Outcomes Attributable to Childhood Adversity

Population attributable fractions are based on meta-analytic estimates of the associations between different levels of exposure to childhood adversity and each health outcome along with the US prevalence of exposure to childhood adversity. Two outcomes had unique exposures: inflammation (≥1 childhood adversity; population attributable fraction = 0.204) and metabolic syndrome (≥2 childhood adversities; population attributable fraction = 0.083). CA indicates childhood adversity.

Figure 2.. Annual US Deaths Attributable to Childhood Adversity

Annual deaths attributable to childhood adversity are based on meta-analytic estimates of the associations between different levels of exposure to childhood adversity and disease outcomes that are currently the leading causes of mortality in the US.

Figure 3.. US Cases of Unhealthy Behaviors and Disease Markers Attributable to Childhood Adversity

Cases of unhealthy behaviors and disease markers attributable to childhood adversity are based on meta-analytic estimates of the associations between different levels of exposure to childhood adversity and each health outcome.