Vital Signs

Estimated Proportion of Adult Health Problems Attributable to Adverse Childhood Experiences and Implications for Prevention — 25 States, 2015–2017

Melissa T. Merrick, PhD; Derek C. Ford, PhD; Katie A. Ports, PhD; Angie S. Guinn, MPH; Jieru Chen, PhD; Joanne Klevens, MD, PhD; Marilyn Metzler, MPH; Christopher M. Jones, PharmD, DrPH; Thomas R. Simon, PhD; Valerie M. Daniel, MPH; Phyllis Ottley, PhD; James A. Mercy, PhD


Morbidity and Mortality Weekly Report. 2019;68(44):999-1005. 

In This Article

Abstract and Introduction


Introduction: Adverse childhood experiences, such as violence victimization, substance misuse in the household, or witnessing intimate partner violence, have been linked to leading causes of adult morbidity and mortality. Therefore, reducing adverse childhood experiences is critical to avoiding multiple negative health and socioeconomic outcomes in adulthood.

Methods: Behavioral Risk Factor Surveillance System data were collected from 25 states that included state-added adverse childhood experience items during 2015–2017. Outcomes were self-reported status for coronary heart disease, stroke, asthma, chronic obstructive pulmonary disease, cancer (excluding skin cancer), kidney disease, diabetes, depression, overweight or obesity, current smoking, heavy drinking, less than high school completion, unemployment, and lack of health insurance. Logistic regression modeling adjusting for age group, race/ethnicity, and sex was used to calculate population attributable fractions representing the potential reduction in outcomes associated with preventing adverse childhood experiences.

Results: Nearly one in six adults in the study population (15.6%) reported four or more types of adverse childhood experiences. Adverse childhood experiences were significantly associated with poorer health outcomes, health risk behaviors, and socioeconomic challenges. Potential percentage reductions in the number of observed cases as indicated by population attributable fractions ranged from 1.7% for overweight or obesity to 23.9% for heavy drinking, 27.0% for chronic obstructive pulmonary disease, and 44.1% for depression.

Conclusions and implications for public health practice: Efforts that prevent adverse childhood experiences could also potentially prevent adult chronic conditions, depression, health risk behaviors, and negative socioeconomic outcomes. States can use comprehensive public health approaches derived from the best available evidence to prevent childhood adversity before it begins. By creating the conditions for healthy communities and focusing on primary prevention, it is possible to reduce risk for adverse childhood experiences while also mitigating consequences for those already affected by these experiences.


Healthy child development contributes to overall population health and prosperity. Decades of research have shown that exposure to violence in childhood (e.g., physical, sexual, or psychological) and witnessing potentially traumatic experiences in the home (e.g., intimate partner violence, mental illness, or substance misuse), collectively referred to as adverse childhood experiences, can have profound and lasting negative effects on health and social outcomes.[1–8] Given the connection between adverse childhood experiences and health, preventing these experiences is strategic for reducing several of the leading causes of adult morbidity and mortality.

Adverse childhood experiences are common and have important implications for health and well-being.[6,9] Whereas everyone is at risk for adverse childhood experiences, numerous studies have documented inequities in such experiences attributed to the historical, social, and economic environments in which some families live.[9–11]

Exposure to adverse childhood experiences can be traumatic, evoking toxic stress responses that have immediate and long-term adverse physiologic and psychologic impacts. These adverse childhood experiences can derail optimal health and development by altering gene expression, brain connectivity and function, immune system function, and organ function.[8] Adverse childhood experiences can also compromise development of healthy coping strategies, which can affect health behaviors, physical and mental health, life opportunities, and premature death.[1–8,12] Adverse childhood experiences have been linked to increased risk for alcohol and substance use disorders, suicide, mental health conditions, heart disease, other chronic illnesses, and health risk behaviors throughout life. Adverse childhood experiences have also been linked to reduced educational attainment, employment, and income, which directly and indirectly affect health and well-being.[1–8] At least five of the 10 leading causes of death have been associated with exposure to adverse childhood experiences, including several contributors to declines in life expectancy.[6,13]

Adverse childhood experiences are preventable.[14–16] Randomized controlled and matched-group trials have demonstrated 48%–52% reductions in rates of child abuse and neglect associated with preschool enrichment and early childhood home visitation programs.[14,15] Preventing adverse childhood experiences is critical to addressing multiple public health and social challenges and to improving the lives of children, families, and communities. To understand the potential impact of preventing adverse childhood experiences in reducing negative health and well-being outcomes, state survey data were used to estimate population attributable fractions representing potential percentage reductions in the number of observed cases of health conditions, health risk behaviors, and socioeconomic impacts.