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


Approximately three fifths of the adults among the 25-state study population experienced at least one type of adverse childhood experience, and approximately one in six reported experiencing four or more types of adverse childhood experiences. This study found that adverse childhood experiences are associated with leading causes of morbidity and mortality and with poor socioeconomic outcomes in adulthood. Persons reporting more types of adverse childhood experiences were at highest risk. These findings are consistent with those from similar analyses conducted in England, Europe, and North America[1,2] and suggest that preventing adverse childhood experiences might reduce occurrences of the outcomes examined, with potential reductions ranging from 1.7% (overweight or obesity) to 44.1% (depression). Given these findings, preventing adverse childhood experiences could have broad positive health, social, and economic impacts. For example, preventing adverse childhood experiences could potentially reduce the number of persons with coronary heart disease, the leading cause of death in the United States,[13] by up to 12.6%, representing a potential reduction of approximately 1.1 million cases of coronary heart disease for the 25 states analyzed. Applied to national estimates in 2017, this translates to up to 1.9 million cases of coronary heart disease, 2.5 million cases of overweight or obesity, 1.5 million incidences of high school noncompletion, and 21 million cases of depression that would have been potentially avoided by preventing adverse childhood experiences.[19]

Those who experienced four or more types of adverse childhood experiences accounted for a disproportionate share of the preventable fraction of every health and socioeconomic outcome measured. Although the prevalence of any type of adverse childhood experience was similar among men and women, the prevalence of four or more types of adverse childhood experiences was higher among women. The prevalence of adverse childhood experiences was also higher among persons aged 18–24 and 25–34 years, particularly the prevalence of four or more types of adverse childhood experiences, compared with other age groups. The higher risk among the younger groups could be due to differences across cohorts in risk, willingness to disclose, or ability to recall adverse childhood experiences. Increased mortality among those with higher adverse childhood experiences could also contribute to this pattern. Strategies to prevent adverse childhood experiences in the first place and to intervene with those who have been exposed to adverse childhood experiences might help to reduce prevalence of engaging in health risk behaviors in young adulthood and subsequent negative health outcomes. These strategies might also help to break the multigenerational cycle of adverse childhood experiences as these age groups are most likely to start families or raise children. Significant racial/ethnic inequities were also observed: AI/AN, blacks, and the Other racial/ethnic groups had substantially higher prevalences of four or more types of adverse childhood experiences, compared with whites. Communities could focus on reducing stressors these groups might face from living in underresourced neighborhoods and from historical and ongoing trauma caused by systemic racism or multigenerational poverty resulting from limited educational and economic opportunities.[14]

Depression, heavy drinking, smoking, lower educational attainment, lack of health insurance, and unemployment were significantly associated with adverse childhood experiences. Previous research has also documented the connection between adverse childhood experiences and substance use and suicide,[6] underscoring the importance of preventing adverse childhood experiences as a strategy for addressing the opioid overdose crisis, reducing the prevalence of suicide, and preventing leading causes of death in the United States. Prevention of adverse childhood experiences is possible with state and community efforts to build resilient families and communities, provide parental support to develop positive parenting and coping skills, and increase access to, and use of, comprehensive health services.[14,15]

The findings of this report are subject to at least six limitations. First, recall and social desirability biases might reduce accuracy of self-reported adverse childhood experiences, thereby underestimating the actual prevalence of adverse childhood experiences. Second, causality cannot be inferred from these cross-sectional data. Third, data were from 25 states and might not be generalizable to other states. Fourth, the data do not assess severity, frequency, or duration of adverse childhood experiences, nor do they contrast the effects of specific types of adverse childhood experiences. Fifth, it was not possible to control for factors that could affect both adverse childhood experiences and selected outcomes (e.g., family socioeconomic position during childhood). Finally, the BRFSS adverse childhood experience module is a brief public health surveillance instrument. As such, it identifies a limited set of adverse childhood experiences and not the full range of childhood adversities. Despite these limitations, the findings from this study can help multiple sectors, including clinicians, researchers, policymakers, and the public, appreciate the connections between cumulative exposure to adversity and mental, physical, and socioeconomic outcomes.

Fundamental to adverse childhood experience prevention is the creation of safe, stable, nurturing relationships and environments for all children and families. CDC's comprehensive approach to preventing adverse childhood experiences uses multiple strategies derived from the best available evidence.[14] These strategies emphasize early prevention and include 1) strengthening economic supports for families (e.g., earned income tax credits, family-friendly work policies); 2) promoting social norms that protect against violence and adversity (e.g., public education campaigns to support parents and positive parenting, bystander approaches to support healthy relationship behaviors); 3) ensuring a strong start for children (e.g., early childhood home visitation, high quality child care, preschool enrichment programs); 4) enhancing skills to help parents and youths handle stress, manage emotions, and tackle everyday challenges (e.g., social emotional learning programs, safe dating and healthy relationship skill programs, parenting skill and family relationship approaches); 5) connecting youths to caring adults and activities (e.g., mentoring and after school programs). The sixth strategy is intervening to lessen immediate and long-term harms through enhanced primary care to identify and address adverse childhood experience exposures with screening, referral, and support; victim-centered services; and advancement of trauma-informed care for children, youths, and adults with a history of adverse childhood experience exposures. This is important for reducing the consequences of adverse childhood experiences and for helping to protect the next generation of children from exposure to violence and other adverse experiences, such as witnessing substance misuse in their household. Multiple studies have documented that substantial reductions in adverse childhood experiences are possible and can have broad and sustained benefits.[14–16] For example, adverse childhood experience prevention strategies are associated with higher academic achievement and reductions in depression, suicidal behavior, arrest and incarceration rates, and substance use in adolescence and adulthood.[14]

Adverse childhood experiences can contribute to a large public health burden across multiple outcomes. Effective, comprehensive approaches to preventing adverse childhood experiences are available. States and communities can use data and resources such as CDC's Preventing Adverse Childhood Experiences (ACEs): Leveraging the Best Available Evidence[14] to better understand adverse childhood experiences in their locales, prioritize adverse childhood experience prevention, and improve the mental, physical, and social well-being of their populations over the lifespan.[14]