REVIEW

Health consequences of adverse childhood experiences:

A systematic review
Karen A. Kalmakis, PhD, FNP-BC (Associate Professor) & Genevieve E. Chandler, PhD, RN (Associate Professor)
University of Massachusetts Amherst, Amherst, Massachusetts

Keywords
Abuse; childhood; primary care; review;
evidence-based practice; family history;
screening.
Correspondence
Karen Kalmakis, PhD, FNP-BC, College of
Nursing, University of Massachusetts Amherst,
222 Skinner Hall, 651 North Pleasant Street,
Amherst, MA 01003. Tel: 413-577-4763;
Fax: 413-577-2550;
E-mail: kalmakis@nursing.umass.edu
Received: 16 January 2014;
accepted: 17 April 2014
doi: 10.1002/2327-6924.12215

Abstract
Purpose: Adverse childhood experiences (ACEs) have been associated with negative health outcomes, but the evidence has had limited application in primary
care practice. The purpose of this study was to systematically review the research
on associations between ACEs and adult health outcomes to inform nurse practitioners (NPs) in primary care practice.
Data sources: The databases PubMed, CINAHL, PsycINFO, and Social
Abstracts were searched for articles published in English between 2008 and 2013
using the search term adverse childhood experiences. Forty-two research articles were included in the synthesis. The evidence was synthesized and is reported
following the preferred reporting items for systematic reviews and meta-analysis
procedure (PRISMA).
Conclusions: ACEs have been associated with health consequences including
physical and psychological conditions, risk behaviors, developmental disruption,
and increased healthcare utilization. Generalization of the results is limited by
a majority of studies (41/42) measuring childhood adversity using self-report
measures.
Implications for practice: NPs are encouraged to incorporate assessment of
patients childhood history in routine primary care and to consider the evidence
that supports a relationship between ACEs and health. Although difficult, talking
about patients childhood experiences may positively influence health outcomes.

Individuals with a history of adverse childhood experiences (ACEs) have a greater risk of physical and
psychological illness later in life (Afifi et al., 2008; Felitti
et al., 1998) and are more likely to engage in several
health-risk behaviors (Dube, Cook, & Edwards, 2010;
Ford et al., 2011). The prevalence of ACE in the United
States is estimated to be 60% of the population (Centers
for Disease Control and Prevention, 2010). Despite the
mounting evidence supporting negative health consequences of ACE, primary care providers continue to treat
patients for a myriad of health problems without knowledge of their childhood history. For example, fewer than
one third of primary practice providers in Massachusetts
regularly screened patients for childhood adversity to
identify and intervene to prevent the health consequences
of ACE (Weinreb et al., 2010). With 76% of the 171,000
nurse practitioners (NPs) in the United States practicing
in primary care settings (American Association of Nurse
Practitioners, 2013), the problem of childhood adversity,


C 2015 American Association of Nurse Practitioners

and its effect on health, must be considered. The objective

of this study was to systematically review the research
on associations between ACEs and negative adult health
outcomes to inform NPs in primary care practice.

Rationale
The clinical impact of ACE first came to light in a
follow-up study of morbidly obese individuals who had
lost >100 pounds (Felitti & Williams, 1998). Those who
regained their weight within 18 months were significantly more likely than those who maintained their
weight loss to have a history of major childhood emotional trauma (Felitti & Williams, 1998). These patients
reported feeling protected by their obesity, less noticed,
and therefore safer from further harm as overweight individuals (Felitti, Jakstis, Pepper, & Ray, 2010). This finding led to a collaboration between the Centers for Disease Control and Prevention and Kaiser Permanentes

Health consequences of adverse childhood experiences

Department of Preventive Medicine to investigate the effects of ACE on health outcomes (Dube et al., 2009). The
multitude of studies that followed, now known as the ACE
studies, found that ACE such as childhood physical, sexual, or emotional abuse as well as household dysfunction
increased the risk of health problems in adulthood (Brown
et al., 2009; Dube et al., 2009; Felitti et al., 1998; Greenfield & Marks, 2009).
The term ACE has been used interchangeably
with terms such as childhood maltreatment (Corso,
Edwards, Fang, & Mercy, 2008) and childhood trauma
(Heitkemper, Cain, Burr, Jun, & Jarrett, 2011). Descriptors
such as sexual abuse, physical abuse, verbal threats, and
living with alcoholic parents are used to describe forms of
ACE. The concept of ACE has been clarified as childhood
events, varying in severity and often chronic, occurring
within a childs family or social environment that cause
harm or distress, thereby disrupting the childs physical
or psychological health and development (Kalmakis &
Chandler, 2014). ACEs have been associated with chronic
health conditions, risky health behaviors, developmental
disruptions, and increased healthcare utilization.

The link between childhood adversity and health

The experience of multiple, chronic traumatic events,
such as abuse and neglect during childhood affect brain
development by overstimulating the autonomic nervous
system (Pervanidou & Chrousos, 2007) and dysregulating
the hypothalamicpituitaryadrenal axis (Trickett, 2010).
Short-term dysregulation of these systems results in physical and behavioral changes as the body adapts to the stressor. However, prolonged stimulation of these systems may
result in stress system disorders, such as allostatic load (a
shift away from allostasis or homeostasis; McEwen, 2007).
The condition of allostatic load is believed to be responsible for physical and psychiatric diseases as the individual
ages (McEwen, 2007).
With the growing evidence that negative health outcomes follow ACE, it would be appropriate, and even necessary for NPs in primary care practice to screen individuals for ACE. However, this evidence has not been incorporated into practice guidelines. For example, a recent article
on obesity management did not mention screening obese
patients for a history of ACE (Meires & Christie, 2011)
despite evidence that ACE is related to obesity (Dube
et al., 2010). Clinical guidelines for diagnosing and managing obesity also do not recommend that providers ask
about ACE, but rather that NPs consider referral for psychosocial concerns (Michigan Quality Improvement Consortium, 2011). Similarly, the guidelines for irritable bowel
syndrome (IBS; National Collaborating Centre for Nursing and Supportive Care, 2008), which has been related to
2

K. A. Kalmakis & G. E. Chandler

ACE (Heitkemper et al., 2011), do not recommend screening for childhood adversity. In fact, the guidelines recommend referral for psychological treatment only after
12 months of pharmacological treatment measures have
failed (National Collaborating Centre for Nursing and Supportive Care, 2008). This systematic review of research on
health outcomes of ACE is intended to educate and raise
awareness among NPs.

Method
The healthcare literature in the World Wide Web
databases PubMed, CINAHL, PsycINFO on ACE was systematically searched using the main search term adverse
childhood experiences and similar terms, for example,
child maltreatment, child trauma, and child misfortune. Articles were included according to these criteria: research studies on the association between ACE and
health outcomes in adults (18 years old); health outcomes were physical (e.g., migraines), psychiatric (e.g.,
depression), health-risk behaviors (e.g., smoking), developmental disruption (e.g., homelessness), and healthcare
utilization (e.g., prescription drug use); published in peerreviewed journals; sampling adult U.S. populations; and
written in English from January 2008 to 2013. Articles
were excluded if studies examined the effect of only one
specific form of childhood adversity on health, for example, sexual abuse or emotional neglect alone. An exception
to these criteria was the original ACE study (Felitti et al.,
1998), which was included although it predated the search
criteria because it provided a dataset used in several subsequent studies. The articles were analyzed and results are
reported using the preferred reporting items for systematic
reviews and meta-analysis (PRISMA) method for systematic reviews (Moher, Liberati, Tetzlaff, & Altman, 2009).

Data sources
Of 1565 articles on health outcomes following ACE
identified in the initial search, 42 were included in the
synthesis (Figure 1). The two authors independently
reviewed each source to extract data on authors, publication dates, study sample, methods, forms of childhood adversity, and health outcomes. The authors met
on several occasions to analyze, discuss, and organize the
findings.

Results
Of the 42 research studies fitting the inclusion and
exclusion criteria, 10 reported on data from a health
maintenance organization (HMO) database of individuals
who received recent health exams in California, Forty-one
studies measured ACE by adult participants retrospective
self-report, with 20 of 41 studies using the self-report

Health consequences of adverse childhood experiences

1,565 records identified by

database searches

Eligibility

876 records screened

ACE instrument (Felitti et al., 1998), three of 41 studies

using the Conflict Tactics Scale (CTS; Straus, Hamby,
Boney-McCoy, & Sugarman, 1996), and the remaining
studies using various other self-report instruments. One
study gathered ACE data from official child services and
court records as opposed to self-report (Topitzes, Mersky,
& Reynolds, 2010). Health consequences were assessed by
various instruments, which are addressed in the discussion
for each category.
Study samples ranged from 36 (De Ravello, Abeita, &
Brown, 2008) to 68,505 (Jun et al., 2008) and included
men only, women only, and both genders. Samples were
obtained from several populations including military personnel (LeardMann, Smith, & Ryan, 2010), incarcerated
women (De Ravello et al., 2008), and HMO patients
(Anda, Brown, Felitti, Dube, & Giles, 2008; Brown et al.,
2009). The majority of studies (37/42) used a correlational
design, with individuals reporting no ACE as controls.
Four studies used matched controls (Benedetti et al.,
2011; Corso et al., 2008; Douglas et al., 2010; Heitkemper
et al., 2011), and one sampled couples (Cunradi, Todd,
Duke, & Ames, 2009). Among the studies sampling
general populations of men and women, the percentage of
respondents who reported experiencing 1 ACE ranged
from 46% (Dube et al., 2010) to 64% (Anda, Brown,
Dube et al., 2008).
To manage the data during analysis, the study results
were divided into five health consequence categories:
physical health conditions (11), psychiatric health conditions (12), health-risk behaviors (12), developmental disruption (4), and healthcare utilization (3) (Tables 15).
The categories were chosen to assist in the presentation

789 records excluded

87 articles assessed for

eligibility

35 articles excluded by
criteria

42 articles included in
synthesis

Included

Figure 1 Systematic process for article selection.

1 additional record identified

through other sources

876 records after duplicates removed

Screening

Identification

K. A. Kalmakis & G. E. Chandler

Table 1 Association of adverse childhood experiences with physical health

conditions
First author

Year

Sample

Anda
Anda
Brown
Chapman
Chapman
Dube

2008
2010
2009
2013
2011
2009

15,472
17,337a
17,337a
25,810
17,337a
15,357a

Dube
Felitti

2010
1998

5378
9508a

Greeneld

2009

1745

Heitkemper
Poon

2010
2011

72
877

Health outcome
Increased risk of COPD
Frequent headaches
Death before age 65
Sleep disturbance
Sleep disturbance
Hospitalization for autoimmune
disease
Obesity, smoking, and poor health
Multiple diseases and risk factors
(e.g., cardiac disease, COPD)
Self-perceived health and select
chronic medical conditions
Sleep disturbances in women with IBS
Sleep problems

Note. a COPD, chronic obstructive pulmonary disease; IBS, irritable bowel

syndrome.
b
Sample data from 1995 to 1997 ACE study on California HMO members.

of the findings, but are not mutually exclusive. Indeed,

aspects of health are often interconnected. Psychological
health influences physical health and health-risk behavior, which, in turn, affect healthcare costs.

Physical health conditions

ACE was associated with physical diseases among a
large cohort of members of a California HMO (Felitti
et al., 1998). In this study, ACE was measured using a
3

Health consequences of adverse childhood experiences

K. A. Kalmakis & G. E. Chandler

Table 2 Association of adverse childhood experiences with psychiatric

health conditions

Table 3 Association of adverse childhood experiences with health-risk

behaviors

First author

First author

Year

Sample

2008

5692

Benedetti

2011

40

Chung
Douglas

2008
2010

1476
2510

Green

2010

9282

Leardmann
Lentz

2010
2010

8391
24,326

Lu

2008

254

Nurius
Shevlin

2012
2011

7444
2353

Waite
Wu

2012
2010

796
804

Health outcome
Suicidal ideation,
psychopathology
Schizophrenia,
emotional reactivity
Depression in women
Mood and anxiety
disorders
Anxiety, disruptive
behavior, substance
use disorders
PTSD
Schizotypal
personality disorder
Multiple psychiatric
problems,
substance misuse,
retraumatized in
adulthood,
homelessness
Mental health issues
Visual and auditory
hallucinations
Depression
PTSD, substance
misuse, smoking,
sex work, STI,
homelessness, and
multiple physical
health problems

Note. PTSD, posttraumatic stress disorder; STI, sexually transmitted

infection.

self-report scale, and health consequences were obtained

from patient records. This relationship has been confirmed
and expanded in subsequent research (Table 1). ACE
has been linked to several physical health consequences
across many body systems, including cardiovascular
disease (Felitti et al., 1998), chronic lung disease (Anda,
Brown, Dube et al., 2008), headaches (Anda, Tietjen,
Schulman, Felitti, & Croft, 2010), autoimmune disease
(Dube et al., 2009), and sleep disturbances (Chapman
et al., 2013). ACEs were also associated with early death
(Brown et al., 2009) and obesity, smoking and general poor heath (Dube, Cood, & Edwards, 2010). Four
studies found a significant relationship between ACE
and sleep disturbances. One found the relationship was
modestly attenuated by social support and emotional
distress (Poon & Knight, 2011), another by frequent
mental distress and smoking (Chapman et al., 2013).
Women with IBS with histories of ACE reported increased
disturbance in sleep as compared to women with IBS who
did not report ACE histories (Heitkemper et al., 2011).
4

Year

Sample

Brown

2010

17,337

Chung

2010

1476

Cunradi

2008

848

Ford
Hahm

2011
2010

25,809
7576

Jun
Mingione
Rothman
Sharp
Strine

2008
2012
2008
2012
2012

68,505
256
3592
598
7279a

Timko
Topitzes

2008
2010

6942
1125

Health outcome
Smoking, increased
risk of lung cancer
Risk behavior during
pregnancy: drinking,
smoking, illicit drug
use
Intimate partner
violence
Smoking
Suicidalilty,
delinquent, and
sexual risk behavior
Smoking
Smoking
Early-age alcohol use
Substance abuse
Alcohol abuse and
psychological
distress
Binge drinking
Smoking

Sample data from 1995 to 1997 ACE study on California HMO members.

Table 4 Association of
developmental disruption

adverse

First author

Year

Sample size

Health outcome

Bleil
De Ravello

2011
2008

259
36

Keeshin
Tsai

2011
2011

64
738

Repeat abortions (>2)

Suicide attempts,
intimate partner
violence
Homelessness
Earlier homelessness,
severity of drug
abuse

childhood

experiences

with

Table 5 Association of adverse childhood experiences with healthcare

utilization
First author

Year

Sample

Health outcome

Anda

2008

15,033a

Cannon

2010

3568

Corso

2008

6168a

Increased use
prescription
medications
Physical and mental
health utilization,
depression, intimate
partner violence
Quality of life as
measured by
healthcare
utilization

Sample data from 1995 to 1997 ACE study on California HMO members.

K. A. Kalmakis & G. E. Chandler

Furthermore, problems falling or staying asleep were

found to increase as ACE score increased (Chapman et al.,
2011).
Health outcomes were assessed by various measures,
including self-reported health conditions (Anda et al.,
2010; Dube et al., 2010), data from medical records
(Felitti et al., 1998), and observation (Heitkemper et al.,
2011). In all cases, significant associations were found between ACE and negative physical health consequences.

Psychological health consequences

As for physical conditions, psychological health outcomes were shown to have strong associations with
ACE. ACEs were associated with lifelong mental health
and addiction issues such as depression, posttraumatic
stress disorder (PTSD), and substance abuse (Table 2).
Study samples in this category were diverse and varied
from low-income pregnant women (Chung, Mathew, Elo,
Coyne, & Culhane, 2008) to individuals with schizophrenia (Benedetti et al., 2011). In each study, ACE was
significantly correlated with negative mental health consequences such as depression (Chung et al., 2008), anxiety (Green et al., 2010), PTSD (Green et al., 2010), as well
as substance dependence partially mediated by mood and
anxiety disorders (Douglas et al., 2010). Study outcomes
were measured by established instruments. For example,
the Composite International Diagnostic Interview (CIDI;
Afifi et al., 2008), the Center for Epidemiological Studys
Depression Scale (Chung et al., 2008), and the Alcohol
Use Disorders and Associated Disabilities Scale IV (AUDADIS IV; Lentz, Robinson, & Bolton, 2010). In addition
to these psychological instruments, one study measured
emotional reactivity with the use of magnetic resonance
imaging (Benedetti et al., 2011).
In addition to studies linking ACE to mental health
outcomes, several studies identified a correlation between
ACE and suicidal ideation/attempts. For example, a
nationwide study found that childhood physical and
sexual abuse, as well as witnessing domestic violence,
significantly impacted on suicide attempts; the authors
concluded that preventing ACE in this sample would have
decreased suicide attempts by 50% for women and 33%
for men (Afifi et al., 2008). All reviewed studies on the
association between ACE and psychiatric or substance
abuse conditions noted the pernicious effect of childhood
maltreatment on mental health well into adulthood.

Health-risk behavior
Several studies in our review found that individuals
reporting a history of ACE engaged in various health-risk
behaviors (Table 3). These individuals were more likely to

Health consequences of adverse childhood experiences

smoke (Ford et al., 2011; Topitzes et al., 2010), binge drink

(Timko, Sutkowi, Pavao, & Kimerling, 2008), and abuse
substances (Sharp, Peck, & Hartsfield, 2012). Furthermore,
individuals with ACE histories were more likely than individuals without ACE histories, to engage in risky behavior
at susceptible times in their development, such as during
pregnancy and adolescence (Chung et al., 2010; Rothman,
Edwards, Heeren, & Hingson, 2008). As with psychiatric
outcomes, health-risk behaviors were measured by established self-report instruments, for example, intimate
partner violence was measured by the CTS and alcohol use
by the Alcohol Use Disorders Identification Test (AUDIT;
Cunradi et al., 2009). In one study, outcome data were obtained from health and death records (Brown et al., 2010).

Developmental disruption
We created a category for health outcomes related
to healthy development, as these outcomes are neither physical nor psychological, but do impact health
(Table 4). For example, homelessness (Keeshin &
Campbell, 2011) affects sleep patterns, nutrition, and sanitation, all of which impact health. Chronically homeless
individuals who reported a history of childhood adversity
experienced homelessness at an earlier age and worse
substance abuse than those with less childhood adversity
(Tsai, Edens, & Rosenheck, 2011). Three of the four studies in this category sampled from vulnerable populations,
including the homeless and incarcerated (De Ravello
et al., 2008; Keeshin & Campbell, 2011; Tsai et al., 2011).
In studies on developmental disruptions such as repeated
abortion (Bleil et al., 2011) and adult relationship violence
(De Ravello et al., 2008), women who reported having
experienced ACE were more likely to have repeated
abortions and to experience intimate partner violence,
respectively, than women without such a history.

Healthcare utilization and cost

ACE also impacted individuals healthcare utilization
and costs (Table 5). ACE was associated with more prescription medications in two studies of male and female
patients; as the number of ACE increased, the risk of having been prescribed multiple classes of pharmaceuticals
also increased (Anda, Brown, Felitti et al., 2008). ACE
was associated with decreased self-assessed quality of
life and high healthcare utilization (Corso et al., 2008).
Furthermore, healthcare costs attributed to ACE have
been linked to reduced health and functioning, family
stress and dysfunction, societal economic losses because
of disability, and financial burdens on the healthcare
system (Afifi et al., 2008).
5

Health consequences of adverse childhood experiences

Discussion
The results of this systematic review demonstrate that
ACE is significantly associated with negative health consequences in adults. In addition, the reviewed studies provide insight into the factors influencing this association.
First, the research supports a cumulative effect of ACE on
health. All studies found that the more adverse experiences a child had, the greater the effect on physical and
psychiatric health as well as behavior (e.g., Dube et al.,
2010; Felitti et al., 1998; Ford et al., 2011; Jun et al., 2008).
With regard to severity, certain forms of ACE may have a
greater influence on adult health outcomes. For example,
parental mental illness, physical and emotional abuse were
found to be significantly associated with all psychiatric
outcomes measured, while parental divorce and imprisonment were associated with only one outcome (Nurius,
Logan-Greene, & Green, 2012). Witnessing violence in the
home was significantly associated with all psychiatric outcomes (Afifi et al., 2008). Additionally, sexual abuse had
the strongest association with sexual risk behavior, delinquency, and suicidatlity when compared to other combinations of ACE (Hahm, Lee, Ozonoff, & Van Wert, 2010).
The studies reviewed did not consistently report any one
adversity as most severe and another as least, but there
were indications that severity was important to the health
consequences of ACE, and that the type of ACE most associated with any given outcome varies.
In addition to the effect of accumulation and severity
of ACE, its timing was found to be significantly associated
with negative health outcomes (Jun et al., 2008) In their
study, Jun et al. (2008) found that abuse during adolescence appeared to be a more important risk factor for early
initiation of smoking among girls when compared to abuse
that occurred in early childhood.
The modifying effect of social and emotional support on
health consequences of ACE is not established. Although
pregnant women were less likely to have symptoms of depression if they experienced a positive maternal relationship (Chung et al., 2008), having a close relationship with
a parent or adult was not a significant modifier of the association between ACE and smoking in a second study
(Mingione, Heffner, Blom, & Anthenelli, 2012). The possible modifiers of the relationship between ACE and adult
health represent an area for further nursing research.

Signicance to nursing
Clinical practice. The nursing profession cannot
ignore the overwhelming evidence for the association
between ACE and negative health consequences. When
obtaining health histories from patients, nurses should
be aware of and inquire about ACE. This particularly
6

K. A. Kalmakis & G. E. Chandler

applies to patients who engage in risky behavior, or

have lifestyle-related disease such as obesity and heart
disease, which have been associated with ACE. Asking about ACE has been shown to facilitate disclosure
(McGregor, Glover, Gautam, & Julich, 2010; Waite,
Gerrity, & Arango, 2010). Nurses who do not ask about
ACE as part of a full history assessment are overlooking
an important risk factor for many health problems and
an opportunity to interrupt disease progression. In fact,
it may be argued that in light of such compelling evidence for the significant impact of childhood adversity on
health, it is unethical not to ask about it (Becker-Blease &
Freyd, 2006). However, there are barriers to asking about
ACE in clinical practice. In a cross-sectional survey of primary care physicians, researchers found that the most frequently reported barriers to asking about ACE were (a)
not enough time to evaluate or counsel patients who report ACE (91.9%), (b) not enough time to ask about ACE
(89.0%), and (c) competing primary care recommendations (65.7%; Weinreb et al., 2010).
When asking patients about ACE, a safe relational
environment is recommended (Read, Hammersley, &
Rudegeair, 2007). Because NPs in primary practice often
have an established ongoing relationship of trust with
their patients, NPs are well suited to ask about childhood
adversity. Providers skilled in using a client-centered approach can normalize the experience, reduce shame, and
facilitate a safe, comfortable environment in which the
patient can disclose sensitive histories (McGregor et al.,
2010). Screening should generate an important dialogue
with patients, asking an open-ended question about a
patients childhood during an annual well visit, is a good
start. For example, the NP may say, Please tell me about
your childhood (Waite et al., 2010). Alternatively, nurses
may adopt the ACE (Dube, Williamson, Thompson, Felitti,
& Anda, 2004) or similar questionnaire into their practice.
If questionnaires are used, providers must remember to
review the responses as part of the patient visit and engage
in a therapeutic dialogue with patients who report ACE.
Following disclosure of ACE, the NPs response is important. A sensitive response expressing sadness for the early
experience and a desire to help followed by a question
of how their childhood experiences have affected their
health is suggested (Felitte et al., 1998). Then invite the
patient to share more about their experience and listen,
patients may find talking about ACE beneficial. Lastly, the
NP should take a few minutes to explain the evidence that
has linked ACE and health. Patients are often not aware of
the health consequences of their childhood experiences.
Understanding of the association may influence their
decision to follow recommended mental health referrals.
It is essential that NPs become knowledgeable about appropriate counseling services in their area and offer to refer

K. A. Kalmakis & G. E. Chandler

patients (Read et al., 2007; Sutherland, Fontenot, & Fantasia, 2014). Currently there are no guidelines for addressing ACE in primary care; however, such a guideline may
be useful to NPs as they begin asking about ACE. The authors are poised to begin work toward establishing clinical
guidelines for ACE screening and interventions in primary
care.
Patients have reported being willing to respond to questions about childhood abuse if they were asked in a sensitive manner, but were much less likely to bring up the subject on their own (Read et al., 2007). Furthermore, those
with a history of ACE were more likely to be receptive
to treatment if they had previously been asked about ACE
(Keeshin & Campbell, 2011). NPs in primary care routinely
ask about smoking habits and weigh patients as part of preventive practice. Asking about ACE is no more difficult and
just as essential to patient care.
The consequences of ACE are important to nurses who
care for patients across the life span. Healthcare professionals have a critical role in (a) preventing ACE, (b)
intervening early to prevent the adoption of risky behaviors, (c) counseling clients who have experienced
adversity in childhood, (d) helping to change modifiable
health-risk behaviors, and (e) alleviating the disease burden in adults whose health problems may be the long-term
consequence of ACE.
Research. Despite the rich evidence on the association between ACE and negative health consequences,
few nurses have focused on this area of research. Although the development of disease following ACE has
been hypothesized to result from the biological stress response (McEwen, 2007), more research is needed to better understand long-term biological changes in the stress
response, particularly with regard to individual and socioenvironmental factors, such as ACE, and its possible modifiers, to understand how it leads to physical
disease many years later (McEwen & Gianaros, 2010;
Taylor, Way, & Seeman, 2011). The association between
ACE and negative health consequences, particularly for
mental health outcomes, may also be mediated by elements of the central nervous system, for example, the
amygdala and serotonergic synapses (Benedetti et al.,
2011; Mingione et al., 2012). This lack of knowledge about
how ACE contributes many years later to disease represent a gap in knowledge that challenges researchers in this
area. Understanding how ACEs lead to disease in adulthood is important for developing nursing interventions to
interrupt the progression of disease.

Limitations
The findings of this review have some limitations. First, a
majority of studies (41/42) measured ACE in adults using

Health consequences of adverse childhood experiences

self-report measures. Although using such measures may

have threatened study reliability through recall bias, retrospective responses to ACE have been found to be generally stable over time (Dube et al., 2004). Second, the
studies generally used similar methods and measures, but
focused on different populations. Third, only two studies measured health outcomes using biological indicators
(Benedetti et al., 2011; Mingione et al., 2012). Despite
these limitations, the evidence for an association between
ACE and negative health consequences is consistent and
widespread.

Conclusion
This review of the literature reveals extensive evidence
on the impact of ACE on individuals future health. ACEs
have been associated with physical and psychiatric health
problems, several health-risk behaviors that represent a
threat to future chronic physical and emotional health
problems, and several developmental disruptions that affect health status.
NPs aware of the consequences of ACE should use this
evidence in their practice to screen for patients with a history of ACE and design appropriate plans of care to help
patients manage their emotional and biological responses
to childhood adversity, thus avoiding or minimizing their
negative health outcomes. In many instances, sensitive interventions can effectively manage distress following ACE
(Waite et al., 2010). Nurses are in the position to provide
patients with the opportunity to tell their story so they can
collaborate on a plan of care that addresses their past issues
for the sake of their future health.

References
References marked with an asterisk indicate studies included in the systematic review.
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