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 neg-
ative 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 prac-
titioners (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 arti-
cles 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 patient’s childhood experiences may positively influence health outcomes.

Individuals with a history of adverse childhood ex-
periences (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 conse-
quences of ACE, primary care providers continue to treat
patients for a myriad of health problems without knowl-
edge 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,
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 signif-
icantly more likely than those who maintained their
weight loss to have a history of major childhood emo-
tional trauma (Felitti & Williams, 1998). These patients
reported feeling “protected” by their obesity, less noticed,
and therefore safer from further harm as overweight indi-
viduals (Felitti, Jakstis, Pepper, & Ray, 2010). This find-
ing led to a collaboration between the Centers for Dis-
ease Control and Prevention and Kaiser Permanente’s


C 2015 American Association of Nurse Practitioners 1
Health consequences of adverse childhood experiences
Department of Preventive Medicine to investigate the ef-
fects 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, sex-
ual, 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; Green-
field & 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 child’s family or social environment that cause
harm or distress, thereby disrupting the child’s 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 hypothalamic—pituitary–adrenal axis (Trickett, 2010).
Short-term dysregulation of these systems results in physi-
cal and behavioral changes as the body adapts to the stres-
sor. 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 responsi-
ble for physical and psychiatric diseases as the individual
ages (McEwen, 2007).
With the growing evidence that negative health out-
comes follow ACE, it would be appropriate, and even nec-
essary for NPs in primary care practice to screen individu-
als for ACE. However, this evidence has not been incorpo-
rated 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 man-
aging obesity also do not recommend that providers ask
about ACE, but rather that NPs consider referral for psy-
chosocial concerns (Michigan Quality Improvement Con-
sortium, 2011). Similarly, the guidelines for irritable bowel
syndrome (IBS; National Collaborating Centre for Nurs-
ing and Supportive Care, 2008), which has been related to
2
K. A. Kalmakis & G. E. Chandler
ACE (Heitkemper et al., 2011), do not recommend screen-
ing for childhood adversity. In fact, the guidelines rec-
ommend referral for psychological treatment only after
12 months of pharmacological treatment measures have
failed (National Collaborating Centre for Nursing and Sup-
portive 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 sys-
tematically searched using the main search term “adverse
childhood experiences” and similar terms, for example,
“child maltreatment,” “child trauma,” and “child misfor-
tune.” Articles were included according to these crite-
ria: research studies on the association between ACE and
health outcomes in adults (ࣙ18 years old); health out-
comes were physical (e.g., migraines), psychiatric (e.g.,
depression), health-risk behaviors (e.g., smoking), devel-
opmental disruption (e.g., homelessness), and healthcare
utilization (e.g., prescription drug use); published in peer-
reviewed 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 exam-
ple, 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 sub-
sequent studies. The articles were analyzed and results are
reported using the preferred reporting items for systematic
reviews and meta-analysis (PRISMA) method for system-
atic 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, pub-
lication dates, study sample, methods, forms of child-
hood 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
K. A. Kalmakis & G. E. Chandler Health consequences of adverse childhood experiences

Identification
1,565 records identified by 1 additional record identified
database searches through other sources

876 records after duplicates removed

Screening
876 records screened 789 records excluded

Eligibility
87 articles assessed for 35 articles excluded by
eligibility criteria

42 articles included in
synthesis
Included

Figure 1 Systematic process for article selection.

ACE instrument (Felitti et al., 1998), three of 41 studies Table 1 Association of adverse childhood experiences with physical health
using the Conflict Tactics Scale (CTS; Straus, Hamby, conditions
Boney-McCoy, & Sugarman, 1996), and the remaining First author Year Sample Health outcome
studies using various other self-report instruments. One
a
Anda 2008 15,472 Increased risk of COPD
study gathered ACE data from official child services and
Anda 2010 17,337a Frequent headaches
court records as opposed to self-report (Topitzes, Mersky,
Brown 2009 17,337a Death before age 65
& Reynolds, 2010). Health consequences were assessed by Chapman 2013 25,810 Sleep disturbance
various instruments, which are addressed in the discussion Chapman 2011 17,337a Sleep disturbance
for each category. Dube 2009 15,357a Hospitalization for autoimmune
Study samples ranged from 36 (De Ravello, Abeita, & disease
Brown, 2008) to 68,505 (Jun et al., 2008) and included Dube 2010 5378 Obesity, smoking, and poor health
Felitti 1998 9508a Multiple diseases and risk factors
men only, women only, and both genders. Samples were
(e.g., cardiac disease, COPD)
obtained from several populations including military per-
Greenfield 2009 1745 Self-perceived health and select
sonnel (LeardMann, Smith, & Ryan, 2010), incarcerated chronic medical conditions
women (De Ravello et al., 2008), and HMO patients Heitkemper 2010 72 Sleep disturbances in women with IBS
(Anda, Brown, Felitti, Dube, & Giles, 2008; Brown et al., Poon 2011 877 Sleep problems
2009). The majority of studies (37/42) used a correlational
Note. a COPD, chronic obstructive pulmonary disease; IBS, irritable bowel
design, with individuals reporting no ACE as controls.
syndrome.
Four studies used matched controls (Benedetti et al., b
Sample data from 1995 to 1997 ACE study on California HMO members.
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 of the findings, but are not mutually exclusive. Indeed,
respondents who reported experiencing ࣙ1 ACE ranged aspects of health are often interconnected. Psychological
from 46% (Dube et al., 2010) to 64% (Anda, Brown, health influences physical health and health-risk behav-
Dube et al., 2008). ior, which, in turn, affect healthcare costs.
To manage the data during analysis, the study results
were divided into five health consequence categories:
physical health conditions (11), psychiatric health condi- Physical health conditions
tions (12), health-risk behaviors (12), developmental dis- ACE was associated with physical diseases among a
ruption (4), and healthcare utilization (3) (Tables 1–5). large cohort of members of a California HMO (Felitti
The categories were chosen to assist in the presentation 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 Table 3 Association of adverse childhood experiences with health-risk
health conditions behaviors

First author Year Sample Health outcome First author Year Sample Health outcome
a
Afifi 2008 5692 Suicidal ideation, Brown 2010 17,337 Smoking, increased
psychopathology risk of lung cancer
Benedetti 2011 40 Schizophrenia, Chung 2010 1476 Risk behavior during
emotional reactivity pregnancy: drinking,
Chung 2008 1476 Depression in women smoking, illicit drug
Douglas 2010 2510 Mood and anxiety use
disorders Cunradi 2008 848 Intimate partner
Green 2010 9282 Anxiety, disruptive violence
behavior, substance Ford 2011 25,809 Smoking
use disorders Hahm 2010 7576 Suicidalilty,
Leardmann 2010 8391 PTSD delinquent, and
Lentz 2010 24,326 Schizotypal sexual risk behavior
personality disorder Jun 2008 68,505 Smoking
Lu 2008 254 Multiple psychiatric Mingione 2012 256 Smoking
problems, Rothman 2008 3592 Early-age alcohol use
substance misuse, Sharp 2012 598 Substance abuse
retraumatized in Strine 2012 7279a Alcohol abuse and
adulthood, psychological
homelessness distress
Nurius 2012 7444 Mental health issues Timko 2008 6942 Binge drinking
Shevlin 2011 2353 Visual and auditory Topitzes 2010 1125 Smoking
hallucinations
a
Waite 2012 796 Depression Sample data from 1995 to 1997 ACE study on California HMO members.
Wu 2010 804 PTSD, substance
misuse, smoking, Table 4 Association of adverse childhood experiences with
sex work, STI, developmental disruption
homelessness, and
multiple physical First author Year Sample size Health outcome
health problems
Bleil 2011 259 Repeat abortions (>2)
Note. PTSD, posttraumatic stress disorder; STI, sexually transmitted De Ravello 2008 36 Suicide attempts,
infection. intimate partner
violence
Keeshin 2011 64 Homelessness
self-report scale, and health consequences were obtained Tsai 2011 738 Earlier homelessness,
from patient records. This relationship has been confirmed severity of drug
abuse
and expanded in subsequent research (Table 1). ACE
has been linked to several physical health consequences
across many body systems, including cardiovascular Table 5 Association of adverse childhood experiences with healthcare
disease (Felitti et al., 1998), chronic lung disease (Anda, utilization
Brown, Dube et al., 2008), headaches (Anda, Tietjen,
First author Year Sample Health outcome
Schulman, Felitti, & Croft, 2010), autoimmune disease
(Dube et al., 2009), and sleep disturbances (Chapman Anda 2008 15,033a Increased use
et al., 2013). ACEs were also associated with early death prescription
medications
(Brown et al., 2009) and obesity, smoking and gen-
Cannon 2010 3568 Physical and mental
eral poor heath (Dube, Cood, & Edwards, 2010). Four health utilization,
studies found a significant relationship between ACE depression, intimate
and sleep disturbances. One found the relationship was partner violence
modestly attenuated by social support and emotional Corso 2008 6168a Quality of life as
distress (Poon & Knight, 2011), another by frequent measured by
mental distress and smoking (Chapman et al., 2013). healthcare
utilization
Women with IBS with histories of ACE reported increased
disturbance in sleep as compared to women with IBS who a
Sample data from 1995 to 1997 ACE study on California HMO members.
did not report ACE histories (Heitkemper et al., 2011).

4
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 be-
tween ACE and negative physical health consequences.
Psychological health consequences
As for physical conditions, psychological health out-
comes 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 schizophre-
nia (Benedetti et al., 2011). In each study, ACE was
significantly correlated with negative mental health con-
sequences such as depression (Chung et al., 2008), anxi-
ety (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 Study’s
Depression Scale (Chung et al., 2008), and the Alcohol
Use Disorders and Associated Disabilities Scale IV (AU-
DADIS 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 indi-
viduals 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 es-
tablished 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 ob-
tained 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 nei-
ther physical nor psychological, but do impact health
(Table 4). For example, homelessness (Keeshin &
Campbell, 2011) affects sleep patterns, nutrition, and san-
itation, 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 stud-
ies 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 pre-
scription medications in two studies of male and female
patients; as the number of ACE increased, the risk of hav-
ing 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 K. A. Kalmakis & G. E. Chandler

Discussion applies to patients who engage in risky behavior, or

have lifestyle-related disease such as obesity and heart
The results of this systematic review demonstrate that
disease, which have been associated with ACE. Ask-
ACE is significantly associated with negative health conse-
ing about ACE has been shown to facilitate disclosure
quences in adults. In addition, the reviewed studies pro-
(McGregor, Glover, Gautam, & Julich, 2010; Waite,
vide insight into the factors influencing this association.
Gerrity, & Arango, 2010). Nurses who do not ask about
First, the research supports a cumulative effect of ACE on
ACE as part of a full history assessment are overlooking
health. All studies found that the more adverse experi-
an important risk factor for many health problems and
ences a child had, the greater the effect on physical and
an opportunity to interrupt disease progression. In fact,
psychiatric health as well as behavior (e.g., Dube et al.,
it may be argued that in light of such compelling evi-
2010; Felitti et al., 1998; Ford et al., 2011; Jun et al., 2008).
dence for the significant impact of childhood adversity on
With regard to severity, certain forms of ACE may have a
health, it is unethical not to ask about it (Becker-Blease &
greater influence on adult health outcomes. For example,
Freyd, 2006). However, there are barriers to asking about
parental mental illness, physical and emotional abuse were
ACE in clinical practice. In a cross-sectional survey of pri-
found to be significantly associated with all psychiatric
mary care physicians, researchers found that the most fre-
outcomes measured, while parental divorce and impris-
quently reported barriers to asking about ACE were (a)
onment were associated with only one outcome (Nurius,
not enough time to evaluate or counsel patients who re-
Logan-Greene, & Green, 2012). Witnessing violence in the
port ACE (91.9%), (b) not enough time to ask about ACE
home was significantly associated with all psychiatric out-
(89.0%), and (c) competing primary care recommenda-
comes (Afifi et al., 2008). Additionally, sexual abuse had
tions (65.7%; Weinreb et al., 2010).
the strongest association with sexual risk behavior, delin-
When asking patients about ACE, a safe relational
quency, and suicidatlity when compared to other combi-
environment is recommended (Read, Hammersley, &
nations of ACE (Hahm, Lee, Ozonoff, & Van Wert, 2010).
Rudegeair, 2007). Because NPs in primary practice often
The studies reviewed did not consistently report any one
have an established ongoing relationship of trust with
adversity as most severe and another as least, but there
their patients, NPs are well suited to ask about childhood
were indications that severity was important to the health
adversity. Providers skilled in using a client-centered ap-
consequences of ACE, and that the type of ACE most as-
proach can normalize the experience, reduce shame, and
sociated with any given outcome varies.
facilitate a safe, comfortable environment in which the
In addition to the effect of accumulation and severity
patient can disclose sensitive histories (McGregor et al.,
of ACE, its timing was found to be significantly associated
2010). Screening should generate an important dialogue
with negative health outcomes (Jun et al., 2008) In their
with patients, asking an open-ended question about a
study, Jun et al. (2008) found that abuse during adoles-
patient’s childhood during an annual well visit, is a good
cence appeared to be a more important risk factor for early
start. For example, the NP may say, “Please tell me about
initiation of smoking among girls when compared to abuse
your childhood” (Waite et al., 2010). Alternatively, nurses
that occurred in early childhood.
may adopt the ACE (Dube, Williamson, Thompson, Felitti,
The modifying effect of social and emotional support on
& Anda, 2004) or similar questionnaire into their practice.
health consequences of ACE is not established. Although
If questionnaires are used, providers must remember to
pregnant women were less likely to have symptoms of de-
review the responses as part of the patient visit and engage
pression if they experienced a positive maternal relation-
in a therapeutic dialogue with patients who report ACE.
ship (Chung et al., 2008), having a close relationship with
Following disclosure of ACE, the NPs response is impor-
a parent or adult was not a significant modifier of the as-
tant. A sensitive response expressing sadness for the early
sociation between ACE and smoking in a second study
experience and a desire to help followed by a question
(Mingione, Heffner, Blom, & Anthenelli, 2012). The pos-
of how their childhood experiences have affected their
sible modifiers of the relationship between ACE and adult
health is suggested (Felitte et al., 1998). Then invite the
health represent an area for further nursing research.
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
Significance to nursing
has linked ACE and health. Patients are often not aware of
Clinical practice. The nursing profession cannot the health consequences of their childhood experiences.
ignore the overwhelming evidence for the association Understanding of the association may influence their
between ACE and negative health consequences. When decision to follow recommended mental health referrals.
obtaining health histories from patients, nurses should It is essential that NPs become knowledgeable about ap-
be aware of and inquire about ACE. This particularly propriate counseling services in their area and offer to refer

6
K. A. Kalmakis & G. E. Chandler
patients (Read et al., 2007; Sutherland, Fontenot, & Fan-
tasia, 2014). Currently there are no guidelines for address-
ing ACE in primary care; however, such a guideline may
be useful to NPs as they begin asking about ACE. The au-
thors 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 ques-
tions about childhood abuse if they were asked in a sensi-
tive manner, but were much less likely to bring up the sub-
ject 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 pre-
ventive 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 profes-
sionals have a critical role in (a) preventing ACE, (b)
intervening early to prevent the adoption of risky be-
haviors, (c) counseling clients who have experienced
adversity in childhood, (d) helping to change modifiable
health-risk behaviors, and (e) alleviating the disease bur-
den in adults whose health problems may be the long-term
consequence of ACE.
Research. Despite the rich evidence on the associ-
ation between ACE and negative health consequences,
few nurses have focused on this area of research. Al-
though the development of disease following ACE has
been hypothesized to result from the biological stress re-
sponse (McEwen, 2007), more research is needed to bet-
ter understand long-term biological changes in the stress
response, particularly with regard to individual and so-
cioenvironmental factors, such as ACE, and its possi-
ble 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 ele-
ments 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 repre-
sent a gap in knowledge that challenges researchers in this
area. Understanding how ACEs lead to disease in adult-
hood 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, ret-
rospective responses to ACE have been found to be gen-
erally stable over time (Dube et al., 2004). Second, the
studies generally used similar methods and measures, but
focused on different populations. Third, only two stud-
ies 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 af-
fect health status.
NPs aware of the consequences of ACE should use this
evidence in their practice to screen for patients with a his-
tory 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 in-
terventions 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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(2008). Population attributable fractions of psychiatric disorders and suicide
ideation and attempts associated with adverse childhood experiences.
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