Health and financial costs of adverse childhood experiences in 28 European countries: a systematic review and meta-analysis

Mapping resilience: a scoping review on mediators and moderators of childhood adversity with a focus on gender patterns

BACKGROUND

Childhood adversity is associated with a host of negative health and socioeconomic outcomes far into adulthood. The process of avoiding such outcomes is often referred to as resilience. Mapping resilience comprehensively and across contexts is highly relevant to public health, as it is a step towards understanding environments and interventions that contribute to preventing or reversing negative outcomes after early adverse experiences.

OBJECTIVES

This review scoped out the literature on resilience factors in relation to adulthood outcomes as diverse as mental health and educational attainment. Our aim was to understand where there is untapped research potential, by examining the current evidence base on resilience factors in terms of (a) resources that can buffer the impact of childhood adversity and (b) the pathways linking adversity to long-term outcomes. Furthermore, we aimed to identify gender patterns in these resources and pathways, which has not been a primary interest of reviews on resilience to date, and which can add to our understanding of the different ways in which resilience may unfold.

ELIGIBILITY CRITERIA

Studies had to include an adversity experienced in childhood, an outcome considered indicative of resilience in adulthood, and at least one putative resilience factor, which had to be approached via mediation or moderation analysis. We considered cohort, case-control and cross-sectional studies.

SOURCES OF EVIDENCE

We searched PubMed, Scopus and PsycINFO and included original, peer-reviewed articles published before 20 July 2023 in English, German, French, Spanish, Dutch and Swedish.

CHARTING METHODS

All three authors collaborated on the extraction of information relevant to answering the research questions. The results were visually and narratively summarised.

RESULTS

We included 102 studies. Traditionally anchored in the field of psychology, the resilience literature focuses heavily on individual-level resilience factors. Gender was considered in approximately 22% of included studies and was always limited to comparisons between men and women. There is no evidence that childhood adversity impacts men and women differently in the long term, but there is some evidence for gender differences in resilience factors.

CONCLUSIONS

There is untapped potential in resilience research. By considering structural-level factors simultaneously with individual-level factors, and including gender as one of the elements that shape resilience, we can map resilience as a heterogeneous, multilevel process from a public health perspective. This would complement the extensive existing literature on individual-level factors and help reframe resilience as a concept that can be intervened on at a structural level, and that is subject to societal norms and forces, such as gender. There is a lack of quantitative studies including transgender and gender-non-conforming persons.

Childhood socio-economic disadvantages versus adverse care experiences: Mediation and moderation impacts on late-life depressive symptoms

BACKGROUND

Whether material deprivation-related childhood socio-economic disadvantages (CSD) and care-related adverse childhood experiences (ACE) have different impacts on depressive symptoms in middle-aged and older people is unclear.

METHODS

In the Guangzhou Biobank Cohort Study, CSD and ACE were assessed by 7 and 5 culturally sensitive questions, respectively, on 8,716 participants aged 50+. Depressive symptoms were measured by 15-item Geriatric Depression Scale (GDS). Multivariable linear regression, stratification analyses, and mediation analyses were done.

RESULTS

Higher CSD and ACE scores were associated with higher GDS score in dose-response manner (P for trend <0.001). Participants with one point increment in CSD and ACE had higher GDS score by 0.11 (95% confidence interval [CI], 0.09-0.14) and 0.41 (95% CI, 0.35-0.47), respectively. The association of CSD with GDS score was significant in women only (P for sex interaction <0.001; women: β (95% CI)=0.14 (0.11-0.17), men: 0.04 (-0.01 to 0.08)). The association between ACE and GDS score was stronger in participants with high social deprivation index (SDI) (P for interaction = 0.01; low SDI: β (95% CI)=0.36 (0.29-0.43), high SDI: 0.64 (0.48-0.80)). The proportion of association of CSD and ACE scores with GDS score mediated via education was 20.11% and 2.28%.

CONCLUSIONS

CSD and ACE were associated with late-life depressive symptoms with dose-response patterns, especially in women and those with low adulthood socio-economic status. Education was a major mediator for CSD but not ACE. Eliminating ACE should be a top priority.

Adverse Childhood Experiences and Risk of Abnormal Body Mass Index: A Global Systematic Review and Meta-Analysis

(1) Objectives: The impact of abnormal body mass index (BMI) on health is extensive, and various risk factors contribute to its effects. This study aimed to examine the association between adverse childhood experiences (ACEs) and BMI categories, including underweight, overweight, obesity, severe obesity, and morbid obesity; (2) Methods: Three databases were searched: Web of Science, PubMed, and Scopus. Manual searches were conducted using Google Scholar and ResearchGate. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to assess the association between ACEs and BMI. A random-effects model was used to combine the ORs and CIs across studies; (3) Results: This meta-analysis included 71 studies. The pooled ORs for the relationship between ACEs and obesity was 1.42 (95% CI: 1.24-1.63, Z = 4.96, p < 0.001), indicating a significant association. ACEs showed a positive association with overweight (OR = 1.16, 95% CI: 1.06-1.27, Z = 3.24, p = 0.001). Specifically, ACEs ≥ 4 were strongly associated with obesity (OR = 2.06, 95% CI: 1.27-3.36, Z = 2.90, p = 0.004). Sexual abuse was also found to be significantly associated with obesity (OR = 1.46, 95% CI: 1.29-1.65, Z = 5.98, p < 0.001); (4) Conclusion: This study finds that individuals who have experienced ACEs are more likely to have a higher BMI in adulthood. Therefore, ACEs should be considered a factor associated with abnormal BMI.

Early Life Interventions: Impact on Aging and Longevity

Across mammals, lifespans vary remarkably, spanning over a hundredfold difference. Comparative studies consistently reveal a strong inverse relationship between developmental pace and lifespan, hinting at the potential for early-life interventions (ELIs) to influence aging and lifespan trajectories. Focusing on postnatal interventions in mice, this review explores how ELIs influence development, lifespan, and the underlying mechanisms. Previous ELI studies have employed a diverse array of approaches, including dietary modifications, manipulations of the somatotropic axis, and various chemical treatments. Notably, these interventions have demonstrated significant impacts on aging and lifespan in mice. The underlying mechanisms likely involve pathways related to mitochondrial function, mTOR and AMPK signaling, cellular senescence, and epigenetic alterations. Interestingly, ELI studies may serve as valuable models for investigating the complex regulatory mechanisms of development and aging, particularly regarding the interplay among somatic growth, sexual maturation, and lifespan. In addition, prior research has highlighted the intricacies of experimental design and data interpretation. Factors such as timing, sex-specific effects, administration methods, and animal husbandry practices must be carefully considered to ensure the reliability and reproducibility of results, as well as rigorous interpretation. Addressing these factors is essential for advancing our understanding of how development, aging, and lifespan are regulated, potentially opening avenues for interventions that promote healthy aging.

The Effectiveness of Preventative Interventions to Reduce Mental Health Problems in at-risk Children and Young People: A Systematic Review of Reviews

Mental health problems are the leading cause of childhood disability worldwide, resulting in poor outcomes for children and young people that persist into adulthood. It is essential that those young people most at risk of developing mental health problems receive effective preventative interventions. Whilst there have been a number of systematic reviews which have examined the effectiveness of secondary prevention interventions for specific groups of children and young people, or to address identified mental health concerns, no review has engaged with the breadth of this literature. We conducted a systematic review of systematic reviews to map this complex field of secondary preventative interventions and identify effective interventions to prevent mental health problems in children and adolescents aged 3-17 years. The review protocol was registered on PROSPERO. We searched five electronic databases from inception to February 2023. The certainty of the evidence was appraised using the AMSTAR 2. We included 49 unique systematic reviews each including between 2 and 249 (mean 34) unique studies; the majority of which were reviews which included only or mostly randomised controlled trials (70%). The reviews examined selective interventions (defined as interventions which are delivered to sub-group populations of young people at increased risk of mental health problems) (n = 22), indicated interventions (defined as interventions which target young people who are found to have pre-clinical symptoms) (n = 15) or a synthesis of both (n = 12). The certainty of the evidence in the reviews was rated as high, (n = 12) moderate (n = 5), low (n = 9) and critically low (n = 23). We found evidence to support both selective and indicated interventions in a range of populations and settings, with most of this evidence available for children and young people in their mid-years (6-10 years) and early adolescence (11-13 years). There was a large body of evidence suggesting that resilience enhancing, cognitive behaviour therapy-based and psychoeducational interventions for children who experience adversity, or those with subclinical externalising problems may offer promise. Early selective interventions for a subpopulation of children and young people who have experienced adversity which combines risk reduction and resilience enhancing approaches directed at children and their families may be effective at reducing mental health problems.

Maternal adverse childhood experiences, child resilience factors, and child mental health problems: A multi-wave study

BACKGROUND

Research suggests that maternal ACEs have intergenerational consequences for offspring mental health. However, very few studies have investigated moderators of this association.

OBJECTIVES

The objective of this longitudinal study was to examine whether child resilience factors moderated the association between maternal ACEs prior to age 18, and child-reported symptoms of anxiety, depression, hyperactivity, and inattention.

PARTICIPANTS AND SETTING

The current study used data from 910 mother-child dyads. Participants were recruited in pregnancy from 2008 to 2010 as part of a longitudinal cohort study.

METHODS

Mothers had previously completed an ACEs questionnaire and reported on their child's resilience factors at child age 8-years. Children completed questionnaires about their mental health problems (symptoms of anxiety, depression, hyperactivity, and attention problems) at ages 10 and 10.5 years. Four moderation models were performed in total.

RESULTS

Results revealed that maternal ACEs predicted child-reported symptoms of anxiety (β = 0.174, p = .02) and depression (β = 0.37, p = .004). However, both these associations were moderated by higher levels of perceived child resilience factors (β = -0.29, p = .02, β = -0.33, p = .008, respectively). Specifically, there was no association between maternal ACEs and child mental health problems in the context of moderate and high levels of child resilience factors.

CONCLUSIONS

Children who have the ability to solicit support from internal and external sources (e.g., being creative, setting realistic goals, making friends easily) may be buffered against the consequences of maternal ACEs on anxiety and depression. Thus, the effects of maternal ACEs on child mental health problems are not deterministic.

Association of adverse childhood experiences with poor health condition among middle-aged and elderly adults in the United States: A nationally retrospective cohort study

BACKGROUND

The specific effects of adverse childhood experiences (ACEs) in adulthood and senectitude were less known. We aim to examine the relationship between early ACEs and overall health condition as well as specific dimensions in the middle-aged and elderly population.

METHODS

In the 2019-2021 Behavioral Risk Factor Surveillance System Study, robust Poisson regression models were used to estimate the relationship between ACE exposure and current health status among adults aged 45 ≥ years.

RESULTS

Of the 195,472 participants, 53.8 % were female and the mean age was 65.0 years. Compared to populations without ACE, ACE exposures were more significantly associated with depression (PR: 2.03, 95 %CI: 1.94-2.21), frequent mental health (PR: 1.85, 95 %CI: 1.74-1.97) and subject cognitive decline (PR: 1.99, 95 %CI:1.85-2.14) than with physical health (PR: 1.37, 95 %CI: 1.32-1.44), with dose-response patterns. The association with mental disorder was especially significant among the elderly population.

CONCLUSION

Early ACEs are associated with adverse health outcomes that persist into later life, particularly mental disorders and cognitive decline. Poor mental health may indirectly influence associations with ACEs and cognitive decline as well as physical health. Our findings emphasize the importance of lifelong psychological screening and support for the ACE-exposed middle-aged and elderly population.

Opening Pandora's box - key facilitators of practice change in detecting and responding to childhood adversity - a practitioner perspective

BACKGROUND

Childhood adversities worsen physical and mental health across the lifespan. Health and social care practitioners play a key role in identifying and responding to childhood adversity, however, may be reluctant to do so due to a perceived lack of services to refer to, time pressures and a deficit of training and confidence. We aimed to (1) quantify changes in practitioner comfort and confidence to identify and respond to childhood adversity following a multimodal intervention within an integrated child and family health and social care hub and (2) to understand barriers and facilitators of practice change.

METHODS

Hub practitioners were surveyed about their competence and comfort to directly ask about and confidence to respond to adversity at baseline and then at six and twelve months post training. Interviews were undertaken to explore practitioner barriers and enablers of practice change. Interviews were recorded, transcribed verbatim, and analysed using reflexive thematic analysis. The theoretical domains framework was used to identify the key drivers of practice change.

RESULTS

Fifteen of 18 practitioners completed all three surveys and 70% reported increased competence and comfort to directly ask, and confidence to respond across a range of adversities over the 12-month intervention. Twenty-one practitioners completed interviews. Six themes were identified as either facilitators or barriers to practice change. Facilitator themes included (1) connection matters, (2) knowledge provides assurance, (3) confidence in ability and (4) choosing change. Barrier themes were (1) never enough time and (2) opening Pandora's box. Following analysis, key drivers of practice change were 'social influence', 'belief in capability', 'knowledge' and 'behaviour regulation' while barriers to practice change were 'environmental context and resources' and 'emotion'.

CONCLUSIONS

Practitioners reported improved confidence in identifying and responding to adversity through a multimodal intervention delivered in an integrated Child and Family Hub. Changing practice requires more than just education and training. Opportunities for social connection and coaching to improve self-confidence and perceived competence are needed to overcome the fear of opening Pandora's box.

How adverse childhood experiences get under the skin: A systematic review, integration and methodological discussion on threat and reward learning mechanisms

Adverse childhood experiences (ACEs) are a major risk factor for the development of multiple psychopathological conditions, but the mechanisms underlying this link are poorly understood. Associative learning encompasses key mechanisms through which individuals learn to link important environmental inputs to emotional and behavioral responses. ACEs may impact the normative maturation of associative learning processes, resulting in their enduring maladaptive expression manifesting in psychopathology. In this review, we lay out a systematic and methodological overview and integration of the available evidence of the proposed association between ACEs and threat and reward learning processes. We summarize results from a systematic literature search (following PRISMA guidelines) which yielded a total of 81 articles (threat: n=38, reward: n=43). Across the threat and reward learning fields, behaviorally, we observed a converging pattern of aberrant learning in individuals with a history of ACEs, independent of other sample characteristics, specific ACE types, and outcome measures. Specifically, blunted threat learning was reflected in reduced discrimination between threat and safety cues, primarily driven by diminished responding to conditioned threat cues. Furthermore, attenuated reward learning manifested in reduced accuracy and learning rate in tasks involving acquisition of reward contingencies. Importantly, this pattern emerged despite substantial heterogeneity in ACE assessment and operationalization across both fields. We conclude that blunted threat and reward learning may represent a mechanistic route by which ACEs may become physiologically and neurobiologically embedded and ultimately confer greater risk for psychopathology. In closing, we discuss potentially fruitful future directions for the research field, including methodological and ACE assessment considerations.

The effectiveness of interventions to prevent and reduce child maltreatment in high-income countries: An umbrella review

BACKGROUND

In recent decades, many interventions targeting the occurrence (primary prevention) or the recurrence (secondary prevention) of child abuse and neglect have been tested. Findings have been synthesized in several meta-analyses and systematic reviews. However, the range of interventions addressed in these studies is very broad, and an integrative assessment of this large spectrum is lacking.

OBJECTIVE

Focusing on high-income countries, we ask (i) what is known about the effectiveness of interventions to prevent or reduce child abuse and neglect and (ii) how robust this evidence is.

METHODS

A systematic review of systematic reviews, called an umbrella review, was conducted. Ten databases on OvidSP and Web of Science were searched up until April 2023. Narrative synthesis was used to document the publications' findings.

RESULTS

44 publications were included in the umbrella review. We did not find that any type of intervention had a clear, consistent, and robust track record of preventing or reducing the occurrence of child abuse and neglect. Rather, publications examining the effectiveness of interventions in all areas frequently reported non-existent, small or inconsistent effects. However, positive effects for particular interventions in specific settings did emerge. Research methodologies showed several and often severe problems.

CONCLUSIONS

We suggest several measures to improve the quality of research and call on practitioners to be persistent in developing more effective interventions.

Trends in the dose-response relationship between adverse childhood experiences and maladaptive metacognitive beliefs: A cross-sectional study

BACKGROUND

Since the publication of the major research on adverse childhood experiences (ACE) at the turn of the millennium, our knowledge about the prevalence and physical and mental consequences of childhood adversities has increased substantially. In parallel, research on metacognition, which plays an important role in understanding our mental functioning, has also been on the rise. Although the adverse effects of ACEs on mental processes and the role of metacognitive deficits in the development of mental disorders are widely known, hardly any research into the interaction between these two areas has been conducted; this is what triggered our investigation.

METHODS

Our research was carried out as a cross-sectional study on a sample of 304 members of the general population. We measured ACEs with the 10-item Adverse Childhood Experiences Questionnaire and maladaptive metacognitions-positive and negative metacognitive beliefs, cognitive confidence, cognitive self-consciousness, and need to control thoughts- using the Meta-Cognitions Questionnaire. The closeness of the relationship between the ACE score and metacognitions was measured using Pearson's linear correlation coefficient, while the association of ACE accumulation with metacognitive beliefs was assessed using generalized linear models.

RESULTS

The most common ACE in our sample turned out to be emotional neglect (44.74%). All the examined maladaptive metacognitive beliefs correlate mildly to moderately with the number of suffered ACEs (r = 0.13-0.34), with an increase in the ACE score leading to a rise in the salience of maladaptive metacognitive beliefs. Moreover, a dose-response relationship was seen between increases in ACE scores and the overall values of metacognition, negative metacognitive beliefs, and the maladaptive metacognitive belief of the need to control thoughts.

CONCLUSIONS

Our results suggest that the more ACEs were experienced in childhood, the more pronounced the dysfunctional metacognitive beliefs are. Therefore, our findings emphasize the importance of further research into the topic.

Impact of Adverse Childhood Experiences in Young Adults and Adults: A Systematic Literature Review

BACKGROUND

Investigations have shown the different impacts that ACEs have on an individual's adult life, on both physical and mental health, but they have not yet shown the issue of the influence of ACEs on adults and young adults. Objective/Participants and Setting: This systematic review, performed according to the PRISMA norms and guidelines, intended to understand the most frequent outcomes of adverse childhood experiences in the life of young adults and adults.

METHODS

Studies were identified through multiple literature search databases at EBSCOhost, Web of Science, and PubMed April 2023, and a total of 279 studies, published between 1999 and 2002, were excluded, 256 because of multiple factors: being duplicates, showing statistical analysis with correlations only, being systematic reviews or case studies, comprising individuals under the age of 18, and not meeting the intended theme; ultimately, we selected for the review a total of 23 studies.

RESULTS AND CONCLUSIONS

The impacts of the various articles are subdivided into three main themes: antisocial and criminal behaviour; sexual Behaviour and intimate partner violence; and attachment, quality of life, and therapeutic alliance.

Causal and common risk pathways linking childhood maltreatment to later intimate partner violence victimization

Childhood maltreatment and intimate partner violence (IPV) victimization are major psychiatric risk factors. Maltreatment substantially increases the likelihood of subsequent IPV victimization, but what drives this association is poorly understood. We analyzed retrospective self-reports of maltreatment and IPV in 12794 participants (58% women, 42% men) from the Twins Early Development Study at ages 21 and 26 using quantitative genetic methods. We estimated the etiological influences common to maltreatment and IPV, and the direct causal effect of maltreatment on IPV beyond such common influences. Participants exposed to maltreatment (~7% of the sample) were 3 times more likely to experience IPV victimization than their peers at age 21, 4 times more likely at 26. The association between maltreatment and IPV was mostly due to environmental influences shared by co-twins (42-43%) and genetic influences (30-33%). The association between maltreatment and IPV was similar for women and men, but its etiology partly differed by sex. Maltreatment had a moderate-to-large effect on IPV in phenotypic models (β = 0.23-0.34), decreasing to a small-to-moderate range in causal models accounting for their common etiology (β = 0.15-0.21). Risk factors common to maltreatment and IPV victimization are largely familial in origin, environmental and genetic. Even considering common risk factors, experiencing maltreatment is causally related to subsequent IPV victimization. Interventions promoting safe intimate relationships among young adults exposed to maltreatment are warranted and should address family-level environmental risk and individual-level risk shaped by genetics.

Disparities by Social Determinants of Health: Links Between Long COVID and Cardiovascular Disease

Long COVID has been defined by the World Health Organisation as "continuation or development of new symptoms 3 months after the initial SARS-CoV-2 infection, with these symptoms lasting for at least 2 months with no other explanation." Cardiovascular disease is implicated as a risk factor, concomitant condition, and consequence of long COVID. As well as heterogeneity in definition, presentation, and likely underlying pathophysiology of long COVID, disparities by social determinants of health, extensively studied and described in cardiovascular disease, have been observed in 3 ways. First, underlying long-term conditions, such as cardiovascular disease and its risk factors, are associated with incidence and severity of long COVID, and previously described socioeconomic disparities in these factors are important in exacerbating disparities in long COVID. Second, socioeconomic disparities in management of COVID-19 may themselves lead to distal disparities in long COVID. Third, there are socioeconomic disparities in the way that long COVID is diagnosed, managed, and prevented. Together, factors such as age, sex, deprivation, and ethnicity have far-reaching implications in this new postviral syndrome across its management spectrum. There are similarities and differences compared with disparities for cardiovascular disease. Some of these disparities are in fact, inequalities, that is, rather than simply observed variations, they represent injustices with costs to individuals, communities, and economies. This review of current literature considers opportunities to prevent or at least attenuate these socioeconomic disparities in long COVID and cardiovascular disease, with special challenges for research, clinical practice, public health, and policy in a new disease which is evolving.

Reconsidering gas as clean energy: Switching to electricity for household cooking to reduce NO2-attributed disease burden

Nitrogen dioxide (NO2) is a prevalent air pollutant in urban areas, originating from outdoor sources, household gas consumption, and secondhand smoke. The limited evaluation of the disease burden attributable to NO2, encompassing different health effects and contributions from various sources, impedes our understanding from a public health perspective. Based on modeled NO2 exposure concentrations, their exposure-response relationships with lung cancer, chronic obstructive pulmonary disease, and diabetes mellitus, and baseline disability-adjusted life years (DALYs), we estimated that 1,675 (655-2,624) thousand DALYs were attributable to NO2 in urban China in 2019 [138 (54-216) billion Chinese yuan (CNY) economic losses]. The transition from gas to electricity for household cooking was estimated to reduce the attributable economic losses by 35%. This reduction falls within the range of reductions achieved when outdoor air meets the World Health Organization interim target 3 and air quality guidelines for annual NO2, highlighting the significance of raising awareness of gas as a polluting household energy for cooking. These findings align with global sustainable development initiatives, providing a sustainable solution to promote public health while potentially mitigating climate change.

Lifetime adversity predicts depression, anxiety, and cognitive impairment in a nationally representative sample of older adults in the United States

OBJECTIVE

Although life stress and adversity are well-known risk factors for mental health problems and cognitive impairment among older adults, limited research has comprehensively examined the impact of both childhood and adulthood adversity on psychiatric and cognitive impairment symptoms over a prolonged period. To address this issue, we investigated how lifetime adversity exposure is related to symptoms of depression, anxiety, and cognitive impairment in a nationally representative, longitudinal sample of older adults in the United States.

METHOD

We analyzed data from the Health and Retirement Study (1992-2016). The sample included 3496 individuals (59.9% female), aged ≥64 years old (Mage = 76.0 ± 7.6 years in 2016). We used the individual-level panel data and ordinary least squares regressions to estimate associations between childhood and adulthood adversities, and later-life depression, anxiety, and cognitive impairment.

RESULTS

Many participants experienced a significant early life (38%) or adulthood (79%) stressor. Moreover, experiencing one childhood adversity (vs. none) was associated with a 17.4% increased risk of adulthood adversity. Finally, as hypothesized, childhood adversity exposure was related to experiencing more depression and anxiety symptoms in later life, whereas adulthood stressor exposure predicted more cognitive impairment as well as more depression and anxiety symptoms.

DISCUSSION

These findings demonstrate significant associations between lifetime adversity and symptoms of depression, anxiety, and cognitive impairment in older adults. Screening for lifetime stressors may thus help healthcare professionals and policymakers identify individuals who could potentially benefit from interventions designed to reduce stress and enhance resilience.

Examining relationships between adverse childhood experiences and coping during the cost-of-living crisis using a national cross-sectional survey in Wales, UK

OBJECTIVES

Adverse childhood experiences (ACEs) can affect individuals' resilience to stressors and their vulnerability to mental, physical and social harms. This study explored associations between ACEs, financial coping during the cost-of-living crisis and perceived impacts on health and well-being.

DESIGN

National cross-sectional face-to-face survey. Recruitment used a random quota sample of households stratified by health region and deprivation quintile.

SETTING

Households in Wales, UK.

PARTICIPANTS

1880 Welsh residents aged ≥18 years.

MEASURES

Outcome variables were perceived inability to cope financially during the cost-of-living crisis; rising costs of living causing substantial distress and anxiety; and self-reported negative impact of rising costs of living on mental health, physical health, family relationships, local levels of antisocial behaviour and violence, and community support. Nine ACEs were measured retrospectively. Socioeconomic and demographic variables included low household income, economic inactivity, residential deprivation and activity limitation.

RESULTS

The prevalence of all outcomes increased strongly with ACE count. Perceived inability to cope financially during the cost-of-living crisis increased from 14.0% with 0 ACEs to 51.5% with 4+ ACEs. Relationships with ACEs remained after controlling for socioeconomic and demographic factors. Those with 4+ ACEs (vs 0 ACEs) were over three times more likely to perceive they would be unable to cope financially and, correspondingly, almost three times more likely to report substantial distress and anxiety and over three times more likely to report negative impacts on mental health, physical health and family relationships.

CONCLUSIONS

Socioeconomically deprived populations are recognised to be disproportionately impacted by rising costs of living. Our study identifies a history of ACEs as an additional vulnerability that can affect all socioeconomic groups. Definitions of vulnerability during crises and communications with services on who is most likely to be impacted should consider childhood adversity and history of trauma.

The role of social support in reducing the long-term burden of cumulative childhood adversity on adulthood internalising disorder

PURPOSE

Previous research indicates that social support is protective for the mental health outcomes of exposure to childhood adversity. However, the impact of social support as a protective factor following exposure to cumulative childhood adversity is understudied with prospective longitudinal data. The aim of this present study was to examine how social support mediates the impact of cumulative exposure to childhood adversity on internalising disorder in adulthood.

METHODS

The Christchurch Health and Development Study (CHDS) is a general population birth cohort, born in 1977 and representative of Christchurch, New Zealand at the time of the cohort members' birth. The present study used a generalised estimating equations (GEE) framework to analyse direct associations between a cumulative measure of childhood adversity (CA) and internalising disorders (major depression, and any anxiety disorder), and indirect associations through social support.

RESULTS

Results indicated a dose-dependent relationship between increased exposure to CA and worsened odds of a diagnosis for major depression and any anxiety disorder, respectively. There was also a significant mediating effect of social support on the direct associations between CA and both major depression (OR (95%CI) =0 .98 (0.97, 0.99), p < 001) and any anxiety disorder (OR (95%CI) = .98 (0.97, 0.99), p < 001).

CONCLUSION

The findings indicate that social support reduces the impact of childhood adversity on adult mental health, and is therefore a target for future work examining potential interventions following CA.

Editorial perspective: protective factors following cumulative childhood adversity

Adverse childhood experiences can have a significant impact on adult psychosocial outcomes. However, negative outcomes are not inevitable, and protective factors can interrupt the realisation of negative developmental trajectories and result in positive adaptation in spite of childhood adversity. Interventions that promote social support, encourage education and academic achievement, and address specific personality and dispositional factors are likely to beneficial for those with experience of childhood adversity. Holistic assessment that considers both neurodevelopmental conditions and trauma symptoms is also important for promoting resilience and avoiding assumptions that mental and behavioural problems in children with cumulative adversity are purely 'social'.

Prevalence of Adverse Childhood Experiences in sub-Saharan Africa: A multicountry analysis of the Violence Against Children and Youth Surveys (VACS)

BACKGROUND

Adverse Childhood Experiences are traumatic events early in life and have been associated with significant negative health outcomes.

OBJECTIVE

To estimate the prevalence of ACEs in five low- and middle-income sub-Saharan African countries.

PARTICIPANTS AND SETTING

Nationally representative data from the Cote d'Ivoire (2018), Kenya (2019), Lesotho (2018), Mozambique (2019), and Namibia (2019) Violence Against Children and Youth Surveys (VACS) were used. Analyses were restricted to youth ages 18-24 years (n = 8766 females and 2732 males).

METHODS

VACS data were analyzed to generate sex-stratified weighted prevalence of individual ACEs (including sexual, physical, and emotional violence; witnessing interparental violence and violence in the community; and orphanhood) and aggregate ACEs (total ACEs; 0, 1-2, and 3 or more), for each country and combined.

RESULTS

The most common type of ACEs among both females and males was witnessing physical violence (males: 55.0 % [95 % CI: 51.1-58.8] and females: 37.2 % [95 % CI = 34.3-40.1]) followed by experiencing physical violence (males: 49.7 % [95 % CI = 45.5-53.9] and in females: 36.5 % [95 % CI = 33.8-39.2]). Prevalence of sexual violence was significantly higher in females than in males (16.0 % [95 % CI = 13.9-18.2] vs 8.3 % [95 % CI = 7.0-9.8]; p < 0.001). About 72 % of females and 82 % of males have experienced at least one form of ACE with 20 % of females and 24.2 % of males experiencing 3 or more ACEs.

CONCLUSION

This study demonstrated that majority of the children in countries in sub-Saharan Africa have experienced multiple ACEs in their lifetime. Understanding the extent of the problem will help design early interventions to reduce childhood exposure to ACEs or mitigate against the harmful impact of ACEs.

Modeling Long-Term Budgetary Impacts of Prevention: An Overview of Meta-analyses of Relationships Between Key Health Outcomes Across the Life-Course

Budget analysis entities often cannot capture the full downstream impacts of investments in prevention services, programs, and interventions. This study describes and applies an approach to synthesizing existing literature to more fully account for these effects. This study reviewed meta-analyses in PubMed published between Jan 1, 2010 and Dec 31, 2019. The initial search included meta-analyses on the association between health risk factors, including maternal behavioral health, intimate partner violence, child maltreatment, depression, and obesity, with a later health condition. Through a snowball sampling-type approach, the endpoints of the meta-analyses identified became search terms for a subsequent search, until each health risk was connected to one of the ten costliest health conditions. These results were synthesized to create a path model connecting the health risks to the high-cost health conditions in a cascade. Thirty-seven meta-analyses were included. They connected early-life health risk factors with six high-cost health conditions: hypertension, diabetes, asthma and chronic obstructive pulmonary disorder, mental disorders, heart conditions, and trauma-related disorders. If confounders could be controlled for and causality inferred, the cascading associations could be used to more fully account for downstream impacts of preventive interventions. This would support budget analysis entities to better include potential savings from investments in chronic disease prevention and promote greater implementation at scale.

Childhood adversity in a youth psychiatric population: prevalence and associated mental health problems

Background: Childhood adversity can have lasting negative effects on physical and mental health. This study contributes to the existing literature by describing the prevalence rates and mental health outcomes related to adverse childhood experiences (ACEs) among adolescents registered for mental health care.Methods: Participants in this cross-sectional study were youths (aged 12-18 years) who were referred to outpatient psychiatric departments in the Netherlands. Demographic information was collected from the medical records. The Child Trauma Screening Questionnaire (CTSQ) was used to examine the presence of ACEs and posttraumatic stress symptoms (PTSS). To assess mental health problems, we used the Dutch translation of the Youth Self Report. Descriptive statistics and frequencies were used to calculate prevalence rates across the various ACEs domains. ANOVA and chi-square tests were used to explore the relationship between ACEs and mental health.Results: Of the 1373 participants, 69.1% reported having experienced at least one ACE and 17.1% indicated exposure to four or more ACEs in their lives. Although there was substantial overlap among all ACE categories, the most frequently reported were bullying (49.2%), emotional abuse (17.8%), physical abuse (12.2%), and sexual abuse (10.1%). Female adolescents (72.7%) reported significantly more ACEs than their male counterparts (27.0%). Furthermore, a higher number of ACEs was associated with significantly more self-reported general mental health problems, an elevated prevalence of both mood and post-traumatic stress disorders, and a greater presence of two or more co-existing psychiatric diagnoses (comorbid psychiatric classification).Conclusions: This cross-sectional study on childhood adversity and its association with mental health showed that ACEs are highly prevalent in youth registered for mental health care. This study provides support for a graded and cumulative relationship between childhood adversity and mental health problems.

Adverse childhood experiences, sarcopenia, and social participation in older adults: a cohort study

OBJECTIVES

To examine the relationships between adverse childhood experiences (ACEs) and developing sarcopenia in older adults and the modifying effects of active social participation.

METHODS

This prospective cohort study used survey data from the China Health and Retirement Longitudinal Study, including baseline surveys from 2011, follow-up data from 2013, follow-up data from 2015, and information on ACEs from the 2014 Life History Survey. Information concerning 10 ACEs, including five threat-related ACEs and five deprivation-related ACEs before 17 years of age was obtained by questionnaires through face-to-face interviews. Sarcopenia status was assessed according to the Asian Working Group for Sarcopenia 2019 algorithm, consisted of low muscle mass, and low muscle strength, or poor physical performance. The relationship between ACEs, social participation, and sarcopenia was evaluated using Cox proportional hazard regression models.

RESULTS

The study population comprised 6859 older adults in main analyses. Having experienced ≥ 3 ACEs led to an increased 31% risk of developing sarcopenia (hazard ratio [HR]:1.31, 95% confidence interval [CI]:1.10-1.56). Participants having experienced ≥ 2 threat-related ACEs (HR:1.22, 95%CI:1.04-1.43) or deprivation-related ACEs (HR:1.22, 95%CI:1.02-1.46) had a 22% higher risk of developing sarcopenia. Active social participation significantly modified the association between ACEs (p < 0.05), especially threat-related ACEs (p < 0.05), and sarcopenia.

CONCLUSIONS

ACEs were associated with the development of sarcopenia; however, social participation had a modifying effect. These findings provide insights for early identification of vulnerable groups, advance intervention timing, and highlight the benefits of promoting active social participation among individuals with sarcopenia who have experienced ACEs.

The relationship between parental adverse childhood experiences and parenting behaviors

BACKGROUND

Adverse childhood experiences (ACEs) are strongly related to the development of various health problems. Several previous studies have revealed the link between ACEs, parental mental health, and child psychopathology. However, the direct association between ACEs and parenting behaviors is still understudied.

OBJECTIVES

To examine the relationship between parental ACEs and parenting, the effect of mental health which possibly mediated parenting behaviors, and the prevalence of ACEs.

PARTICIPANTS AND SETTING

Data was obtained from 403 parents of 6-18-year-old students in Chiang Mai, Thailand, from January to February 2023.

METHODS

Relationships among ACEs, depression, anxiety, stress, and parenting behaviors were examined using correlation analysis and path analysis. The direct and indirect effects of potential associated factors on parenting behaviors were also examined.

RESULTS

Overall, 62.5 % of parents reported at least one ACE. Path analysis revealed significant direct effects of ACEs on poorer mental health in all subscales: depression, anxiety, and stress (β = 0.19, 0.21, 0.18 respectively). ACEs were directly associated with the use of corporal punishment (β = 0.15). Stress also had a positive direct effect on inconsistent discipline (β = 0.18).

CONCLUSION

ACEs are common in parents and associated with mental health problems. ACEs also affect parenting behaviors via direct and indirect pathways. It is important to detect and provide interventions to parents having a history of ACEs and poor mental health to improve the quality of parenting practices.

Childhood maltreatment and risk of endocrine diseases: an exploration of mediating pathways using sequential mediation analysis

BACKGROUND

Adverse childhood experiences (ACEs), including childhood maltreatment, have been linked with increased risk of diabetes and obesity during adulthood. A comprehensive assessment on the associations between childhood maltreatment and all major endocrine diseases, as well as the relative importance of different proposed mechanistic pathways on these associations, is currently lacking.

METHODS

Based on the UK Biobank, we constructed a cohort including 151,659 participants with self-reported data on childhood maltreatment who were 30 years of age or older on/after January 1, 1985. All participants were followed from the index date (i.e., January 1, 1985, or their 30th birthday, whichever came later) until the first diagnosis of any or specific (12 individual diagnoses and 9 subtypes) endocrine diseases, death, or the end of follow-up (December 31, 2019), whichever occurred first. We used Cox models to examine the association of childhood maltreatment, treated as continuous (i.e., the cumulative number of experienced childhood maltreatment), ordinal (i.e., 0, 1 and ≥ 2), or binary (< 2 and ≥ 2) variable, with any and specific endocrine diseases, adjusted for multiple covariates. We further examined the risk of having multiple endocrine diseases using Linear or Logistic Regression models. Then, sequential mediation analyses were performed to assess the contribution of four possible mechanisms (i.e., suboptimal socioeconomic status (SES), psychological adversities, unfavorable lifestyle, and biological alterations) on the observed associations.

RESULTS

During an average follow-up of 30.8 years, 20,885 participants received a diagnosis of endocrine diseases. We observed an association between the cumulative number of experienced childhood maltreatment and increased risk of being diagnosed with any endocrine disease (adjusted hazard ratio (HR) = 1.10, 95% confidence interval 1.09-1.12). The HR was 1.26 (1.22-1.30) when comparing individuals ≥ 2 with those with < 2 experienced childhood maltreatment. We further noted the most pronounced associations for type 2 diabetes (1.40 (1.33-1.48)) and hypothalamic-pituitary-adrenal (HPA)-axis-related endocrine diseases (1.38 (1.17-1.62)), and the association was stronger for having multiple endocrine diseases, compared to having one (odds ratio (95% CI) = 1.24 (1.19-1.30), 1.35 (1.27-1.44), and 1.52 (1.52-1.53) for 1, 2, and ≥ 3, respectively). Sequential mediation analyses showed that the association between childhood maltreatment and endocrine diseases was consistently and most distinctly mediated by psychological adversities (15.38 ~ 44.97%), while unfavorable lifestyle (10.86 ~ 25.32%) was additionally noted for type 2 diabetes whereas suboptimal SES (14.42 ~ 39.33%) for HPA-axis-related endocrine diseases.

CONCLUSIONS

Our study demonstrates that adverse psychological sequel of childhood maltreatment constitutes the main pathway to multiple endocrine diseases, particularly type 2 diabetes and HPA-axis-related endocrine diseases. Therefore, increased access to evidence-based mental health services may also be pivotal in reducing the risk of endocrine diseases among childhood maltreatment-exposed individuals.

The social determinants of mental health and disorder: evidence, prevention and recommendations

People exposed to more unfavourable social circumstances are more vulnerable to poor mental health over their life course, in ways that are often determined by structural factors which generate and perpetuate intergenerational cycles of disadvantage and poor health. Addressing these challenges is an imperative matter of social justice. In this paper we provide a roadmap to address the social determinants that cause mental ill health. Relying as far as possible on high-quality evidence, we first map out the literature that supports a causal link between social determinants and later mental health outcomes. Given the breadth of this topic, we focus on the most pervasive social determinants across the life course, and those that are common across major mental disorders. We draw primarily on the available evidence from the Global North, acknowledging that other global contexts will face both similar and unique sets of social determinants that will require equitable attention. Much of our evidence focuses on mental health in groups who are marginalized, and thus often exposed to a multitude of intersecting social risk factors. These groups include refugees, asylum seekers and displaced persons, as well as ethnoracial minoritized groups; lesbian, gay, bisexual, transgender and queer (LGBTQ+) groups; and those living in poverty. We then introduce a preventive framework for conceptualizing the link between social determinants and mental health and disorder, which can guide much needed primary prevention strategies capable of reducing inequalities and improving population mental health. Following this, we provide a review of the evidence concerning candidate preventive strategies to intervene on social determinants of mental health. These interventions fall broadly within the scope of universal, selected and indicated primary prevention strategies, but we also briefly review important secondary and tertiary strategies to promote recovery in those with existing mental disorders. Finally, we provide seven key recommendations, framed around social justice, which constitute a roadmap for action in research, policy and public health. Adoption of these recommendations would provide an opportunity to advance efforts to intervene on modifiable social determinants that affect population mental health.

Association of early life adversity with cardiovascular disease and its potential mechanisms: a narrative review

Strong epidemiological evidence has shown that early life adversity (ELA) has a profound negative impact on health in adulthood, including an increased risk of cardiovascular disease, the leading cause of death worldwide. Here, we review cohort studies on the effects of ELA on cardiovascular outcomes and the possible underlying mechanisms. In addition, we summarize relevant studies in rodent models of ELA. This review reveals that the prevalence of ELA varies between regions, time periods, and sexes. ELA increases cardiovascular health risk behaviors, susceptibility to mental illnesses, and neuroendocrine and immune system dysfunction in humans. Rodent models of ELA have been developed and show similar cardiovascular outcomes to those in humans but cannot fully replicate all ELA subtypes. Therefore, combining cohort and rodent studies to further investigate the mechanisms underlying the association between ELA and cardiovascular diseases may be a feasible future research strategy.

Childhood abuse and neglect and profiles of adult emotion dynamics

Childhood maltreatment (CM) is experienced by ∼40% of all children at major personal and societal costs. The divergent associations between emotional, physical, and sexual abuse or neglect in childhood and differences in adult emotional functioning and regulation were examined in terms of daily emotion intensity, variability, instability, inertia, and diversity, reported over 30 days by 290 Dutch aged 19-73. Participants described their abuse/neglect experiences retrospectively using the Childhood Trauma Questionnaire (CTQ). Dissecting CM effects on adult emotion dynamics may inform theories on the ontogenesis and functioning of emotions, on effects of abuse and neglect, to better understand (dys)functional emotional development, and to prevent their adverse sequelae. Structural equation models (SEM) showed that most types of CM were associated with specific patterns of emotion dynamics, and only emotional abuse had no unique effects on the emotional dynamic indices. Emotional neglect was associated with most measures of emotion dynamics (i.e., less intense, variable, unstable, and diverse emotions). Sexual abuse associated with increases and physical neglect decreases in negative affect variability and instability. Physical abuse was associated with inertia but with a small effect size. Social contact frequency did not mediate much of the relationship between CM types and emotion dynamics.

Adverse Childhood Experiences and Depression: The Mediating Role of Resilience and Emotional Regulation

The current study examined the mediating roles of resilience and emotional regulation in the association between childhood trauma and depressive symptoms among individuals who experienced adverse childhood experiences (ACEs). Data from 200 women aged 17 to 77 years who were psychiatric outpatients were collected using self-reported questionnaires assessing child adversity, depressive symptoms, resilience, and emotional regulation. A positive correlation was found between a subscale of the ACE-IQ and depression. Childhood trauma was associated with higher risk of depressive symptoms among participants with lower resilience (an association that was partly explained by resilience level [mediation]). Emotional regulation was not a significant mediator in the childhood trauma-depression association. Our findings indicate that resilience is a key mediator between childhood trauma and depression. Individuals who experienced childhood trauma may benefit from evidence-based interventions focused on strengthening resilience and improving coping strategies. [Journal of Psychosocial Nursing and Mental Health Services, 62(1), 45-54.].

Adverse childhood experience is associated with an increased risk of reporting chronic pain in adulthood: a stystematic review and meta-analysis

Background: Adverse childhood experiences (ACEs) have been shown to negatively affect health in adulthood. Estimates of associations between ACEs and chronic painful conditions are lacking.Objectives: This systematic review and meta-analysis aimed to evaluate associations between exposure to ACEs and chronic pain and pain-related disability in adults.Methods: We searched 10 electronic databases from inception to February 2023. We included observational studies assessing associations between direct ACEs (childhood sexual, physical, emotional abuse, or neglect) alone or in combination with indirect ACEs (witnessing domestic violence, household mental illness), and adult chronic pain (≥3 months duration) and pain-related disability (daily activities limited by chronic pain). Pairs of reviewers independently extracted data and assessed study risks of bias. Random-effect models were used to calculate pooled adjusted odds ratios [aOR]. Tau square [T2], 95% prediction intervals [95%PI] and I2 expressed the amount of heterogeneity, and meta-regressions and subgroup meta-analyses investigated sources of heterogeneity (PROSPERO: CRD42020150230).Results: We identified 85 studies including 826,452 adults of which 57 studies were included in meta-analyses. Study quality was generally good or fair (n = 70). The odds of reporting chronic pain in adulthood were significantly higher among individuals exposed to a direct ACE (aOR, 1.45, 95%CI, 1.38-1.53). Individuals reporting childhood physical abuse were significantly more likely to report both chronic pain (aOR, 1.50, 95CI, 1.39-1.64) and pain-related disability (1.46, 95CI, 1.03-2.08) during adulthood. Exposure to any ACEs alone or combined with indirect ACEs significantly increase the odds of adult chronic painful conditions (aOR, 1.53, 95%CI, 1.42-1.65) and pain-related disability (aOR, 1.29; 95%CI, 1.01-1.66). The risk of chronic pain in adulthood significantly increased from one ACE (aOR, 1.29, 95%CI, 1.22-1.37) to four or more ACEs (1.95, 95%CI, 1.73-2.19).Conclusions: Single and cumulative ACEs are significantly associated with reporting of chronic pain and pain-related disability as an adult.

Hidden family rules: perspective on a dysfunctional paternalistic system and the persistence of pain

This article explores how paternalistic control and power reside within the family system and how this may influence pain and its persistence. Drawing upon clinical case studies and existing literature, this exploration emphasises the role of paternal dysfunction in creating emotional memory images and delves into how this may influence the chronification and treatment resistance of pain (i.e., making pain "sticky"). We argue that a dysfunctional paternalistic family system, often characterised by authoritarian dynamics, emotional neglect, and abuse, results in adverse experiences and emotional memory images that create a fertile ground for the entrenchment and propagation of psychosomatic symptoms, including pain. Further, the paper emphasizes the potential intergenerational effects of such a scenario, where inherited "Family Rules" drive maladaptive coping mechanisms, which contribute to the persistence of psychological and physiological distress across generations. Understanding these complexities offers new perspectives on treating psychological disorders and their physiological ramifications. It also highlights the urgency of addressing dysfunctional familial dynamics in psychotherapeutic interventions for both immediate and long-term psychophysiological health outcomes.

Consensus building on definitions and types of child maltreatment to improve recording and surveillance in Europe: protocol for a multi-sectoral, European, electronic Delphi study

INTRODUCTION

Child maltreatment (CM) is a complex global public health issue with potentially devastating effects on individuals' physical and mental health and well-being throughout the life course. A lack of uniform definitions hinders attempts to identify, measure, respond to, and prevent CM. The aim of this electronic Delphi (e-Delphi) study is to build consensus on definitions and types of CM for use in surveillance and multi-sectoral research in the 34 countries in the Euro-CAN (Multi-Sectoral Responses to Child Abuse and Neglect in Europe) project (COST Action CA19106).

METHODS AND ANALYSIS

The e-Delphi study will consist of a maximum of three rounds conducted using an online data collection platform. A multi-disciplinary expert panel consisting of researchers, child protection professionals (health and social care), police, legal professionals and adult survivors of CM will be purposefully recruited. We will approach approximately 100 experts, with between 50 and 60 of these anticipated to take part. Participants will rate their agreement with a range of statements relating to operational definitions and types of CM, and free-text comments on each of the statements to give further detail about their responses and areas of uncertainty. Consensus has been defined a priori as ≥70% of the panel agreeing or disagreeing with the statement after the final round. The responses to the open-ended questions will be analysed using a 'codebook' approach to thematic analysis, and used to refine the statements between rounds where no consensus is reached.

ETHICS AND DISSEMINATION

Ethical approval has been granted from the Cardiff University School of Medicine ethics committee (reference number SMREC22/96). Results will be submitted for publication in a peer-reviewed journal and presented at workshops (including for the participants) and international academic conferences. The Euro-CAN network will also be used to disseminate the results, with results briefings and presentations to key public health and other relevant organisations in the field.

Childhood contact with social services and risk of suicide or sudden death in young adulthood: identifying hidden risk in a population-wide cohort study

BACKGROUND

Childhood out-of-home care is associated with premature death in adulthood, in particular death by suicide, accidents and violence. However, little is known about the mortality risk in the much larger population of adults that had contact with social services in childhood but never entered out-of-home care. We determine the association between all tiers of contact with children's social services and risk of suicide and other sudden deaths in young adulthood.

METHODS

This population-wide, longitudinal, record-linkage study of adults in Northern Ireland born between 1985 and 1997 (n=437 008) followed each individual from age 18 years to July 2021 (maximum age 36 years). Cox regression models estimated the association between level of contact with social services in childhood (no contact; referred but assessed as not in need (NIN); child in need (CIN) and child in care (CIC)) and risk of death by suicide and sudden death in young adulthood.

RESULTS

Individuals with childhood social care contact (n=51 097) comprised 11.7% of the cohort yet accounted for 35.3% of sudden deaths and 39.7% of suicide deaths. Risk of suicide or sudden death increased stepwise with level of childhood contact and was highest in adults with a history of out-of-home care (suicide HR 8.85 (95% CI 6.83 to 11.4)). Individuals assessed as NIN, and those deemed a CIN, had four times the risk of death by suicide in young adulthood compared with unexposed peers (HR 4.25 (95% CI 3.26 to 5.53) and HR 4.49 (95% CI 3.75 to 5.39), respectively).

CONCLUSION

Childhood contact with social services is a risk marker for death by suicide and sudden death in young adulthood. Risk is not confined to adults with a history of out-of-home care but extends to the much larger population that had contact with social services but never entered care.

Economic Burden of Health Conditions Associated With Adverse Childhood Experiences Among US Adults

Importance

Adverse childhood experiences (ACEs) are preventable, potentially traumatic events in childhood, such as experiencing abuse or neglect, witnessing violence, or living in a household with substance use disorder, mental health problems, or instability from parental separation or incarceration. Adults who had ACEs have more harmful risk behaviors and worse health outcomes; the economic burden associated with these issues is uncertain.

Objective

To estimate the economic burden of ACE-associated health conditions among US adults.

Design, Setting, and Participants

In this economic evaluation, regression models of cross-sectional survey data from the 2019-2020 Behavioral Risk Factor Surveillance System (BRFSS) and previous studies were used to estimate ACE population-attributable fractions (PAFs) (ie, the fraction of total cases associated with a specific exposure) for selected health outcomes (anxiety, arthritis, asthma, cancer, chronic obstructive pulmonary disease, depression, diabetes, heart disease, kidney disease, stroke, and violence) and risk factors (heavy drinking, illicit drug use, overweight and obesity, and smoking) among the 2019 US adult population. Adverse childhood experience PAFs were used to calculate the proportion of total condition-specific medical spending and lost healthy life-years related to ACEs using Global Burden of Disease Study data. Data analysis was performed from September 10, 2021, to November 29, 2022.

Exposure

Adverse childhood experiences (age <18 years).

Main Outcomes and Measures

Monetary valuation of ACE-associated morbidity and mortality using standard US value of statistical life methods and presented in terms of annual and lifetime per affected person and total population estimates at the national and state levels.

Results

A total of 820 673 adults, representing 255 million individuals, participated in the BRFSS in 2019 and 2020. An estimated 160 million of the total 255 million US adult population (63%) had 1 or more ACE, associated with an annual economic burden of $14.1 trillion ($183 billion in direct medical spending and $13.9 trillion in lost healthy life-years). This was $88 000 per affected adult annually and $2.4 million over their lifetimes. The lifetime economic burden per affected adult was lowest in North Dakota ($1.3 million) and highest in Arkansas ($4.3 million). Twenty-two percent of adults had 4 or more ACEs and comprised 58% of the total economic burden-the estimated per person lifetime economic burden for those adults was $4.0 million.

Conclusions and Relevance

In this cross-sectional analysis of the US adult population, the economic burden of ACE-related health conditions was substantial. The findings suggest that measuring the economic burden of ACEs can support decision-making about investing in strategies to improve population health.

Specific domains of positive childhood experiences (PCEs) associated with improved adult health: A nationally representative study

Background

Positive childhood experiences (PCEs) are supportive relationships and environments associated with improved health when aggregated into composite scores. Adverse childhood experiences (ACEs), a reciprocal measure to PCEs, are associated with worse health in aggregate scores and when disaggregated into measures of specific ACE types (hereafter domains). Understanding the associations between specific PCE domains and health, while accounting for ACEs, may direct investigations and intervention planning to foster PCE exposure.

Methods

We analyzed data from the nationally representative United States longitudinal Panel Study of Income Dynamics. Five PCE domains were examined: (i) peer support and healthy school climate, (ii) neighborhood safety, (iii) neighborhood support, and nurturing relationships with (iv) maternal and (v) paternal figures. Survey weighted logistic regression models tested associations between each PCE domain measure and adult general health rating, controlling for demographic covariates and nine ACE exposures: physical, emotional, or sexual abuse/assault; emotional neglect; witnessing intimate partner violence or household substance use; having a parent with mental illness; any parental separation or divorce; and/or having a deceased or estranged parent. Secondary outcomes included adult functional status and mental and physical health diagnoses. We also tested for statistical interactions between PCE domain and ACE score measures.

Results

The sample included 7105 adults. Higher scores for the "peer support and healthy school climate" and "neighborhood safety" domain measures showed the most protective relationships with the adverse health conditions tested, most notably for mental illness. The relationship between PCE domain measures and health outcomes was attenuated, but not statistically moderated by ACE exposure.

Conclusion

Experiencing childhood peer support, a healthy school climate, and neighborhood safety were especially protective against multiple adult health conditions, including for ACE exposed individuals. Interventions that promote PCEs may yield population health gains.

Development and initial validation of the THL Adverse Childhood Experiences Questionnaire (ACE-THL)

BACKGROUND

The research on adverse childhood experiences (ACEs) has deepened our understanding of the long-lasting and cumulative effects of childhood adversities. However, the instruments measuring ACEs have several shortcomings, including limited item coverage, collapsing of items and response options, simplistic scoring, and inadequate psychometric assessments.

OBJECTIVE

To design and conduct preliminarily psychometric testing for a brief new self-report instrument-the THL Adverse Childhood Experiences questionnaire (ACE-THL)-with a comprehensive set of clearly formulated items and appropriate response options.

METHODS

A previously published process model was applied to develop the ACE-THL questionnaire, which was validated by cognitive interviews (N = 20). Interviewers and interviewees completed the questionnaire separately for a cross-informant comparison. In a separate survey panel validation, the respondents filled out the ACE-THL twice, two weeks apart (N = 513, with 426 in the follow-up). Interview data were used to improve item clarity, and test-retest reliability and structural validity were assessed with repeated survey data.

RESULTS

The final 14-item questionnaire, including 12 ACE items and two items measuring protective experiences, was highly acceptable to the respondents. In the factor analysis of the quantitative data, a sufficiently single-dimensional construct was found, remaining stable in retesting two weeks later. The internal consistency (omega) of the a priori one-dimensional model was 0.89 and 0.90 at baseline and follow-up, respectively. The high test-retest reliability (mean score rank order correlation 0.93) of the ACE-THL indicated that the probed perceptions of childhood experiences are stable.

CONCLUSION

Based on the initial validation, the 14-item ACE-THL questionnaire is a reliable and valid instrument to measure adverse childhood experiences, as well as protective experiences.

The burden of disease attributable to indoor air pollutants in China from 2000 to 2017

BACKGROUND

High-level exposure to indoor air pollutants (IAPs) and their corresponding adverse health effects have become a public concern in China in the past 10 years. However, neither national nor provincial level burden of disease attributable to multiple IAPs has been reported for China. This is the first study to estimate and rank the annual burden of disease and the financial costs attributable to targeted residential IAPs at the national and provincial level in China from 2000 to 2017.

METHODS

We first did a systematic review and meta-analysis of 117 articles from 37 231 articles identified in major databases, and obtained exposure-response relationships for the candidate IAPs. The exposure levels to these IAPs were then collected by another systematic review of 1864 articles selected from 52 351 articles. After the systematic review, ten IAPs with significant and robust exposure-response relationships and sufficient exposure data were finally targeted: PM2·5, nitrogen dioxide, sulphur dioxide, ozone, carbon monoxide, radon, formaldehyde, benzene, toluene, and p-dichlorobenzene. The annual exposure levels in residences were then evaluated in all 31 provinces in mainland China continuously from 2000 to 2017, using the spatiotemporal Gaussian process regression model to analyse indoor originating IAPs, and the infiltration factor method to analyse outdoor originating IAPs. The disability-adjusted life-years (DALYs) attributable to the targeted IAPs were estimated at both national and provincial levels in China, using the population attributable fraction method. Financial costs were estimated by an adapted human capital approach.

FINDINGS

From 2000 to 2017, annual DALYs attributable to the ten IAPs in mainland China decreased from 4620 (95% CI 4070-5040) to 3700 (3210-4090) per 100 000. Nevertheless, in 2017, IAPs still ranked third among all risk factors, and their DALYs and financial costs accounted for 14·1% (95% CI 12·3-15·6) of total DALYs and 3·45% (3·01-3·82) of the gross domestic product. Specifically, the rank of ten targeted IAPs in order of their contribution to DALYs in 2017 was PM2·5, carbon monoxide, radon, benzene, nitrogen dioxide, ozone, sulphur dioxide, formaldehyde, toluene, and p-dichlorobenzene. The DALYs attributable to IAPs were 9·50% higher than those attributable to outdoor air pollution in 2017. For the leading IAP, PM2·5, the DALYs attributable to indoor origins are 18·3% higher than those of outdoor origins.

INTERPRETATION

DALYs attributed to IAPs in China have decreased by 20·0% over the past two decades. Even so, they are still much higher than those in the USA and European countries. This study can provide a basis for determining which IAPs to target in various indoor air quality standards and for estimating the health and economic benefits of various indoor air quality control approaches, which will help to reduce the adverse health effects of IAPs in China.

FUNDING

The National Key Research and Development Program of China and the National Natural Science Foundation of China.

Adverse childhood experiences increase the risk for low perceived social participation and health-related quality of life in a large-scale population-based study in Germany

BACKGROUND

Adverse childhood experiences (ACEs) are highly prevalent and increase the risk for long-term adverse health outcomes. Next to well-known ACE-associated risks for morbidity, recent research is increasingly invested in exploring pathways towards health, overall functioning, and partaking in society following early adversity.

OBJECTIVES

Thus, this study aims to assess the association between latent classes of ACEs with perceived social participation and health-related Quality of Life (QoL) in a large population-based sample and to explore potential moderators of these associations.

METHOD

A representative sample of the German population (N = 2531; Mage = 48.7; 51 % women) was cross-sectionally investigated for ACEs, social participation (KsT-5), and health-related QoL (EuroQol-5D-5L). Latent Class Analysis (LCA) was performed to derive groups with similar ACE patterns. Multiple regression analyses were used to investigate the association of latent classes of ACEs with social participation and health-related QoL and to explore potential moderators.

RESULTS

Four distinct latent classes of ACEs were identified; "no/low ACEs" (N = 1968, 77.8 %); "household-dysfunction" (N = 259, 10.2 %), "child abuse and neglect" (N = 188, 7.4 %), and "polyadversity" (N = 116, 4.6 %). Compared to participants in the no/low ACE class, those in the ACE-exposed classes showed overall lower levels of perceived social participation and health-related QoL. The polyadversity class showed lower levels of social participation compared to the two other ACE-exposed classes. Chronic stress, living with a partner, education, current job/educational involvement, and gender were found to moderate these associations in exploratory analyses.

CONCLUSIONS

This study shows people exposed to ACEs to have a higher risk for lower perceived social participation and lower health-related QoL - an increased risk, however, is not a deterministic uninventable fortune. Reduction of chronic stress, fostering of social support, and educational and vocational paths as interventional targets are discussed to enable those with precarious starting conditions to partake in society.

Adverse childhood experiences: a meta-analysis of prevalence and moderators among half a million adults in 206 studies

Exposure to adverse childhood experiences (ACEs), including maltreatment and family dysfunction, is a major contributor to the global burden of disease and disability. With a large body of international literature on ACEs having emerged over the past 25 years, it is timely to now synthetize the available evidence to estimate the global prevalence of ACEs and, through a series of moderator analyses, determine which populations are at higher risk. We searched studies published between January 1, 1998 and August 5, 2021 in Medline, PsycINFO and Embase. Study inclusion criteria were using the 8- or 10-item ACE Questionnaire (±2 items), reporting the prevalence of ACEs in population samples of adults, and being published in English. The review protocol was registered with PROSPERO (CRD42022348429). In total, 206 studies (208 sample estimates) from 22 countries, with 546,458 adult participants, were included. The pooled prevalence of the five levels of ACEs was: 39.9% (95% CI: 29.8-49.2) for no ACE; 22.4% (95% CI: 14.1-30.6) for one ACE; 13.0% (95% CI: 6.5-19.8) for two ACEs; 8.7% (95% CI: 3.4-14.5) for three ACEs, and 16.1% (95% CI: 8.9-23.5) for four or more ACEs. In subsequent moderation analyses, there was strong evidence that the prevalence of 4+ ACEs was higher in populations with a history of a mental health condition (47.5%; 95% CI: 34.4-60.7) and with substance abuse or addiction (55.2%; 95% CI: 45.5-64.8), as well as in individuals from low-income households (40.5%; 95% CI: 32.9-48.4) and unhoused individuals (59.7%; 95% CI: 56.8-62.4). There was also good evidence that the prevalence of 4+ ACEs was larger in minoritized racial/ethnic groups, particularly when comparing study estimates in populations identifying as Indigenous/Native American (40.8%; 95% CI: 23.1-59.8) to those identifying as White (12.1%; 95% CI: 10.2-14.2) and Asian (5.6%; 95% CI: 2.4-10.2). Thus, ACEs are common in the general population, but there are disparities in their prevalence. They are among the principal antecedent threats to individual well-being and, as such, constitute a pressing social issue globally. Both prevention strategies and downstream interventions are needed to reduce the prevalence and mitigate the severity of the effects of ACEs and thereby reduce their deleterious health consequences on future generations.

Early-Life Factors and Multimorbidity Risk Later in Older Age: Evidence Based on CHARLS

INTRODUCTION

Early-life factors were reported to exert influence on the health condition of individuals in the long-term. However, limited research explored the connection between early-life factors and multimorbidity in later years.

METHODS

We utilized the data from the China Health and Retirement Longitudinal Study to assess this possible association in the present cross-sectional study. Multimorbidity was determined based on 14 common chronic diseases included in the study. Logistic regression was employed to examine the link between early-life factors and subsequent multimorbidity.

RESULTS

Out of 7,578 participants who met the inclusion criteria for analysis, 3,765 (49.68%) were females. The mean age was 68.25 ± 6.70 years. Participants who rated their health during childhood as average (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.63-0.96) or better [OR 0.72, 95% CI 0.57-0.91] were significantly less likely to experience multimorbidity in older life. By contrast, experiencing violence from two of the family members was significantly associated with future multimorbidity (OR [95% CI], 1.29 [1.04-1.60]). A superior family financial situation was also negatively associated with multimorbidity, with average (OR [95% CI], 0.72 [0.63-0.83]) and better off than average (OR [95% CI], 0.76 [0.62-0.93]).

DISCUSSION

Individuals with poor health status, inferior family socioeconomic status, or experienced violence from family members in childhood were more likely to suffer from multimorbidity in later life. Enhanced social monitoring of potentially adverse conditions in youngsters and targeted interventions could help mitigate the progression of multimorbidity in later life.

Killing pain? A prospective population-based study on trauma exposure in childhood as predictor for frequent use of over-the-counter analgesics in young adulthood. The HUNT study

Frequent and increasing use of over-the-counter analgesics (OTCA) is a public health concern. Pain conditions and psychological distress are related to frequent OTCA use, and as exposure to potentially traumatic events (PTE) in childhood appears to increase risk of experiencing such symptoms, we aimed to assess childhood PTEs and related symptoms in adolescence as predictors for frequent OTCA use in young adulthood. Prospective population survey data were used (n = 2947, 59.1% female, 10-13 years follow-up). Exposure to PTEs, symptoms of post-traumatic stress, anxiety and depression, musculoskeletal pain and headache were assessed in adolescence (13-19 years). Use of OTCA was assessed in young adulthood (22-32 years) and use of OTCA to treat musculoskeletal pain and headache served as separate outcomes in ordinal logistic regression analyses. Overall, exposure to childhood PTEs, particularly direct interpersonal violence, was significantly and consistently related to more frequent use of OTCA to treat musculoskeletal pain and headaches in young adulthood. Adjusting for psychological symptoms and pain attenuated associations, indicating that these symptoms are of importance for the relationship between traumatic events and OTCA use. These findings emphasize the need to address symptomatology and underlying causes at an early age.

Adversity profiles of children receiving care and support from social services: A latent-class analysis of school-aged children in Wales

BACKGROUND

Children receive care and support from social services due to the risk of harm or impeded development or because of disability. This study aimed to identify typologies of adversity experienced by children receiving care and support from social services and to explore how typologies differ by sociodemographic characteristics.

METHODS

This is a cross-sectional study of 'Children Receiving Care and Support' (N = 12 792) during 2017/2018 in Wales, UK. We sought to (1) examine the prevalence of household adversities experienced by children in receipt of care and support from social services; (2) identify typologies of household adversities; and (3) explore how typologies of household adversities differ by family characteristics (demographics, measures of social disadvantage, perinatal and care factors).

RESULTS

We found evidence for multiple risk factor constellations. The four-class solution suggested four distinct classes of adversities: child disability (50.0%), low adversities (20.3%), family poor health (6.7%) and multiple risks (23.0%). Children in the 'multiple risk' class were significantly more likely to be younger, more deprived and 'looked after' by the local authority compared with those in the 'low adversities' class.

CONCLUSIONS

Given the presence of different constellations of household adversities, policies and interventions that address multiple risk factors simultaneously may be more effective and have longer-lasting benefits.

Depression among Patients with an Implanted Left Ventricular Assist Device: Uncovering Pathophysiological Mechanisms and Implications for Patient Care

Depression is a common and devastating mental illness associated with increased morbidity and mortality, partially due to elevated rates of suicidal attempts and death. Select patients with end-stage heart failure on a waiting-list for a donor heart undergo left ventricular assist device (LVAD) implantation. The LVAD provides a circulatory flow of oxygenated blood to the body, mimicking heart functionality by operating on a mechanical technique. LVAD improves functional capacity and survivability among patients with end-stage heart failure. However, accumulating data suggests that LVAD recipients suffer from an increased incidence of depression and suicide attempts. There is scarce knowledge regarding the pathological mechanism and appropriate treatment approach for depressed LVAD patients. This article summarizes the current evidence on the association between LVAD implantation and occurrence of depression, suggesting possible pathological mechanisms underlying the device-associated depression and reviewing the current treatment strategies. The summarized data underscores the need for a rigorous pre-(LVAD)-implantation psychiatric evaluation, continued post-implantation mental health assessment, and administration of antidepressant treatment as necessary.

Comparison of Person-Centered and Cumulative Risk Approaches in Explaining the Relationship Between Adverse Childhood Experiences and Behavioral and Emotional Problems

Adverse childhood experiences (ACEs) commonly co-occur, and researchers often estimate their impact using a cumulative risk approach. The person-centered approach offers another approach to operationalize the co-occurrence of ACEs. This study aims to estimate latent classes of ACEs in a sample of U.K. children, examine their relationship with emotional and behavioral problems, and compare the explanatory value of the latent classes to cumulative risk scores. Data were collected among a general population sample of British 10-year-old children extracted from the U.K. Household Longitudinal Study (N = 601). Seven items characterized ACEs, comprising parent-report physical discipline, emotional abuse, supervisory neglect, maternal psychological distress, child-report parental educational disinterest, bullying victimization, and adverse neighborhood. Outcome measures were derived from the self-report Strengths and Difficulties Questionnaire including total difficulties, emotional symptoms, conduct problems, hyperactivity, peer problems, and prosocial behavior. Latent class analysis resulted in a three-class solution: low ACEs, household challenges, and community challenges. Compared to the other classes, the community challenges class scored substantially worse on total difficulties, emotional symptoms, and peer subscales. The cumulative risk score was associated with all outcomes except prosocial behavior. Cumulative risk models accounted for a larger proportion of variance compared with the latent class models, except for peer problems which the person-centered model explained better. This study confirms that ACEs are associated with impairment in child functioning, and that both person-centered and cumulative risk approaches can capture this relationship well. Specifically, the person-centered approach demonstrated how co-occurring risk factors in the community challenges class produced particularly poor internalizing outcomes.

[Family stressors on young children's emotional development]

BACKGROUND

Adverse childhood experiences (ACE) have been pointed out as risk factors for physical and mental health, with consequences extending from childhood into adulthood. Based on research regarding the effects of selected ACE as well as the accumulation of ACE, this article investigates how different types of family stressors are linked to children's negative emotionality in infancy and early childhood.

METHODS

Data are from the KiD 0-3 study (N = 5583) and the follow-up of a subsample after 2 years (n = 681). Based on 14 stress factors, we distinguish families with no/little stressors, socioeconomic stressors, parenting stressors, and multiple stressors.

RESULTS

Children in multiply stressed families have the highest risk of high negative emotionality (compared to unstressed families: Odds Ratios [OR] ranging from 13.00 to 6.81), controlling for demographic characteristics, child-related stress factors (e.g., excessive crying), and caregiver childhood stress. Children in families primarily characterized by parenting stress also showed a significantly increased risk of high negative emotionality (OR ranging from 8.31 to 6.95), whereas this did not hold for children from socioeconomically stressed families (without parenting stress) compared to those from unstressed families. Longitudinal analyses of the follow-up subsample showed that changes in the number of stressors were also associated with parallel changes in children's negative emotionality.

DISCUSSION

These results confirm findings from international research on ACE in Germany and for early childhood. They underline the importance of a well-developed early intervention system.

Spousal concordance in adverse childhood experiences and the association with depressive symptoms in middle-aged and older adults: findings across China, the US, and Europe

Background

Adverse childhood experiences (ACEs) are associated with higher depressive risks in adulthood. Whether respondents' ACEs are associated with their own depressive symptoms in adulthood and whether this association extends to their spouses' depressive symptoms remain unexplored.

Methods

Data were from China Health and Retirement Longitudinal Study (CHARLS), the Health and Retirement Study (HRS), and the Survey of Health, Ageing and Retirement in Europe (SHARE). ACEs were categorized into overall, intra-familial, and extra-familial ACEs. Correlations of couples' ACEs were calculated using Cramer's V and partial Spearman's correlation. Associations of respondents' ACEs with spousal depressive symptoms were assessed using logistic regression, and mediation analyses were conducted to explore the mediating role of respondents' depressive symptoms.

Results

Significant associations between husbands' ACEs and wives' depressive symptoms, with odds ratios (ORs) and 95% confidence intervals (CIs) of 2.09 (1.36-3.22) for 4 or more ACEs in CHARLS, and 1.25 (1.06-1.48) and 1.38 (1.06-1.79) for 2 or more ACEs in HRS and SHARE. However, wives' ACEs were associated with husbands' depressive symptoms only in CHARLS and SHARE. Findings in intra-familial and extra-familial ACEs were consistent with our main results. Additionally, respondents' depressive symptoms mediated more than 20% of the effect of respondents' ACEs on spousal depressive symptoms.

Conclusion

We found that ACEs were significantly correlated between couples. Respondents' ACEs were associated with spousal depressive symptoms, with respondents' depressive symptoms mediating the association. The bidirectional implications of ACEs on depressive symptoms should be considered within household and effective interventions are warranted.

Childhood adversity is associated with hospitalisations and survival following external causes and non-communicable diseases: a 46-year follow-up of a Stockholm birth cohort

BACKGROUND

Childhood adversity indicated by involvement with child welfare services (ICWS) is associated with increased risks of disease and injuries in young adulthood. It is yet unknown whether such risks are limited to external causes and mental and behavioural disorders or whether they extend beyond early adulthood and to non-communicable diseases (NCDs) with later onset. Moreover, it has not been explored whether ICWS associates with decreased survival prospects following hospitalisation.

METHODS

Based on prospective data for a 1953 Stockholm birth cohort (n=14 134), ICWS was operationalised distinguishing two levels in administrative child welfare records (ages 0-19; 'investigated' and 'placed' in out-of-home care (OHC)). Hospitalisations and all-cause mortality (ages 20-66) were derived from national registers. Hospitalisation records were categorised into external causes and NCDs, and nine subcategories. Negative binomial regression models were used to estimate differences in hospitalisation risks between those with and without experiences of ICWS and Cox survival models to estimate mortality after hospitalisation.

RESULTS

Placement in OHC was associated with higher risks of hospitalisation due to external causes and NCDs and all investigated subcategories except cancers. Risks were generally also elevated among those investigated but not placed. ICWS was further linked to higher mortality risks following hospitalisation.

CONCLUSION

Differential risk of morbidity and differential survival may explain inequalities in mortality following childhood adversity. We conclude that the healthcare sector might play an important role in preventing and mitigating the elevated risks of externally caused morbidity, disease and premature mortality observed among those with a history of ICWS.

Supporting student learning and development through trauma-informed campuses

Many students come to higher education with a history of trauma. College life may also expose students to traumatizing events. While the past decade has witnessed greater discussion of trauma-informed frameworks, it has not regularly been applied to the college environment. We advance the concept of a trauma-informed campus, where administrators, faculty, staff, and students from diverse disciplines create an environment that recognizes the widespread nature of trauma, integrates knowledge about trauma into practices and procedures, and minimizes further re-traumatization for all community members. A trauma-informed campus is prepared for students' past or future traumatic experiences, while also recognizing and responding to structural and historical harms. In addition, it recognizes the role of the surrounding community challenges, particularly how violence, substance use, hunger, poverty, and housing insecurity may contribute to further trauma or negatively impact healing. We use an ecological model to frame and shape the construct of trauma-informed campuses.

Air Purifier Intervention to Remove Indoor PM2.5 in Urban China: A Cost-Effectiveness and Health Inequality Impact Study

Using air purifiers is an intervention to reduce exposure to fine particulate matter (PM_2.5) for health benefits. We performed a comprehensive simulation in urban China to estimate the cost-effectiveness of long-term use of air purifiers to remove indoor PM_2.5 from indoor and ambient air pollution in five intervention scenarios (S1-S5), where the indoor PM_2.5 targets were 35, 25, 15, 10, and 5 μg/m³, respectively. In scenarios S1 to S5, 5221 (95% uncertainty interval: 3886-6091), 6178 (4554-7242), 8599 (6255-10,109), 11,006 (7962-13,013), and 14,990 (10,888-17,610) thousand disability-adjusted-life-years (DALYs) can be avoided at the cost of 201 (199-204), 240 (238-243), 364 (360-369), 522 (515-530), and 921 (905-939) billion Chinese Yuan (CNY), respectively. A high disparity in per capita health benefits and costs was observed by city, which expanded with the decrease of the indoor PM_2.5 target. The net benefits of using purifiers in cities varied across scenarios. Cities with a lower ratio of annual average outdoor PM_2.5 concentration to gross domestic product (GDP) per capita tended to achieve higher net benefits in the scenario with a lower indoor PM_2.5 target. Controlling ambient PM_2.5 pollution and developing the economy can reduce the inequality in air purifier use across China.