While adverse childhood experiences and trauma, including childhood abuse and neglect, have often been viewed from the lens of psychiatry, their influence on physical health, health behaviors, and factors that moderate health now garner more attention. This article reviews recent literature that has changed clinical and social viewpoints on child abuse and neglect and can be used as a primer to better understand (1) influences of child abuse and neglect on physical illness; (2) critical diagnostic advances relevant to persons who have experienced child abuse and neglect; and (3) ethical, research, and practical questions generated by these new understandings.
Trauma’s Roles in Health
Increasing attention is being paid to the impact of child abuse and neglect on health. The rapidly growing knowledge base on long-term outcomes of those exposed to child abuse and neglect in the form of both trauma and adverse childhood experiences (ACEs), such as childhood economic hardship, neglect, sexual abuse, emotional abuse, discrimination, racism, household dysfunction, exposure to violence, parental mental illness, and parental substance use has warranted this attention. These types of maltreatment have often been viewed only from the lens of psychiatry, but it is now clear that, beyond their impact on mental health, these experiences affect biological mechanisms that influence physical health, health behaviors, and other factors that moderate good health, making it a general concern for all of health care and for those invested in improving health outcomes at large.
Given these wide-ranging health impacts, health care systems and individual practitioners must be prepared to evaluate childhood maltreatment-related health concerns. Many clinicians feel unprepared to do this sort of work, and it was likely absent from their training.5 This article aims to review recent core literature that has broadened medicine’s understanding of the forms of child abuse and neglect. It also provides a primer to better understand (1) the impact of child abuse and neglect on physical health; (2) critical diagnostic advances relevant to those who have experienced ACEs; and (3) the ethical, research, and practical issues that arise from this new understanding of child abuse and neglect.
Physical Impact of Child Abuse and Neglect
In 1998, a Kaiser Permanente survey of adults revealed that ACEs were common among patients undergoing routine medical evaluations and were related to serious health risks and conditions in later life. More specifically, the researchers found that over half of 13 000 respondents had been exposed to at least one ACE, with risk for substance use, suicide attempts, and serious medical conditions—such as ischemic heart disease, cancer, and liver disease—increasing with the breadth of exposure to ACEs. The lifetime health effects of child abuse and neglect have since been researched and characterized in depth.
In 2017, the American Heart Association published a scientific statement outlining the downstream effects of ACEs, which included trauma, on cardiac disease.8 Increased cardiac disease and cardiac disease risk factors in adults who experienced maltreatment as children are seen in mostly high-income countries. This cornerstone publication gave further scientific credence to the critical role of child abuse and neglect in physical health more generally. Specifically, it highlighted that ACEs affect physical health through 3 mechanisms:
- change in health behaviors (eg, decreased physical activity, tobacco use),
- biological embedding (eg, inflammation, abnormal endocrine function), and
- increases in mental health problems. Given this broadened understanding, efforts are needed to mitigate the impact of child abuse and neglect on people’s overall health.