Submit manuscript...
Journal of
eISSN: 2574-9943

Dermatology & Cosmetology

Research Article Volume 7 Issue 3

Adverse childhood experiences (ACEs) and associated health outcomes among adults with skin cancer

Chidubem AV Okeke,1 Jonathan P Williams,2 Joseph H Tran,1 Angel S Byrd3

1Howard University College of Medicine, Washington, DC, USA
2Department of Psychiatry, Icahn School of Medicine at Mount Sinai Morningside-West, New York, NY, USA
3Department of Dermatology, Howard University College of Medicine, Washington, DC, USA

Correspondence: Chidubem Okeke, Howard University College of Medicine, Department of Dermatology 520 W Street NW, Room 3035/3036, Washington, DC, USA

Received: August 15, 2023 | Published: August 23, 2023

Citation: Okeke CAV, Williams JP, Tran JH, et al. Adverse childhood experiences (ACEs) and associated health outcomes among adults with skin cancer. J Dermat Cosmetol. 2023;7(3):91-97. DOI: 10.15406/jdc.2023.07.00243

Download PDF

Abstract

Background: Ongoing investigations established the relationship between adverse childhood experiences (ACEs) and chronic diseases, such as high blood pressure, diabetes, atopic dermatitis, and psoriasis. However, the specific association between ACEs and skin cancer remains relatively unexplored in scientific literature.

Objective: This study aimed to evaluate the relationship between adverse childhood experiences (ACEs) and measures of health-related quality of life (HRQOL) among individuals with a skin cancer diagnosis.

Methods: Data from the 2019 Behavioral Risk Factors and Surveillance Study (BRFSS) were analyzed. The study included 418,268 adults, with 41,773 individuals diagnosed with skin cancer. HRQOL measures, including physical health, mental health, and lifestyle impairment, were assessed using self-reported data. ACEs were identified through participants' responses to 11 specific questions. Multivariable logistic regression analyses adjusted for demographic variables.

Results: Skin cancer survivors with a history of ACEs reported significantly poorer physical health (OR 1.39, 95% CI 1.24-1.56) and mental health (OR 2.13, 95% CI 1.81-2.51) compared to those without ACEs. They also experienced higher levels of lifestyle impairment related to health (OR 1.31, 95% CI 1.16-1.48). Commonly reported ACEs included parental separation, exposure to domestic violence, and verbal abuse.

Discussion: This study highlights the detrimental impact of childhood maltreatment on HRQOL among skin cancer survivors. Healthcare professionals should be attentive to the unique needs of this population by providing comprehensive support and interventions.

Conclusion: Childhood maltreatment has a significant negative impact on HRQOL among skin cancer survivors. The study emphasizes the importance of addressing the psychological and emotional well-being of individuals with a history of ACEs. Healthcare professionals should consider the specific needs of this vulnerable population to provide appropriate care and support. Further research is required to deepen our understanding of the underlying mechanisms and to develop effective interventions to improve the well-being of skin cancer survivors with a history of childhood maltreatment. Furthermore, longitudinal analyses and objective measures are needed to establish causal relationships and mitigate potential biases.

Keywords: ACEs, BRFSS, health outcomes, skin cancer, dermatology, quality of life, psychodermatology

Abbreviations

ACE, adverse childhood experiences; HRQOL, health-related quality of life; BRFSS, behavioral risk factors and surveillance study; CDC, centers for disease control and prevention

Introduction

Skin cancers are one of the most common cancers in the United States (US).1,2 Research has highlighted the detrimental effects of adverse childhood experiences (ACEs) on individuals' overall health and well-being throughout their lives. These experiences, such as abuse, neglect, and household dysfunction, have been linked to various chronic diseases, prompting ongoing investigations into their long-term impact, particularly concerning different forms of cancer.2,3

ACEs have been shown to be associated with the adoption of risky health behaviors in adulthood, such as smoking, alcohol use, and substance abuse.

These risk factors are directly associated with an increased risk of cancer development as well as worsened health outcomes.4,5Additionally, ACEs have been posited to have their own inherent influence on cancer development and survival.5,6 Research has shown that adults who have experienced ACEs have also been associated with lower serum levels of IL-2.6 As IL-2 is an immune modulator directly associated with preventing tumor progression, it has been hypothesized that these lower serum levels of IL-2 may be associated with the worse prognosis and survival seen in cancer patients who have experienced ACEs.5

While the correlation between ACEs and adverse health outcomes in adulthood is well-established, the specific association between ACEs and skin cancer remains relatively unexplored in scientific literature.

Therefore, this study aims to highlight the potential relationship between ACEs and health-related quality of life (HRQOL) measures among individuals diagnosed with skin cancer. By examining these factors, a more comprehensive understanding of the multifaceted impact of ACEs on skin cancer patients can be attained, potentially leading to improved care and support for this vulnerable population.

Material and methods

This cross-sectional study analyzed information from the Behavioral Risk Factors and Surveillance Study (BRFSS) dataset. The BRFSS is a nationwide health-related telephone survey administered to adults aged 18 years and older throughout the United States. Disseminated annually by the Centers for Disease Control and Prevention (CDC) and state health departments, the BRFSS presents population level data regarding health-determining risk factors and behaviors, chronic disease prevalence, and utilization of preventative services. States participating in the BRFSS began collecting data on adverse childhood experiences starting in 2009. Iterative proportional fitting is applied to survey results to ensure the data is weighted appropriately and remains nationally representative. This continuously generated de-identified dataset is reviewed by an Institutional Review Board and is publicly accessible.

The BRFSS 2019 dataset includes measures of HRQOL such as physical health, mental health, lifestyle impairment, skin cancer prevalence, and measures of adverse experiences during childhood. Multiple studies have confirmed this questionnaire’s validity and reliability.7 Any participant who has received a positive diagnosis of skin cancer is presented as either having skin cancer (+) or not having skin cancer (-). Health status pertaining to physical health, mental health, and poor health contributing to lifestyle impairment was determined by asking about the number of days to which physical health, mental health, or poor physical health contributing to lifestyle impairment applied within the last the 30 days. Those who reported having 1-13 days or 14-30 days of poor physical health, poor mental health, or poor health contributing to lifestyle impairment were dichotomized as having “Good” or “Poor” health status respectively.

Responses to having ever experienced any number of the 11 ACEs presented were categorized as being participants “With” or “Without” a history of ACEs. Specific ACEs surveyed within this study are included in Table 1.

ACE Category

Survey Question

Response Option

Household Issues

   

Mentally Ill Household Member

Did you live with anyone who was depressed, mentally ill, or suicidal?

Yes/No

Substance Abuse in Household

Did you live with anyone who was a problem drinker or alcoholic?

Yes/No

 

Did you live with anyone who used illegal street drugs or who abused prescription medications?

Yes/No

Incarcerated Household Member

Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility

Yes/No

Parental Separation

Were your parents separated or divorced?

Yes/No

Violence between Household Adults

How often did you parents or adults in your home ever slap, hit, kick, punch, or beat each other up?

Never/Once/More Than Once

Childhood Abuse

 

 

 

 

 

Yes/No

Physical Abuse

Not including spanking, (before age 18), how often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way?

Never/Once/More Than Once

Verbal Abuse

How often did a parent or adult in your home ever swear at you, insult you, or put you down?

Never/Once/More Than Once

Sexual Abuse

How often did anyone at least 5 years older than you or an adult, ever touch you sexually?

Never/Once/More Than Once

 

How often did anyone at least 5 years older than you or an adult, try to make you touch them sexually?

Never/Once/More Than Once

 

How often did anyone at least 5 years older than you or an adult, force you to have sex?

Never/Once/More Than Once

Table 1

Results

A total of 418,268 adults participated in the 2019 BRFSS survey. Of the sampled population, 41,773 individuals (10%) have received a diagnosis of skin cancer (Figure 1) 6,724 (56%) adult skin cancer survivors reported experiencing at least one ACE throughout their childhood (Figure 2).  Among adult skin cancer survivors, the highest reported adverse experience during childhood was being sworn at, insulted, or put down (Figure 3). Demographic information regarding adult skin cancer survivors is presented (Table 2). Adult skin cancer survivors with any history of ACEs were predominantly over the age of 65-years-old (68%), female (54%), White and non-Hispanic (95%), overweight (38%), graduates of college/technical school (41%), and at an income level greater than or equal to $50,000 (50%) compared to skin cancer survivors without a history of ACEs. These individuals also more likely to have health insurance coverage (97%) compared to skin cancer survivors without a history of ACEs.

Figure 1 Prevalence of adult skin cancer survivors in sampled population. Behavioral Risk Factor Surveillance System (BRFSS), 2019.

Figure 2 Prevalence of adverse childhood experiences (ACEs) among adults with and without diagnosis of skin cancer.
Behavioral Risk Factor Surveillance System (BRFSS), 2019.

Figure 3 Distribution of adult skin cancer survivors across measures of adverse childhood experiences.
Behavioral Risk Factor Surveillance System (BRFSS), 2019.

   

(+) Skin Cancer Total n (%)

(+) Skin Cancer w/ ACEs n (%)

(+) Skin Cancer w/o ACEs n (%)

p-value

Age

       

< 0.0001

 

18-24 years old

30 (0.25)

25 (0.37)

5 (0.09)

 
 

25-34 years old

78 (0.65)

54 (0.80)

24 (0.45)

 
 

35-44 years old

226 (1.87)

160 (2.38)

66 (1.23)

 
 

45-54 years old

775 (6.42)

520 (7.73)

255 (32.90)

 

55-64 years old

2,231 (18.48)

1,415 (21.04)

816 (15.26)

 

65+ years old

8,732 (72.33)

4,550 (67.67)

4,182 (78.20)

Sex

       

0.062

 

Male

5,700 (47.22)

3,124 (46.46)

2,576 (48.17)

 

Female

6,372 (52.78)

3,600 (53.54)

2,772 (51.83)

Race/Ethnicity

     

< 0.0001

 

White, Non-Hispanic

11,609 (96.16)

6,411 (95.35)

5,198 (97.20)

 

Black, Non-Hispanic

90 (0.75)

57 (0.85)

33 (0.62)

 
 

Asian, Non-Hispanic

8 (0.07)

4 (0.06)

4 (0.07)

 
 

American Indian/Alaskan Native, Non-Hispanic

66 (0.55)

40 (0.59)

26 (0.49)

 
 

Hispanic

112 (0.93)

78 (1.16)

34 (0.64)

 
 

Other Race

187 (1.55)

134 (1.99)

53 (0.99)

 

BMI

       

< 0.0001

 

Underweight

201 (1.73)

112 (1.73)

89 (1.74)

 
 

Normal Weight

3,540 (30.53)

1,890 (29.14)

1,650 (32.30)

 

Overweight

4,450 (38.38)

2,432 (37.50)

2,018 (39.50)

 

Obese

3,404 (29.36)

2,052 (31.64)

1,352 (26.46)

Education

     

< 0.0001

 

Did not graduate High School

652 (5.42)

428 (6.38)

224 (4.20)

 
 

Graduated High School

3,054 (25.37)

1,658 (24.72)

1,396 (26.17)

 

Attended College/Technical School

3,286 (27.29)

1,901 (28.35)

1,385 (25.97)

 

Graduated College/Technical School

5,048 (41.93)

2,719 (40.55)

2,329 (43.66)

Income

       

< 0.0001

 

< $15,000

667 (5.53)

467 (8.25)

200 (3.74)

 
 

$15,000-24,999

1,477 (12.23)

905 (15.99)

572 (10.70)

 

$25,000-34,999

1,095 (9.07)

627 (11.08)

468 (8.75)

 
 

$35,000-49,999

1,530 (12.67)

841 (14.86)

689 (12.88)

 

³ $50,000

5,098 (42.23)

2,820 (49.82)

2,278 (54.15)

Health Insurance Coverage

   

< 0.0001

 

Yes

11,785 (97.80)

6,530 (97.22)

5,255 (98.54)

 

No

265 (2.20)

187 (2.78)

78 (1.46)

 

Physical Health

     

< 0.0001

 

Good (0-13d)

9,451 (81.01)

5,091 (78.17)

4,360 (84.61)

 

Poor (14-30d)

2,215 (18.99)

1,422 (21.83)

793 (15.39)

Mental Health

     

< 0.0001

 

Good (0-13d)

10,585 (89.86)

5,672 (86.50)

4,913 (94.08)

 

Poor (14-30d)

1,194 (10.14)

885 (13.50)

309 (5.92)

 

Poor health with lifestyle impairment

 

< 0.0001

 

Good (0-13d)

4,996 (78.15)

3,033 (76.44)

1,963 (80.95)

 

Poor (14-30d)

1,397 (21.85)

935 (23.85)

462 (19.05)

Table 2 Demographic characteristics among Adult Skin Cancer Survivors. Behavioral Risk Factor Surveillance System (BRFSS), 2019

Unadjusted bivariate analyses were conducted to evaluate the relationship between adult skin cancer survivors with any history of ACEs and measures of HRQOL including physical health, mental health, health status contributing to lifestyle activities impairment (Table 3). Adult skin cancer survivors had significantly higher odds of having poor physical health (OR 1.54, 95% CI 1.40 - 1.69), poor mental health (OR 2.48, 95% CI 2.17 - 2.84), and poor health contributing to lifestyle activities impairment (OR 1.31, 95% CI 1.16 - 1.48) compared to adult skin cancer survivors without a history of ACEs.

 

Odds Ratio (95% CI) (+) Skin Cancer

p-value

 

w/ ACEs

w/o ACEs

 

Physical Health

1.54 (1.40, 1.69)

reference

< 0.0001

Mental Health

2.48 (2.17, 2.84)

reference

< 0.0001

Poor Health with Lifestyle Impairment

1.31 (1.16, 1.48)

reference

< 0.0001

Table 3 Associations between measures of physical health, mental health, and health contributing to lifestyle impairment among adult skin cancer survivors with and without a history of adverse childhood experiences (ACEs). Behavioral Risk Factor Surveillance System (BRFSS), 2019

Multivariable logistic regression analyses were conducted to further evaluate the relationship between adult skin cancer survivors with any history of ACEs and measures of HRQOL after adjusting for demographic variables (Table 4). Adult skin cancer survivors with any history of ACEs had significantly higher odds of having poor physical health (OR 1.39, 95% CI 1.24 - 1.56) and poor mental health (OR 2.13, 95% CI 1.81 - 2.51) compared to adult skin cancer survivors without a history of ACEs.

   

Odds Ratio (95% CI)

 
   

Physical Health

Mental Health

Poor Health with Lifestyle Impairment

ACE Exposure

     
 

No

Reference

Reference

Reference

 

Yes

1.39 (1.24, 1.56)*

2.13 (1.81, 2.51)*

1.14 (0.98, 1.33)

Age

       
 

18-24 years old

Reference

Reference

Reference

 

25-34 years old

1.52 (0.28, 8.21)

0.72 (0.25, 2.01)

1.00 (0.22, 4.66)

 

35-44 years old

2.67 (0.57, 12.61)

0.44 (0.17, 1.16)

1.82 (0.46, 7.15)

 

45-54 years old

2.50 (0.55, 11.40)

0.38 (0.15, 0.95)*

1.58 (0.42, 5.93)

 

55-64 years old

2.85 (0.63, 12.83)

0.24 (0.10, 0.59)*

1.80 (0.49, 6.66)

 

65+ years old

2.61 (0.58, 11.73)

0.13 (0.05, 0.32)*

1.40 (0.38, 5.16)

Sex

       
 

Male

Reference

Reference

reference

 

Female

0.97 (0.87, 1.08)

1.45 (1.25, 1.68)*

0.87 (0.76, 1.01)

Race/Ethnicity

     
 

White, Non-Hispanic

Reference

Reference

reference

 

Black, Non-Hispanic

0.94 (0.51, 1.76)

1.10 (0.56, 2.17)

0.92 (0.45, 1.89)

 

Asian, Non-Hispanic

2.59 (0.42, 16.06)

2.96 (0.31, 28.07)

4.98 (0.77, 32.13)

 

American Indian/Alaskan Native, Non-Hispanic

1.92 (1.00, 3.68)*

2.18 (1.07, 4.44)*

0.88 (0.43, 1.81)

 

Hispanic

0.83 (0.48, 1.44)

0.89 (0.48, 1.67)

1.25 (0.70, 2.23)

 

Other Race

1.83 (1.25, 2.66)*

2.43 (1.60, 3.69)*

1.74 (1.12, 2.70)*

BMI

       
 

Underweight

Reference

Reference

Reference

 

Normal Weight

0.40 (0.27, 0.59)

0.59 (0.36, 0.96)*

0.43 (0.27, 0.69)*

 

Overweight

0.44 (0.30, 0.65)

0.70 (0.43, 1.14)

0.44 (0.28, 0.71)*

 

Obese

0.73 (0.49, 1.08)

0.88 (0.54, 1.44)

0.69 (0.43, 1.09)

Education

     
 

Did not graduate High School

Reference

Reference

Reference

 

Graduated High School

0.72 (0.57, 0.90)*

0.83 (0.63, 1.10)

0.75 (0.58, 0.98)

 

Attended College/Technical School

0.73 (0.58, 0.92)*

0.92 (0.70, 1.22)

0.76 (0.58, 1.00)*

 

Graduated College/Technical School

0.58 (0.46, 0.74)

0.64 (0.47, 0.86)*

0.57 (0.43, 0.75)*

Income

       
 

< $15,000

Reference

Reference

Reference

 

$15,000-24,999

0.65 (0.53, 0.80)*

0.65 (0.51, 0.82)*

0.61 (0.48, 0.77)*

 

$25,000-34,999

0.47 (0.37, 0.58)*

0.51 (0.39, 0.67)*

0.48 (0.37, 0.63)*

 

$35,000-49,999

0.30 (0.24, 0.37)*

0.31 (0.24, 0.41)*

0.33 (0.26, 0.44)*

 

³ $50,000

0.19 (0.15, 0.23)*

0.20 (0.16, 0.26)*

0.25 (0.20, 0.32)*

Health Insurance Coverage

   
 

No

Reference

Reference

Reference

 

Yes

1.33 (0.91, 1.93)

0.90 (0.62, 1.31)

1.03 (0.67. 1.57)

Table 4 Multivariate logistic regression evaluating the relationship between ACEs and measures of physical health, mental health, and health contributing to lifestyle impairment among adult skin cancer survivors
Behavioral Risk Factor Surveillance System (BRFSS), 2019 (*) Indicates a significant p-value <0.05

Discussion

This study provides valuable insights into the impact of childhood maltreatment on HRQOL among skin cancer survivors. By examining a large, nationally representative sample, this study contributes to the existing literature by shedding light on an important, but understudied area. Our findings underscore the significant deleterious role of childhood maltreatment in influencing HRQOL outcomes among skin cancer survivors.

The first key finding of this study is that skin cancer survivors with a history of ACEs reported poorer physical and mental health outcomes compared to their counterparts without such experiences. This finding is consistent with prior research demonstrating the enduring effects of childhood maltreatment on various health outcomes throughout the lifespan. Researchers had previously found that ACEs were associated with an increased chance of development of obesity in adulthood8 as well as development of other chronic health conditions such as high blood pressure,9 diabetes,5,10 atopic dermatitis,11 and psoriasis.12 While a direct mechanism of association has not been determined for these conditions, different biological pathways have been proposed to explain this phenomenon. One pathway suggests that ACEs cause a change in epigenetic mechanisms to the immune system, which may ultimately predispose patients exposed to ACEs to illness as well as chronic inflammation.13-15

Another proposed pathway suggests that repeated ACEs may cause dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, which causes cortisol to be disproportionately produced. This dysregulation in HPA axis and cortisol production may cause patients to respond inadequately to inflammation and stress, which predisposes patients to chronic inflammation, fatigue, infection, and neurological issues.16-20 Despite the inconclusive mechanism of association between ACEs and these biological findings, this study, along with previous research, highlights the long-lasting impact of ACEs on the well-being of individuals, even after they have survived skin cancer.

Furthermore, this study's inclusion of multiple HRQOL measures provides a comprehensive assessment of the overall well-being of skin cancer survivors with a history of childhood maltreatment. The findings indicate that these individuals not only experience poorer physical health but also suffer from compromised mental health and lifestyle impairment. These findings are consistent with previous studies that found that ACEs negatively affected the physical and mental development of patients who experienced ACEs.21 The effect of ACEs on physical health, mental health, and lifestyle impairment may have multiple proposed explanations. Patients with a history of multiple ACEs were often found to face barriers with educational success,22,23 health literacy,24 and poor reading ability.25

These barriers are negatively affecting a patient’s knowledge of and access to medical care, which results in delays in both diagnosis and treatment. This is also congruent with previous research that showed that education regarding skin cancer and health literacy can influence skin cancer prevention and treatment.26,27 Additionally, patients with a history of ACEs of neglect are predisposed to engaging in risky health behaviors such as smoking, alcohol use, illicit drug use, or unsafe sex practices.28-30

These behaviors put patients at increased risk of developing chronic health conditions such as obesity, hypertension, hypercholesteremia, as well as development of different types of cancer and can even development of mental health disorders.31,32 These behaviors may stem from neglect, where patients may not have been educated or prevented from engaging in these behaviors at an early age, or in homes where the adults engage in these behaviors themselves, research has shown that it can create a self-perpetuating generational cycle of ACEs.33-35 Ultimately, the present study highlights the multifaceted nature of the impact of childhood maltreatment on HRQOL and emphasizes the importance of addressing both the physical and psychological aspects of well-being in this population.

This knowledge of a patient’s developmental history becomes instrumental in ensuring better HRQOL outcomes for skin cancer survivors and ultimately calls for comprehensive, multidisciplinary, coordinated care for these patients. Healthcare professionals should also recognize the potential psychological and emotional challenges faced by individuals with a history of ACEs and skin cancer. A holistic approach to care, which considers the specific needs of this vulnerable population, is thus crucial. Regular communication and information-sharing between providers play a crucial role as this ensures that everyone involved is aware of the child's progress, any changes in their condition, and potential adjustments required in their treatment plan. Collaborative efforts can help identify any gaps in care, prevent misunderstandings, and promote a more streamlined and efficient healthcare journey for the developing patient. By being vigilant in screening for ACEs in both pediatric and adult patients and offering appropriate support and interventions, healthcare professionals can potentially prevent worse HRQOL outcomes in future skin cancer survivors and improve the overall well-being of skin cancer survivors who have experienced childhood maltreatment.

It is important to acknowledge that the cross-sectional design of this study limits the ability to establish causal relationships between childhood maltreatment and HRQOL outcomes. Future research utilizing longitudinal analyses could provide stronger evidence regarding the temporal associations between ACEs and HRQOL in skin cancer survivors. Additionally, the reliance on self-reported data introduces the possibility of recall bias. Future studies could incorporate objective measures of childhood maltreatment, such as official records or reports, to enhance the reliability and validity of the findings. These methodological improvements would strengthen the evidence base and contribute to a more nuanced understanding of the relationship between childhood maltreatment and HRQOL among skin cancer survivors.

Conclusion

This study's findings regarding the detrimental impact of childhood maltreatment on HRQOL among skin cancer survivors in a nationally representative sample carry significant implications for clinical practice and public health. This study contributes to the growing body of knowledge on the long-term consequences of ACEs and emphasizes the need for comprehensive and tailored support for both individuals currently facing ACEs as well as individuals with a history of childhood maltreatment and skin cancer. Further research is warranted to elucidate the underlying mechanisms driving this relationship and to identify effective interventions that promote resilience and improve the well-being of this vulnerable population.

Acknowledgments

CAVO is the inaugural recipient of the Women’s Dermatologic Society-La Roche Posay Dermatology Fellowship. ASB is the inaugural recipient of the Skin of Color Society Career Development Award as well as the Society for Investigative Dermatology Freinkel Diversity Fellowship Award, and recipient of the Robert A. Winn Diversity in Clinical Trials Development Award, funded by Bristol Myers Squibb Foundation.

Conflicts of interest

Authors declare there is no conflict of interest.

References

  1. Ottwell R, Cook C, Greiner B, et al Lifestyle behaviors and sun exposure among individuals diagnosed with skin cancer: a cross-sectional analysis of 2018 BRFSS data. J Cancer Surviv. 2021;15(5):792–798.
  2. Holman DM, Ports KA, Buchanan ND, et al. The Association between adverse childhood experiences and risk of cancer in adulthood: a systematic review of the literature. Pediatrics. 2016;138(Suppl 1):S81–S91.
  3. Ports KA, Holman DM, Guinn AS, et al. Adverse childhood experiences and the presence of cancer risk factors in adulthood: a scoping review of the literature from 2005 to 2015. J Pediatr Nurs. 2019;44:81–96.
  4. Brown DW, Anda RF, Felitti VJ, et al. Adverse childhood experiences are associated with the risk of lung cancer: a prospective cohort study. BMC Public Health. 2010;10:20.
  5. Hughes K, Bellis MA, Hardcastle KA, et al. The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. Lancet Public Health. 2017;2(8):e356–e366.
  6. Steel JL, Antoni M, Pathak R, et al. Adverse childhood experiences (ACEs), cell-mediated immunity, and survival in the context of cancer. Brain Behav Immun. 2020;88:566–572.
  7. Pierannunzi C, Hu S S, Balluz L. A systematic review of publications assessing reliability and validity of the behavioral risk factor surveillance system (BRFSS), 2004-2011. BMC Medical Research Methodology. 2013;13:49.
  8. Williamson DF, Thompson TJ, Anda RF, et al. Body weight and obesity in adults and self-reported abuse in childhood. Int J Obes Relat Metab Disord. 2002;26(8):1075–1082.
  9. Su S, Wang X, Pollock JS, et al. Adverse childhood experiences and blood pressure trajectories from childhood to young adulthood: the Georgia stress and heart study. Circulation. 2015;131(19):1674–1681.
  10. Merrick MT, Ford DC, Ports KA, et al. Vital signs: estimated proportion of adult health problems attributable to adverse childhood experiences and implications for prevention - 25 states, 2015-2017. MMWR Morb Mortal Wkly Rep. 2019;68(44):999–1005.
  11. McKenzie C, Silverberg JI. Association of adverse childhood experiences with childhood atopic dermatitis in the United States. Dermatitis. 2020;31(2):147–152.
  12. Akamine AA, Rusch GS, Nisihara R, et al. Adverse childhood experiences in patients with psoriasis. Trends Psychiatry Psychother. 2022;44:e20210251.
  13. Lang J, McKie J, Smith H, et al. Adverse childhood experiences, epigenetics and telomere length variation in childhood and beyond: a systematic review of the literature. Eur Child Adolesc Psychiatry. 2020;29(10):1329–1338.
  14. Chen MA, LeRoy AS, Majd M, et al. Immune and epigenetic pathways linking childhood adversity and health across the lifespan. Front Psychol. 2021;12:788351.
  15. Soares S, Rocha V, Kelly-Irving M, et al. Adverse childhood events and health biomarkers: a systematic review. Front Public Health. 2021;9:649825.
  16. Miller GE, Chen E, Parker KJ. Psychological stress in childhood and susceptibility to the chronic diseases of aging: moving toward a model of behavioral and biological mechanisms. Psychol Bull. 2011;137(6):959–997.
  17. Kalmakis KA, Meyer JS, Chiodo L, et al. Adverse childhood experiences and chronic hypothalamic-pituitary-adrenal activity. Stress. 2015;18(4):446–450.
  18. Kempke S, Luyten P, De Coninck S, et al. Effects of early childhood trauma on hypothalamic-pituitary-adrenal (HPA) axis function in patients with Chronic Fatigue Syndrome. Psychoneuroendocrinology. 2015;52:14–21.
  19. Clemens V, Burgin D, Eckert A, et al. Hypothalamic-pituitary-adrenal axis activation in a high-risk sample of children, adolescents and young adults in residential youth care - Associations with adverse childhood experiences and mental health problems. Psychiatry Res. 2020;284:112778.
  20. Schreuder MM, Vinkers CH, Mesman E, et al. Childhood trauma and HPA axis functionality in offspring of bipolar parents. Psychoneuroendocrinology. 2016;74:316–323.
  21. Bright MA, Knapp C, Hinojosa MS, et al. The comorbidity of physical, mental, and developmental conditions associated with childhood adversity: a population based study. Matern Child Health J. 2016;20(4):843–853.
  22. Hardcastle K, Bellis MA, Ford K, et al. Measuring the relationships between adverse childhood experiences and educational and employment success in England and Wales: findings from a retrospective study. Public Health. 2018;165:106–116.
  23. Jimenez ME, Wade R Jr, Lin Y, et al. Adverse experiences in early childhood and kindergarten outcomes. Pediatrics. 2016;137(2):e20151839.
  24. Jelley M, Wen F, Miller-Cribbs J, et al. Adverse childhood experiences, other psychosocial sources of adversity, and quality of life in vulnerable primary care patients. Perm J. 2020;24:18.277.
  25. Johnson AD, Martin A, Brooks-Gunn J, et al. Order in the House! associations among household chaos, the home literacy environment, maternal reading ability, and children's early reading. Merrill Palmer Q (Wayne State Univ Press). 2008;54(4):445–472.
  26. Heckman CJ, Auerbach MV, Darlow S, et al. Association of skin cancer risk and protective behaviors with health literacy among young adults in the USA. Int J Behav Med. 2019;26(4):372–379.
  27. Chapman LW, Ochoa A, Tenconi F, et al. Dermatologic health literacy in underserved communities: a case report of south Los Angeles middle schools. Dermatol Online J. 2015;21(11): 13030.
  28. Garrido EF, Weiler LM, Taussig HN. Adverse childhood experiences and health-risk behaviors in vulnerable early adolescents. J Early Adolesc. 2018;38(5):661–680.
  29. Dube SR, Miller JW, Brown DW, et al. Adverse childhood experiences and the association with ever using alcohol and initiating alcohol use during adolescence. J Adolesc Health. 2006;38(4):444.e1–10.
  30. Dube SR, Felitti VJ, Dong M, et al. Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study. Pediatrics. 2003;111(3):564–572.
  31. Bomysoad RN, Francis LA. Adverse childhood experiences and mental health conditions among adolescents. J Adolesc Health. 2020;67(6):868–870.
  32. Lowthian E, Anthony R, Evans A, et al. Adverse childhood experiences and child mental health: an electronic birth cohort study. BMC Med. 2021;19(1):172.
  33. Woods-Jaeger BA, Cho B, Sexton CC, et al. Promoting resilience: breaking the intergenerational cycle of adverse childhood experiences. Health Educ Behav. 2018;45(5):772–780.
  34. Augsburger M, Meyer-Parlapanis D, Bambonye M, et al. Appetitive aggression and adverse childhood experiences shape violent behavior in females formerly associated with combat. Front Psychol. 2015;6:1756.
  35. Dube SR, Anda RF, Felitti VJ, et al. Adverse childhood experiences and personal alcohol abuse as an adult. Addict Behav. 2002;27(5):713–725.
Creative Commons Attribution License

©2023 Okeke, et al. This is an open access article distributed under the terms of the, which permits unrestricted use, distribution, and build upon your work non-commercially.