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Biological factor, barrier 2 of 6

Early-life adversity

Adverse childhood experiences, meaning abuse, neglect, and household dysfunction, are associated with worse health and outcomes decades later.

Evidence

  • ACE meta-analysis. Hughes et al. (2017) pooled 37 studies with 253,719 participants. Four or more adverse experiences raised risk for all 23 outcomes. Odds ratios were under 2 for inactivity, obesity, and diabetes and over 7 for problematic drug use and violence.
  • Limits of recall. Adults' recall agrees only moderately with records collected during childhood, and minimally for subjective items such as emotional abuse (Reuben et al., 2016). Hughes et al. also reported high variation between studies.
  • Later costs. Later harms concentrate in a small group whose problems trace largely to early disadvantage, so the evidence supports better childhoods, not labels (Caspi et al., 2016, Rivenbark et al., 2018).

What can be done

Actions rated on the strength-rating scale (A strong and replicated, B solid but limited, C weak or debated, D contested or failed), applied to the specific claim made.

  • Income support for families with young children (B). In Alaska, an extra $1,000 in a child's first months cut child protection referrals by age 3 by about 10% (Bullinger, Packham, and Raissian, 2023). Each additional $1,000 in per-child tax credit refunds was followed by about 5% fewer state maltreatment reports over the next four weeks (Kovski et al., 2022), and a $1 rise in the minimum wage was linked to 9.6% fewer neglect reports (Raissian and Bullinger, 2017). All three studies are from the United States.
  • Home visiting that builds parent sensitivity (A that a small effect exists). A meta-analysis of 77 studies with 48,761 participants found a small reduction in maltreatment (d = 0.135), with larger effects for programs focused on parental sensitivity or using video feedback (Gubbels et al., 2021).
  • Free parenting programs in low- and middle-income countries (B). In South Africa, a 14-session program delivered by trained community members cut caregiver-reported abuse by 45%, though adolescents did not report a significant change (Cluver et al., 2018). These Parenting for Lifelong Health programs are free to use.
  • School violence prevention (B). In a trial of 42 Ugandan schools, students reporting physical violence from staff in the past week fell from 48.7% to 31.0% with the Good School Toolkit (Devries et al., 2015).
  • School-based cognitive behavioral programs for at-risk youth (B). In Chicago, Becoming a Man cut violent-crime arrests among participants by 20% and made them 9% more likely to graduate on time, according to J-PAL's summary of the first trial with 2,740 youth, at $1,100 to $1,850 per student per year. The arrest reduction disappeared a year after the first trial ended, while the graduation gain persisted, and the published paper reports larger effects of participation (J-PAL summary, Heller et al., 2017).
  • Universal postpartum nurse visits (C). In a trial of the Family Connects model, child protection investigations by age 5 were 39% lower, but the result was significant only at the 90% level, and a second trial run by a community agency was less clear (Goodman et al., 2021).
  • Use with caution: Nurse-Family Partnership (D for its original benefits). The early U.S. trial found 46% fewer abuse and neglect reports at 15 years (Olds et al., 1997), but large later trials in England with 1,645 mothers (Robling et al., 2016) and South Carolina with about 5,000 found no benefit on birth outcomes or child harm (McConnell et al., 2022, Swanson et al., 2025).
  • Use with caution: Triple P (D). Almost all studies had authors linked to the developer, and there was no difference against active controls (Wilson et al., 2012).
  • Not recommended: ACE questionnaire screening as a prevention tool (D). In two long-term cohorts, ACE scores predicted individual outcomes only slightly better than chance (Baldwin et al., 2021), and a co-originator of the ACE study states the questionnaire was not designed for screening (Anda, Porter, and Brown, 2020).
  • Framework: WHO's INSPIRE package groups proven approaches to ending violence against children, including parent support and income strengthening (WHO, 2016).

Proposed and experimental methods

Methods that are proposed, under trial, approved in some places, or tried and then failed. Each shows a stage label and an evidence rating. A stage label shows how far a method has progressed, not whether it works. The stage labels are explained on the biological factor page.

  • Unconditional cash in infancy, newer results (Large trial, B). Builds on the Baby's First Years entry in "Chronic and toxic stress" in the biological factors (Noble et al., 2025, Troller-Renfree et al., 2022). Peer-reviewed age 4 reports from the same trial (400 mothers given $333 a month versus 600 given $20) found no effect on maternal depression, anxiety, or body mass index, or on child body mass index or health (Duncan et al., 2025), and no effect on the preregistered primary or secondary measures of child brain activity, with higher alpha power seen only in exploratory analyses (Troller-Renfree et al., 2026). On a secondary outcome, a DNA methylation measure of the pace of biological aging, children in high-cash families aged 0.17 standard deviations more slowly (P = 0.037), with no effect in mothers (Raffington et al., 2026).
  • Baby bonds (Approved but not scaled, B for program facts only). Connecticut, the first U.S. state program, launched on July 1, 2023 and invests $3,200 for each child whose birth is covered by its Medicaid program (HUSKY), usable at ages 18 to 30 to buy a home, start a business, pay for education or training, or save for retirement. 7,810 babies were eligible in the first six months and about 15,000 a year are expected (Office of Governor Lamont, 2024). No outcome data exist, and any effect on early-life adversity would be indirect and many years away.
  • Predictive risk scores for child maltreatment hotline calls (Approved but not scaled, contested, C). The Allegheny Family Screening Tool in Pennsylvania scores calls using county administrative data to help screeners decide which reports to investigate. A county-commissioned Stanford evaluation of October 2019 to March 2021, using a before and after design with a comparison group rather than randomization, found screen-ins rose by 2 percentage points, higher-risk children became more likely to be investigated, and the Black versus white gap in case openings for screened referrals narrowed by 92%, though the authors note other county policy changes may explain part of this (Allegheny County DHS, 2023). The developers cautioned that poor and minority communities may be disadvantaged by reliance on government administrative data (Chouldechova et al., 2018), and an ACLU-led audit found the county's household rule labels 33% of Black households "high risk" versus 20% of non-Black households and that scoring at the household level lowers accuracy and widens racial gaps (Gerchick et al., 2023).
  • Reversed: Expanded monthly Child Tax Credit (Failed or reversed, B). Builds on the income support entry above. In 2021 the United States paid most families with children a monthly child allowance. After the first payment, food insufficiency in households with children fell 3.7 percentage points, about 25.9% (Shafer et al., 2022). Monthly payments ended in January 2022, and by July 2022 food insufficiency in these households had risen from 12.7% to 16.0%, about a 25% increase, with the largest rise in low-income households (Bovell-Ammon et al., 2022). Both studies come from the same research group and use repeated cross-sectional, self-reported Census survey data.

Sources cited on this page

  1. Hughes, K., Bellis, M. A., Hardcastle, K. A., et al. (2017). The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. Lancet Public Health, 2(8), e356-e366. DOI30118-4) B Moderate
  2. WHO: Congenital disorders fact sheet (2023) B Moderate
  3. WHO: Nearly 1.8 billion adults not doing enough physical activity (2024) B Moderate: agency estimate
  4. Anda, R. F., Porter, L. E., & Brown, D. W. (2020). Inside the adverse childhood experience score: Strengths, limitations, and misapplications. American Journal of Preventive Medicine, 59(2), 293-295. link B Moderate
  5. Baldwin, J. R., Caspi, A., Meehan, A. J., Ambler, A., Arseneault, L., Fisher, H. L., et al. (2021). Population vs individual prediction of poor health from results of adverse childhood experiences screening. JAMA Pediatrics, 175(4), 385-393. link A Strong
  6. Bullinger, L. R., Packham, A., & Raissian, K. M. (2023). Effects of universal and unconditional cash transfers on child abuse and neglect (NBER Working Paper No. 31733). National Bureau of Economic Research. link B Moderate
  7. Cluver, L. D., Meinck, F., Steinert, J. I., Shenderovich, Y., Doubt, J., Herrero Romero, R., et al. (2018). Parenting for Lifelong Health: A pragmatic cluster randomised controlled trial of a non-commercialised parenting programme for adolescents and their families in South Africa. BMJ Global Health, 3(1), e000539. link B Moderate
  8. Devries, K. M., Knight, L., Child, J. C., Mirembe, A., Nakuti, J., Jones, R., et al. (2015). The Good School Toolkit for reducing physical violence from school staff to primary school students: A cluster-randomised controlled trial in Uganda. The Lancet Global Health, 3(7), e378-e386. link B Moderate
  9. Goodman, W. B., Dodge, K. A., Bai, Y., Murphy, R. A., & O'Donnell, K. (2021). Effect of a universal postpartum nurse home visiting program on child maltreatment and emergency medical care at 5 years of age: A randomized clinical trial. JAMA Network Open, 4(7), e2116024. link C Limited
  10. Gubbels, J., van der Put, C. E., Stams, G. J. J. M., Prinzie, P. J., & Assink, M. (2021). Components associated with the effect of home visiting programs on child maltreatment: A meta-analytic review. Child Abuse & Neglect, 114, 104981. link A Strong
  11. Heller, S. B., Shah, A. K., Guryan, J., Ludwig, J., Mullainathan, S., & Pollack, H. A. (2017). Thinking, fast and slow? Some field experiments to reduce crime and dropout in Chicago. The Quarterly Journal of Economics, 132(1), 1-54. link B Moderate
  12. Kovski, N. L., Hill, H. D., Mooney, S. J., Rivara, F. P., & Rowhani-Rahbar, A. (2022). Short-term effects of tax credits on rates of child maltreatment reports in the United States. Pediatrics, 150(1), e2021054939. link B Moderate
  13. McConnell, M. A., Rokicki, S., Ayers, S., Allouch, F., Perreault, N., Gourevitch, R. A., et al. (2022). Effect of an intensive nurse home visiting program on adverse birth outcomes in a Medicaid-eligible population: A randomized clinical trial. JAMA, 328(1), 27-37. link B Moderate
  14. Noble, K., Magnuson, K., Duncan, G., Gennetian, L. A., Yoshikawa, H., Fox, N. A., et al. (2025). The effect of a monthly unconditional cash transfer on children's development at four years of age: A randomized controlled trial in the U.S. (NBER Working Paper No. 33844). National Bureau of Economic Research. link B Moderate
  15. Olds, D. L., Eckenrode, J., Henderson, C. R., Jr., Kitzman, H., Powers, J., Cole, R., Sidora, K., Morris, P., Pettitt, L. M., & Luckey, D. (1997). Long-term effects of home visitation on maternal life course and child abuse and neglect: Fifteen-year follow-up of a randomized trial. JAMA, 278(8), 637-643. link B Moderate
  16. Raissian, K. M., & Bullinger, L. R. (2017). Money matters: Does the minimum wage affect child maltreatment rates? Children and Youth Services Review, 72, 60-70. link B Moderate
  17. Robling, M., Bekkers, M.-J., Bell, K., Butler, C. C., Cannings-John, R., Channon, S., et al. (2016). Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): A pragmatic randomised controlled trial. The Lancet, 387(10014), 146-155. link B Moderate
  18. Swanson, K., Ayers, S., Oviedo, D., Zhou, R. A., Bates, M. A., Baicker, K., Chien, A. T., & McConnell, M. (2025). Intensive nurse home visiting and early childhood outcomes: A randomized clinical trial. JAMA Pediatrics, 179(8), 857-866. link B Moderate
  19. Troller-Renfree, S. V., Costanzo, M. A., Duncan, G. J., Magnuson, K., Gennetian, L. A., Yoshikawa, H., Halpern-Meekin, S., Fox, N. A., & Noble, K. G. (2022). The impact of a poverty reduction intervention on infant brain activity. Proceedings of the National Academy of Sciences, 119(5), e2115649119. link D Contested: (contested)
  20. Wilson, P., Rush, R., Hussey, S., Puckering, C., Sim, F., Allely, C. S., Doku, P., McConnachie, A., & Gillberg, C. (2012). How evidence-based is an "evidence-based parenting program"? A PRISMA systematic review and meta-analysis of Triple P. BMC Medicine, 10, 130. link B Moderate
  21. Bovell-Ammon, A., McCann, N. C., Mulugeta, M., Ettinger de Cuba, S., Raifman, J., & Shafer, P. (2022). Association of the expiration of child tax credit advance payments with food insufficiency in US households. JAMA Network Open, 5(10), e2234438. link B Moderate
  22. Chouldechova, A., Benavides-Prado, D., Fialko, O., & Vaithianathan, R. (2018). A case study of algorithm-assisted decision making in child maltreatment hotline screening decisions. Proceedings of Machine Learning Research, 81, 134-148. link B Moderate
  23. Duncan, G. J., Magnuson, K., Kunin-Batson, A. S., Yoshikawa, H., Fox, N. A., Halpern-Meekin, S., et al. (2025). Cash transfers and their effect on maternal and young children's health: A randomized clinical trial. JAMA Pediatrics, 179(8), 867-875. link B Moderate
  24. Gerchick, M., Jegede, T., Shah, T., Gutierrez, A., Beiers, S., Shemtov, N., et al. (2023). The devil is in the details: Interrogating values embedded in the Allegheny Family Screening Tool. In Proceedings of the 2023 ACM Conference on Fairness, Accountability, and Transparency (pp. 1292-1310). Association for Computing Machinery. link B Moderate
  25. Raffington, L., Willems, Y. E., Sperber, J. F., Zarandooz, S., Costanzo, M. A., Notterman, D. A., et al. (2026). Effects of a randomized controlled trial of unconditional cash transfers on epigenetic measures of ageing and cognition in children and mothers. Nature Human Behaviour. Advance online publication. link C Limited
  26. Shafer, P. R., Gutiérrez, K. M., Ettinger de Cuba, S., Bovell-Ammon, A., & Raifman, J. (2022). Association of the implementation of child tax credit advance payments with food insufficiency in US households. JAMA Network Open, 5(1), e2143296. link B Moderate
  27. Troller-Renfree, S. V., Costanzo, M. A., Duncan, G. J., Magnuson, K., Gennetian, L. A., Yoshikawa, H., et al. (2026). The impact of a monthly unconditional cash transfer on child brain activity: A 4-year follow-up. Developmental Cognitive Neuroscience, 78, 101673. link B Moderate
  28. Wilson, C. (2024, April 1). Oregon governor signs bill criminalizing drug possession. Oregon Public Broadcasting. link B Moderate

Every source for this factor is listed on the biological factor page.