nature medicine

Review article [Link]

Adverse childhood experiences and

lifelong health

Received: 27 March 2023 Zulfiqar A. Bhutta1,2 , Supriya Bhavnani3, Theresa S. Betancourt4,

Mark Tomlinson 5,6 & Vikram Patel7,8
Accepted: 30 May 2023

Published online: 18 July 2023

With the advent of the sustainable development goals, the field of global
Check for updates child health has shifted its focus from reducing mortality to improving
health, nutrition and development outcomes — often measured as
human capital. A growing knowledge of the biology of development and
neuroscience has highlighted the importance of adverse environmental
exposures, collectively termed adverse childhood experiences (ACEs) on
health outcomes. ACEs are associated with short-term, medium-term and
long-term negative consequences for health and development and their
effects may be multiplicative, especially during critical periods of sensitivity
and developmental plasticity. Some of these effects are compounded by
emerging global threats such as climate change, conflict and population
displacement. In this Review, we discuss the key mechanisms linking ACEs to
health outcomes and consider promising strategies to prevent and mitigate
their effects, highlighting evidence from programs in low-income and
middle-income countries. Finally, we emphasize the need for early recognition
of ACEs and delivery of packages of interventions spanning key sectors such as
health, education, women’s empowerment and social protection.

A key ambition of the sustainable development goals, especially goal 3 development and well-being across the lifespan3,4. ACEs from early
for global health, was to move the primary focus on reducing child mor- childhood through to adolescence have been associated with a wide
tality to a wider strategy of addressing child health and development. range of long-term health problems, in particular mental ill-health,
As a part of this broader focus, attention has shifted to recognizing and diabetes and heart problems5–7. Whereas much research has focused
addressing ACEs1 and their immediate and long-term consequences. on severe experiences of early adversity, recent research has demon-
Examples of ACEs include physical violence, emotional abuse, neglect, strated that less severe and commonly experienced stressful life events
living in an impoverished or violent home, as well as parental events during childhood and adolescence also contribute to accelerated
that impact a child — such as parental incarceration, mental illness, biological aging, thus requiring an understanding of ACEs that truly
suicide, divorce or forced displacement2. ACEs must also be considered captures the full span of childhood8,9.
in the context of largely ignored threats related to climate change and A greater understanding of the social and biological factors
environmental degradation, which will impact the lives of children and involved in exposure to ACEs and their consequences will illuminate
families even more in the decades ahead. opportunities for interventions. Evidence-based programs are needed,
ACEs are very common especially using a broad definition and by to foster a broader view of child development that extends beyond
some estimates, more than half the global population has been exposed survival to overall health and flourishing across the life course10.
to at least one — with these having cascading effects on child health, Indeed, research has revealed an increasing number of evidence-based

Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada. 2Institute for Global Health & Development, The Aga Khan
1

University, South Central Asia, East Africa, United Kingdom, and Karachi, Pakistan. 3Child Development Group, Sangath, Goa, India. 4Boston College
School of Social Work, Chestnut Hill, MA, USA. 5Institute for Life Course Health Research, Stellenbosch University, Cape Town, South Africa. 6School of
Nursing and Midwifery, Queens University, Belfast, UK. 7Department of Global Health and Population, Harvard Chan School of Public Health, Boston, MA,
USA. 8Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA. e-mail: [Link]@[Link]

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Review article [Link]

interventions for preventing ACEs related to child and family violence, who is a victim of intimate partner violence18. Caregivers who are expe-
as well as behavior change interventions to increase monitoring and riencing stress in their daily lives, such as due to marital conflict or
support for children in the home, school and community environ- poverty, or who are experiencing mental health problems, may be
ments. Mental health and psychosocial support interventions now unable to engage in responsive caregiving, which can result in neglect
exist and have been evaluated both in low-resource and culturally or child maltreatment. Such impairment in attachment relationships
diverse settings (discussed in later sections). However, promoting can in turn lead to low cognitive stimulation, limited emotional support
the growth, development and well-being of children globally will also and poor attachment. Nutrition and hygiene may also be affected by
require investments in implementation science, to scale and sustain limited breastfeeding, incorrect timing of the introduction of com-
these evidence-based interventions and to link them to sustainable sys- plementary foods, neglect of sanitation and hygiene issues and poor
tems of care, particularly in the context of humanitarian emergencies. diet during development2,5,18,19. These caregiving dynamics may also
Recent advances in child health have been set back by the corona- be compounded by exposure to, and repeated infections with enteric
virus disease 2019 (COVID-19) pandemic and its social and economic pathogens in the environment, more prevalent in low-income commu-
consequences11, as well as the burden of armed conflict, climate change nities with unsafe drinking water and limited hygiene and sanitation
and forced migration around the globe. Global costs due to ACEs are services. The Malnutrition and Enteric Disease Study has provided
large, given their impact not only on long-term health but also on learn- robust evidence of the link between such exposures during childhood
ing and social outcomes (such as poor educational outcomes, lost work and physical growth and other developmental deficits20. Further, grow-
and productivity)12. Investments in nurturing care, access to services ing up in conditions of adversity has also been associated with exposure
and child protection and security, as well as increased opportunities to environmental toxins (such as lead), which are known to impact
for education, economic self-sufficiency and advancement — for vul- brain development and lifelong health21. As children mature and begin
nerable children as well as their families — can all help to prevent ACEs to interact with peers and adults in their schools and neighborhoods,
and mitigate their effects. the potential for their exposure to violence also broadens to include
This Review will discuss the environments associated with ACEs, bullying in schools and community violence. In communities affected
the mechanisms linking these to child health and developmental out- by communal violence or chronic insecurity, parents may make difficult
comes, and the factors that moderate risk. We consider what is known decisions to flee — which can lead to further insecurity due to disrup-
about interventions to prevent ACEs as well as interventions to mitigate tion of key familial and community relationships, as well as further
their impact and, finally, we highlight some promising policies and new exposure to violence and poor living conditions under situations of
initiatives to reduce the burden and consequences of ACEs globally. forced migration22.
During adolescence, a range of harmful environments are associ-
Mechanisms linking adverse childhood ated with ACEs, including exposure to bullying and sexual violence,
experiences to health and development educational difficulties (often due to cognitive development delays
This section elaborates on three key questions related to the impact associated with ACEs in earlier life), oppressive social norms (such
of ACEs on lifelong health and social outcomes and draws upon recent as forced or early marriage in some contexts) and substance use. In
literature and field experience. First, we consider how certain social conflict settings, adolescents may be caught up in the perpetration of
environments create adverse living conditions experienced by children violence — for example, being involved with armed groups — which con-
and adolescents (Fig. 1). Second, we consider how these environments fers additional risks to both health and development23. Sexual violence
act on biological mechanisms, which can influence child development affects both boys and girls globally. In the recent CDC/UNICEF Violence
and lifelong health (Fig. 2). Third, we examine how a variety of determi- Against Children Surveys, 11% of girls and 27% of women sampled in
nants of ACEs interact to modify risk and confer protection. Sub-Saharan Africa had experienced sexual violence in the past year18.

The social environments associated with adverse childhood Physiological mechanisms through which adverse childhood
experiences experiences influence lifelong health
We argue that the exposure to harmful social environments that The impact of ACEs on child development and lifelong health is ulti-
typically define ACEs in childhood can, in fact, begin prenatally. For mately mediated through biological systems (reviewed in ref. 24). The
instance, a mother struggling with addiction may consume substances brain is particularly vulnerable to adversities throughout childhood,
in pregnancy that impact the developing fetus and manifest as preterm given its protracted development that continues from conception until
birth and low birth weight; smaller volume of brain areas associated young adulthood. One of the most distinctive characteristics of brain
with executive function, reward processing and emotion regulation development is its plasticity to adapt to environmental stimuli25. Certain
in childhood; and cardio-metabolic disorders in adulthood13,14. The areas of the brain undergo critical periods of development at different
programming of the fetus by the intrauterine milieu forms the foun- times; sensory and motor function areas develop early in childhood,
dation of the hypothesis of the ‘Developmental Origins of Health and while higher-order functions like language and cognition continue to
Disease’, first postulated by David J. Barker15. Epidemiological studies develop into adolescence. While plasticity is most pronounced in the
have observed associations between low birth weight and a range of earliest years of life, some degree of waning plasticity is evident across
health conditions across the life course including poor cognitive abil- the life course. Recent evidence has shown that a second wave of cel-
ity, mental illness, cancers and respiratory illness, emphasizing the lular processes of synaptogenesis, pruning and myelination occurs
long-term impact of this prenatal exposure16. in adolescence, rendering this a crucial period of plasticity in which
ACEs are typically associated with the absence of nurturing envi- the brain is sensitive to the environment26. Exposure to ACEs in early
ronments, especially in early childhood. Chronic and intense exposure life can disrupt brain development in the form of reduced gray and
to ACEs — for example, due to persistent abuse or violence, without white matter volumes (including in brain regions responsible for the
adequate protection — can result in toxic stress that impairs the devel- stress response) and reduced myelination, resulting in an altered con-
opment of brain architecture. This triggers a range of potentially harm- nectome3. Beyond structural integrity, ACEs also impact baseline and
ful physiological processes that impair cognitive development and task-related brain function, measured as aberrant experience-related
increase the risk of chronic conditions in later life17. potentials and functional connectivity3. These effects on brain structure
UNICEF estimates that about 3 in 4 children aged between 2 and and function have been shown to persist through to adolescence8.
4 years are exposed to harsh physical punishment and 1 in 4 children Another developmental process, unique to adolescence, is that
under the age of 5 (an estimated 176 million children) live with a mother of the differential maturation of brain regions27. The prefrontal cortex

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Review article [Link]

Exposure to adverse Opportunities

childhood experiences for intervention

Preconception Antenatal care Labor and

and pregnancy and nutrition childbirth care
Maternal Maternal Protection from
malnutrition illness and stress violence and harm
Hygenic cord Postnatal
Birth and thermal care care

Birth Preterm and

asphyxia SGA birth Access to
health care
Optimal Complementary
Infancy
breastfeeding feeding

Mental
Infectious disease Nurturing health care
Inadequate Abuse and prevention care
Preschool
stimulation neglect
Chronic Prevention
exposure to Support for NCD screening services
Childhood Infectious School-age development and treatment
toxic stress
malnutritiont diseases

Forced Economic and

displacement Climate Adolescence Economic
disasters educational
due to conflict security
advancement

Bullying Chronic
NCDs Adulthood

Injuries Disability

Negative adult outcomes Interventions mitigate the negative consequences of

and loss of human capital, early adversities and support achievement of human potential
intergenerational effects

Intergenerational
effects

Fig. 1 | Adverse childhood experiences and opportunities for intervention sanitation and air pollution. Interventions can help to prevent and mitigate the
across the life course. Harmful social environments that typically define ACEs negative consequences of ACEs, reducing the number of preterm or small for
can begin prenatally and opportunities for intervention exist throughout the gestational age (SGA) births, supporting the achievement of human potential
life course. Chronic exposure to toxic stress can continue through infancy and (indicated by physical and mental health, adult stature, social behavior and
into adulthood and can include financial insecurity (often associated with abject relationships, academic achievement and socioeconomic status) and reducing
poverty), violence and conflict, untreated chronic disease or disability, as well as the burden of noncommunicable diseases (NCDs).
hazardous environmental conditions such as unsafe drinking water, inadequate

(which is responsible for impulse control and inhibition) matures later known relationship with brain function through the gut–brain axis,
than the limbic region (which controls emotions, such as the craving presents another physiological system that is altered by adversities.
for social rewards). This is a key reason why impulsivity and risk-taking An infant’s gut microbiome is determined by their mother’s own gut
behaviors are characteristic of adolescence and, in turn, why a range microbiome in pregnancy, as well as the mode of delivery, early life
of risk behaviors such as substance use, risky sexual behavior and nutrition and weaning (including mother’s nutritional status for breast-
self-harm emerge at this age28 — often in the context of adverse experi- fed infants), but its composition and function are altered by ACEs33,34.
ences during this stage of life. An expanding area of research involves Work from rodent models suggests a mediating role of the gut micro-
the role of emotion regulation as a key mediator between early adver- biome in the relationship between ACEs and inflammatory and HPA
sity (including trauma exposure) and outcomes in later life. Emotion axis responses35.
regulation acts as a mediator in that it allows us to modulate intensity ACEs are also hypothesized to accelerate the development of
and duration of emotional states, and is conceptualized as a transdi- biological systems relative to chronological age. Biological aging has
agnostic factor underlying internalizing and externalizing disorders. been demonstrated through an observation of accelerated timing
Perturbation in the stress response of the hypothalamus–pituitary– and tempo of pubertal development in children facing threat-related
adrenal (HPA) axis, which develops across childhood, represents another adversities36. At a cellular level, biological aging due to threat is evi-
extensively studied mechanism through which early life adversities act. denced through shortened telomere length37 and altered DNA meth-
Elevated basal levels of the stress hormone cortisol in saliva and hair, ylation status38. These present the likely mechanisms by which fetal
and hyperarousal are the most commonly reported changes in the HPA programming occurs in the uterus. Cellular aging also represents a
axis in response to ACEs2,29. However, recent systematic reviews report mechanism by which the detrimental impacts of ACEs are embedded
a lack of consensus on these associations, likely due to the variability within individuals, resulting in the intergenerational transmission of
in adversities studied and the heterogeneity in research contexts30,31. physiological effects of adversities, even when psychosocial stressors
Recent research has demonstrated that toxic stress can also act occur prenatally or are alleviated. For example, placental telomere
through the immune system, via elevated inflammatory markers like length has been shown to mediate the relationship between ACEs and
C-reactive protein and cytokines32. The gut microbiome, which has a infant stress physiology39.

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Brain: decreased volume

and connectome, altered
function

Gut microbiome: HPA axis: basal cortisol,

composition and HPA reactivity
function

Adverse Poor physical and

childhood mental health outcomes
experiences across the life course
Timing, duration and number
of adversities; genetic vulnerabilities;
gender; protective factors Immune system:
elevated inflammatory
markers (C-reactive protein
and cytokines) Intergenerational
transmission of
Epigenetic changes: adversity
shortened telomeres,
increased DNA methylation

Fig. 2 | Mechanisms by which adverse childhood experiences impact on physiological processes. The degree to which these processes are affected
neurodevelopment and health outcomes. The timing, duration and frequency determines the downstream impact on physical and mental health, as well
of ACEs, as well as other factors including gender, presence of protective as intergenerational transmission of these effects (mediated by epigenetic
factors and genetic vulnerabilities, all interact to determine the impact of ACEs changes).

Future research should involve systematic study of the diverse mental and physical health — ultimately influencing the trajectories
physiological alterations mediated by ACEs to aid in biomarker discov- of child development and health outcomes across the life course40.
ery. Biomarkers, in turn, can lend themselves to multiple uses such as Relatively little is known about the influence of confluent complex
the identification of children at risk of long-term negative outcomes crises and early adverse exposures to broader insults — such as conflict
and critical windows of opportunity to intervene (that is, develop- settings, climate change and other emergencies — on mental health and
mental periods when physiological system malleability is greatest), developmental outcomes in children. With the growing recognition
with the goal of implementing effective and targeted interventions3. of the links between ACEs and health outcomes (including the les-
sons learnt from COVID-19)43, the importance of mental health among
Moderators of risk school-age children and adolescents is coming to the fore and begs
It is important to acknowledge that the occurrence of adverse experi- immediate action. Also notable are the potential long-term impacts
ences in childhood is, on its own, insufficient to accurately predict their of prolonged school closures in some regions during the COVID-19
impact on health outcomes. There are many moderating factors that pandemic, which resulted in an unacceptable and inequitable loss of
can influence the likelihood and extent of long-term consequences. education and an unfortunate increase in child marriages44.
To begin with, the unique genetic and environmental characteristics
of every child means there will be variability in how each individual Interventions to address adverse childhood
responds to a particular form of adversity. For example, children who experiences and promote optimal child
experience highly responsive care demonstrate lower risk of elevated development
cortisol due to adversities, while a child in less-responsive care may Over the last two decades, we have seen a revolution in our understand-
have a more severe stress response40. Thus, the protective experiences ing of brain development and the importance of the first 1,000 days (the
that occur within the context of adversities can mitigate their impact. period from conception to 2 years of age) for building the foundations
Similarly, intersectionality is at play, whereby experiencing ACEs in the of optimal development across the life course45. Two other concepts —
context of structural discrimination (such as racism or gender inequity) biological embedding and the developmental cascade — have built on
can disproportionately affect Black children or LGBTQ+ children41. these insights into early brain development and provide a description of
Thus, genetic or fetal factors and family or social environments can how adversity ‘gets under the skin’46. ‘Biological embedding’ describes
either exacerbate or mitigate the impact of ACEs42. Several factors how early adversities result in stable epigenetic modifications and,
warrant consideration, including the developmental timing of expo- importantly, how they shape individual response to later adversity
sure to ACEs, their intensity, and whether they occur in isolation or in exposure. Developmental cascades describe how functioning in one
combination (as is often the case) — as these factors may interact to domain of behavior may ‘spill over’ to impact on other domains. These
determine outcomes. conceptual advances have offered insights into the nature and duration
In addition to transmitting the impact of ACEs to the next genera- of the interventions that are required throughout life, to promote child
tion, it is important to note that there is also a bidirectionality between development and well-being.
the occurrence of ACEs and their health impacts. For example, exposure
to ACEs can create downward spirals in which an individual child’s biol- The Nurturing Care Framework and beyond
ogy is altered through the mechanisms described above, resulting in The culmination of this scientific revolution was the launch of the
problematic behaviors that fuel further exposure to ACEs. This can World Health Organization (WHO) Nurturing Care Framework (NCF)
result in a cascading effect of ACEs accumulating throughout childhood in 2018 (ref. 47). The NCF is an evidence-based framework compris-
and adolescence and being reinforced by risky behaviors and poor ing five components — good health, adequate nutrition, security and

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Table 1 | Relevant World Health Organization guidelines and early interventions. It is therefore crucial that early intervention is
resources not seen as a ‘quick-fix’ or a one-time solution. Due to the limited
number of long-term follow-up studies of longitudinal interven-
Age range Guideline tion cohorts, our understanding of the mechanisms that might
Antenatal Recommendations on antenatal care for a positive sustain impacts is limited64. Recently, there has been a call for a global
pregnancy experience49 effort to harness the potential of longitudinal cohorts to better under-
Postnatal period Recommendations on maternal and newborn care stand the factors contributing to sustainability/fade-out of interven-
for a positive postnatal experience52 tion effects64.
Children aged 0–3 years Improving early childhood development50
Defining the scale of focus
Children aged 0–17 years WHO guidelines on parenting interventions to
prevent maltreatment and enhance parent–child The original Centers for Disease Control study65 of ACEs included in
relationships53 their definition physical, sexual or emotional abuse, neglect, domes-
Adolescents aged Guidelines on mental health promotive and tic violence, imprisonment, substance abuse, parental mental health
10–19 years preventive interventions for adolescents51 problems or family breakdown. Subsequently, others have expanded
this list to include living in care (rather than with a parent) and paren-
tal bereavement. The focus on individual harms has meant that most
intervention research to date has sought to mitigate individual psy-
safety, responsive caregiving and opportunities for early learning. The chological harm, for example, using cognitive behavioral therapy66,
first three domains are not new, while the latter two mark an impor- brief motivational interviewing67, family-based systemic interventions,
tant step forward, with regards to the relational components of brain group psychoeducation68 and parent training69.
development. A key principle of the NCF is the importance of enabling In line with this, a recent systematic review examining the evidence
environments, which are created by services, policies, programs and for different interventions for people who have experienced ACEs was
communities. While the NCF was originally conceived to cover the equivocal70. The review found that cognitive behavioral therapy for
period from conception to age 2 years, creating enabling environments mental health outcomes showed the most promise, but concluded
is of course essential throughout childhood into young adulthood. This that there was a lack of evidence on service-level or community-level
approach offers the opportunity to conceptualize interventions that interventions, and on social or behavioral outcomes70. The same is
consider both prevention and mitigation through a developmental true for preventive interventions. In a systematic review and network
lens, from the first 1,000 days through to adolescence and women’s meta-analysis, Caldwell and colleagues71 concluded that interventions
health, and across the life course. based in the educational setting that focused solely on child cognitions
To this end, Black and colleagues48 have recently built on the and emotions to prevent depression or anxiety showed little effective-
foundation provided by the NCF and extended the concept through ness. Instead, addressing the wider familial and structural context in
adolescence — with the key domains being health, nutrition, safety and which interventions are implemented is essential if impacts are to be
security, learning and relationships. The scientific revolution, together maintained.
with the NCF and its extension across the life course, provides a road The ‘cumulative risk model’, which focuses on the number of adver-
map for intervention in adverse contexts49–53. Table 1 provides exam- sities rather than severity, type, timing and dose72, is a concept that
ples of recent WHO guidelines that provide a useful starting point for has typically been used to explain the relationship between ACEs and
researchers thinking about integrated solutions across the life course, outcomes. However, from a life-course perspective, focusing only on
in addition to broader social sector support strategies. the number of distinct types of adversities oversimplifies the complex-
ity of child and adolescent development and omits (for example) that
Assessing the evidence for effective interventions neurobiological susceptibility is not categorical and should be viewed
As we have shown, adversities occurring during critical/sensitive peri- as occurring on a continuum73. The cumulative risk model also does not
ods of early brain development may increase the risk of later poor out- account for the fact that many adversities are experienced over a long
comes (mental health disorders, for example) by way of their impact on time frame or may reappear at intervals along a child’s developmental
neurobiological systems involved in affective and behavioral regula- trajectory. This underscores the need for strategies that have continued
tion54–56. And while exploring sensitive periods is a key aspect of ongoing support for at-risk families and children across the first two decades
research, testing the sensitive period hypothesis is difficult in many of life with adequate follow-up74.
contexts, given that it requires developmental variation in adversity
exposure. In one ongoing community-based longitudinal study, for Enabling environments and structural interventions
example, exposure to adversity was universal — with every child at Following evidence that individual-level interventions have limited
age 8 years having had at least one adverse experience, with a mean impact and recognition of the need for wider interventions address-
of over 2.5 experiences57. ing social determinants, the 2022 Lancet Series on optimizing child
There is a wealth of evidence showing how early intervention and adolescent health and development reviewed the evidence for
(targeting sensitive periods) may be highly effective. Examples include a holistic agenda for child health74–77. Responding in a timely manner
the original Jamaica Home Visiting program58 interventions to improve and appropriately to ensure that children survive and thrive requires
caregiver–child interaction59,60 and child attachment60, as well as shared a combination of discrete time-bound interventions to improve child
reading interventions targeting child cognitive development61 and health and development, together with ongoing targeted interven-
home visiting in the early years to prevent violence and engage fathers57 tions across the life course. Bailey and colleagues78 have described
(Table 2). However, in the context of chronic adversity, demonstrat- one-off interventions (whether delivered early or late in the life
ing the long-term impact of an early intervention is more complex. course) as ‘foot-in-the-door interventions’. These interventions are
Although the Jamaica Home Visiting program has shown impressive critical to provide children and their families with specific skills at
benefits into adulthood62, this is the exception; many other studies specific times to better navigate adversity and stressors. The Lancet
either do not have long-term follow-ups or have suggested that benefits series presented a blueprint for the delivery of ‘foot-in-the-door’
for child development may ‘fade out’ over time63. time-bound interventions as well as a model for necessary structural,
Child exposure to high levels of chronic adversity may social and behavioral interventions across time, taking into account
overwhelm potentially protective influences such as the benefit of sensitive life periods.

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Table 2 | Studies of interventions to mitigate childhood adversity and promote developmenta

Study name, location Intervention, timing Main outcome (if available)

Perinatal and preschool period

Women and Infants Integrated Growth Study82 Community health worker-delivered, home-based Substantially reduced incidence of low birth
N = 13,500 intervention involving integrated and concurrent delivery of weight and stunting at 24 months
Delhi, India health, nutrition, WaSH and psychosocial care.
Preconception through pregnancy and early childhood.
The Healthy Life Trajectories Initiative (Bukhali)81 Community health worker-facilitated intervention to support Study is currently in progress with results
N = 6,800 behavior change through individual sessions in person or forthcoming
Soweto, South Africa telephonically, with supportive text messaging.
Preconception and continuing through pregnancy, infancy
and childhood.
Benefits of Early Booksharing61 Community health worker-delivered, group-based shared Positive effects on child language and
N = 140 reading intervention targeting child language, attention, attention; caregiver sensitivity and reciprocity
Khayelitsha, South Africa behavior problems and prosocial behavior.
Caregivers and their 21–28-month-old children.
Jamaica Home Visiting Program and REACH Home visiting by community health aide, providing stunted Benefits for child development; with additional
UP58,62 children with nutritional supplementation and psychosocial benefits 4 and 20 years later.
N = 127 stimulation
Kingston, Jamaica 9–24-month-old children. Follow-up at age 7–8 years.
Thula Sana (Hush Baby)60,63 Community health worker-delivered home-visiting Positive impact on caregiver sensitive
N = 449 intervention targeting the caregiver–child interaction, child interaction, secure attachment at 18 months,
Khayelitsha, South Africa attachment and maternal mental health. and reduced levels of maternal depressed
Pregnancy through 6 months of age. Follow-up at age 13 mood when children were aged 13 years.
years.
Sugira Muryango Family Strengthening A father-engaged early childhood development and Improved caregiver–child interaction, reduced
Intervention for preventing violence and violence-prevention home-visiting program delivered by harsh discipline, reduced violent victimization
promoting arly childhood development59,83 trained lay workers. of female caregivers, improved hygiene
N = 541 Children aged 6–36 months. behaviors, and decreased caregiver depression
Rwanda and anxiety.
Middle childhood and adolescence
‘Parenting for Lifelong Health: Sinovuyo Kids’79 A community health worker-delivered home-based Reduced child problem behaviors, improved
N = 296 parenting program to increase positive parenting and positive parenting and less physical and
Cape Town, South Africa reduce harsh parenting and conduct problems in children. psychological discipline
Children aged 2–9 years.
Strengthening school-based interventions for A lay counselor-facilitated whole-school intervention to Positive perception of school climate, reduced
promoting adolescent health (SEHER)84 promote healthy social environment (‘school climate’) and bullying and improved mental health
N = 13,035 early interventions for psychological distress.
Bihar, India Children aged 13–15 years.
Classroom-based interventions85 Locally identified, nonspecialized facilitators delivering a Consistent preventive benefits but was not
N = 329 classroom-based school intervention aimed at reducing successful for treatment for posttraumatic
Burundi symptoms of posttraumatic stress disorder, depression and stress disorder and depressive symptoms
anxiety, and improving a sense of hope and functioning in
children affected by war.
Children and adolescents aged 8–17 years.
Early Adolescent Skills for Emotions86 Nonspecialist group-based intervention to improve young Reduction in internalizing behavior.
N = 471 adolescents’ mental health; focused on reducing symptoms No impact on attention, depression,
Jordan of internalizing and externalizing behavior, depression, posttraumatic stress, well-being, functioning
posttraumatic stress, functioning, school belongingness or school belongingness. Caregivers had less
and caregivers’ parenting and mental health. psychological distress.
Syrian refugees aged 10–14 years.
Youth Readiness Intervention (YRI)87 A lay counselor-facilitated, common elements group-based Positive effects on emotion regulation,
N = 436 mental health intervention for multisymptomatic prosocial attitudes/behaviors, social support
Sierra Leone war-affected youth. and reduced functional impairment; improved
Youth aged 15–24 years. school enrollment, school attendance and
classroom behavior
‘Parenting for Lifelong Health: Sinovuyo Teen’80 Community health worker-delivered group-based Lower rates of abuse, less corporal punishment
N = 552 parenting program for families reporting conflict with their and improved positive parenting
Eastern Cape Province, South Africa. adolescents.
Adolescents aged 10–18 years.
Common Elements Treatment Approach88 Lay providers delivered a Common Elements Treatment Decreases in symptoms of internalizing and
N = 38 Approach developed for comorbid presentations of externalizing disorders, posttraumatic stress
Somali refugee camps on the Ethiopian/Somali depression, anxiety, traumatic stress, and/or externalizing and improvements in well-being
border symptoms in refugees.
Children aged ~11 years.
a
Interventions purposively chosen to reflect a combination of life-course interventions, interventions with long-term follow-up, and covering different domains of development. WaSH, water,
sanitation and hygiene.

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It is essential that interventions not only focus on individual fac- Conclusion

tors (such as psychosocial support; trauma-focused treatment), but To achieve the goal of improved child health and development
also address the proximal environment (improved parenting; attuned worldwide, government leaders and policymakers must focus on
responsive caregiving) as well as the distal environment (provision of country-level ownership, with close monitoring and accountability.
clean water; safe and secure play areas and schools and neighborhoods New and renewed global and regional mechanisms to track progress of
free of violence). Parenting interventions, for example, focusing on the child and adolescent health and development will help in this endeavor,
early years60,61, middle childhood79 or adolescence80 provide essential as will targeted research to improve our understanding of implemen-
parenting skills at a specific life stage to prevent or mitigate an immi- tation gaps and priorities. Given current global threats and complex
nent risk78. But given the arguments above, we argue (following the emergencies, researchers and governments must act to protect child
NCF) that it is the presence of enabling environments subsequent to health and future human capital through strategies that go beyond
the interventions that will be the crucial determinants of whether early universal health coverage, to multisectoral interventions that build
gains are sustained in the longer term78. resilience and response capabilities at scale.
Linked to this is the increasing interest in ongoing interventions
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cumulative risk to characterizing specific mechanisms. J. Child The authors are grateful to T. Vaivada for support in drawing Fig. 1,
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