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Etiology & Impact

The Cost of ACE

Ruth Gerson, MD, and David L. Corwin, MD

Stopping the abuse and maltreatment of children carries an inherent moral imperative, but there is another reason to focus on preventing maltreatment. Child abuse brings with it a massive economic burden, partially because of the costs of intervention but predominantly stemming from the immediate and long-term impact on physical and emotional health and functioning. Many have recoiled at the idea of wanting to put a monetary value on a child’s suffering, which has limited the research done in this area. But mounting evidence described below clarifies the profound economic cost of ACEs and underscores the financial—as well as the moral—imperative of effective prevention and treatment.

The Centers for Disease Control and Prevention (CDC) has estimated that the economic toll associated with child maltreatment is between $124 and $585 billion across the lifetime.1 Why the fourfold range in this estimate? To understand the range in these numbers, it is necessary to understand how such numbers are derived.  

Research into the costs associated with adverse childhood experiences can take different forms. Some studies look at cost per case, others per year (and within these, some examining cost per new case per year, and others taking a prevalence approach). Some look at all forms of ACEs, others at only physical or sexual abuse (not emotional abuse, neglect, exposure to domestic violence or parental drug use, or others).

Perhaps the most important methodological difference in this research is the estimation of the number of children affected by maltreatment and other ACEs. The CDC’s first estimate of $124 billion is the most conservative one—the minimum cost that can be assumed—in that it looked only at confirmed child maltreatment cases occurring in one year, to then estimate the lifetime cost for each victim of maltreatment.

Confirmed cases of child maltreatment are those for which child protective services has investigated and found sufficient credible evidence (including physical evidence and interviews) to declare that the abuse did occur. Unfortunately, in many cases of child maltreatment, there is no physical evidence of abuse (particularly in cases of sexual or emotional abuse), the child is shamed or pressured into recanting their report, or for whatever other reason there is insufficient evidence even if the abuse did occur. Thus, reports including confirmed cases only likely vastly underestimate the true prevalence of child maltreatment.2

When the CDC report’s authors included all new reports of child maltreatment (not just substantiated cases) and included those ascertained in the National Incidence Survey (and not included in the child protective services’ report), the incidence of maltreatment more than doubled. This leads to the more accurate total cost estimate of $585 billion.

The higher estimate also does not include the costs of other ACEs beyond child maltreatment (childhood exposure to domestic violence, parental substance abuse, and other ACEs are often left out of child abuse cost studies), the costs of other consequences of childhood adversity such as future homelessness or the costs of medical care after 65 years of age. Many chronic diseases cost the most as people age.

A recent study in the Netherlands using a large population cohort (aged 18-65) examined the impact of maltreatment as well as psychological abuse, emotional neglect, parental depression/anxiety, parental substance use, and other disruptive early life events including death of a parent and divorce.3 This study found that psychological abuse had the greatest impact on later disability, followed by other forms of maltreatment (physical or sexual abuse, emotional neglect), parental psychopathology, and other disruptive early life experiences, with each of these acting independently as a predictor of disability. This suggests that if the cost of other ACEs were included, the estimations of long-term health costs would substantially increase.  

The conclusion of the Netherlands study is that the burden of disease associated with ACEs was greater than all other common psychiatric disorders combined.3 This is a remarkable statement given the World Health Organization finding that depression is the most costly disease in middle- to high-income countries around the world.4

Further research is needed to clarify these additional costs and to elucidate the specific versus cumulative costs of different maltreatment experiences and other ACEs. But these data reveal the massive economic burden of childhood adversity and the economic imperative for effective prevention and intervention efforts.


1. Fang X, Brown DS, Florence CS, Mercy JA. The economic burden of child maltreatment in the United States and implications for prevention. Child Abuse & Neglect 2012 36:156-165. Summary and info graphic.

2. Drake B. Unraveling “unsubstantiated.” Child Maltreatment. 1996;1(3):261-271.

3. Cuijpers P, Smit F, Unger F, et al. The disease burden of childhood adversities in adults: a population-based study. Child Abuse & Neglect. 2011;35:937-945.

4. World Health Organization. The Global Burden of Disease: 2004 Update. Geneva, Switzerland: WHO Press; 2008. 

© 2015 by Academy on Violence and Abuse