CONTEXT

A growing body of research has examined the role of maternal adverse childhood experiences (ACEs) on child behavior problems.

OBJECTIVE

To summarize the literature examining the association between maternal ACEs and child behavior problems via a systematic review.

DATA SOURCES

Electronic searches were conducted in Medline, PsycINFO, and Embase (1998–June 2020). Reference lists were reviewed. In total, 3048 records were screened.

STUDY SELECTION

Studies were included if an association between maternal ACEs and child externalizing (eg, aggression) and/or internalizing (eg, anxiety) problems was reported. In total, 139 full-text articles were reviewed for inclusion.

DATA EXTRACTION

Data from 16 studies met full inclusion criteria. Studies were synthesized by child externalizing and internalizing outcomes.

RESULTS

Maternal ACEs were significantly associated with child externalizing problems across all studies (number of studies synthesized per outcome [k] = 11). Significant associations were also found for inattention, hyperactivity, and impulsivity (k = 4), and aggression (k = 2). For internalizing problems (k = 11), significant associations were identified across 8 studies and nonsignificant associations were reported for 3 studies. Maternal ACEs were consistently associated with child anxiety and depression (k = 5). However, inconsistent findings were reported for somatization (k = 2).

LIMITATIONS

Results are limited to mother-child dyads and questionnaire measures of behavior problems in primarily North American countries.

CONCLUSIONS

Mothers’ ACEs demonstrated largely consistent associations with children’s behavior problems. Future research is needed to determine if specific types of maternal ACEs (eg, household dysfunction) are more strongly associated with child behavior problems.

A growing body of research suggests the negative impact of adverse childhood experiences (ACEs) (ie, experiences of childhood abuse, neglect, and household dysfunction before age 18 years) on physical and mental health may span generations. Indeed, studies have shown children of mothers with ACE histories are at greater risk for poor developmental, health, and behavioral outcomes in childhood, including externalizing (eg, aggression, inattention) and internalizing (eg, depression, anxiety) symptoms.19  Accordingly, there is growing momentum to incorporate the ACEs questionnaire10  as an adversity screening tool in pediatric,11,12  primary care,11,12  and perinatal13  settings, to help identify children who may be at risk and provide avenues for intervention. Recent studies have suggested the assessment of parental ACEs in pediatric primary care settings is feasible, as well as acceptable to many parent participants.14,15  However, other research bodies have urged caution against universal ACEs screening,16  given querying childhood adversity in the absence of trauma-informed practices may increase risk of retraumatization.17  In addition, parents’ childhood adversity is a distal risk factor for intergenerational outcomes16  that may not account for substantial variance in children’s behavioral problems, in comparison with proximal risk factors, such as parental mental health or parenting practices.18  Thus, greater clarity regarding the consistency of the association between parental ACEs and child behavioral problems is needed to determine the use of assessing for parental ACEs in the context of child behavior problems.

Currently, there are inconsistencies with regard to the magnitude and statistical significance of associations between parental ACEs and child behavior problems. Specifically, although some studies have identified moderate intergenerational associations,19,20  others have found weak or null associations.8,21  One potential explanation for discrepant findings in the existing literature may be because of variability among sample sociodemographic factors that may amplify or attenuate associations. For example, ACEs are found at higher rates among individuals with low socioeconomic status22  and members of historically oppressed racial and ethnic groups.2325  Similarly, children with lower socioeconomic status have a greater risk for internalizing and externalizing difficulties.2628 

The aim of the current study was to conduct a systematic review to synthesize findings on the association between maternal ACEs and child behavior problems. In terms of child outcomes, we examine externalizing problems and their subtypes (eg, inattention, aggression), as well as internalizing problems and their subtypes (eg, anxiety, depression). We focus on behavioral problems, rather than broader developmental concerns because of the small number of studies that have examined these outcomes. In addition, there was an insufficient number of studies to include father-child dyads in this review, and we therefore focus on mother-child dyads only. A secondary aim of this systematic review was to describe the sociodemographic factors (eg, income level and race and ethnicity) of the samples reporting an association between maternal ACEs and child behavior problems to inform potential explanations for variability across included studies.

Maternal ACEs were defined according to the original 8-item ACE Questionnaire10  and its 10-item extension,29  which includes reports of child maltreatment and household dysfunction before the age of 18 years. Child maltreatment included physical abuse, sexual abuse, emotional abuse, physical neglect, and emotional neglect. Household dysfunction included witnessing domestic violence in the home, parent mental illness, parent incarceration, parent substance and/or alcohol abuse, and parent divorce or separation. Adapted versions of the 8- and 10-item measures were also considered for inclusion and retained if they did not deviate substantially from the original ACE domains (see Table 1 for an overview of adapted measures). Consistent with broadband definitions,30  child behavior problems included externalizing symptoms (ie, difficulties with inattention, hyperactivity, impulsivity, oppositionality, conduct, or aggression) and internalizing symptoms (ie, difficulties with depression, anxiety, somatization, withdrawal, or emotional problems).

TABLE 1

Descriptive Information on Study Measures

Study (Year)nParent and Child CharacteristicsACEs MeasureBPs Measure
% MothersAge at ACEs, y% Male SexAge at BPs, yACE CategoriesMeanRange% 4+ ACEsMeasureInformant
Adkins et al (2020)1  50 69.00 42.50 36.00 10.00 10 original — 0–10 19.80 SDQ Parent 
Dennis et al (2019)39  326 100.00 40.30 47.90 9.89 10 original 3.42 0–10 44.50 PROM, CSSI Child 
Doi et al (2020)3  9390 100.00 — 46.20 13.75 Death of parent, parental divorce, intimate partner violence against mother, physical abuse, neglect, psychological abuse — 0–6 — SDQ, DSRS Parent, child 
Esteves et al (2020)4  155 100.00 28.00 53.50 1.50 10 original 2.29 0–10 — CBCL Parent 
Fredland et al (2018)33  266 100.00 30.76 50.70 1.00, 2.00, 3.00 8 original — 0–10 59.30 CBCL Parent 
Hatch et al (2020)5  144 100.00 29.86 50.40 4.23 10 original 3.08 0–10 41.40 CBCL Parent 
Haynes (2019)40  1515 — — 49.10 12.50 8 original — 0–11 22.60 Single-itema Parent 
Khan and Renk (2019)20  146 100.00 32.08 43.80 3.10 10 original 2.10 0–10 26.70 CBCL Parent 
Kumar et al (2018)34  394 100.00 31.56 45.00 6.78 Physical neglect, emotional neglect, parental absence, divorce, or separation, household alcohol or substance use, chronic mental illness, incarcerated member, member treated violently, emotional abuse, physical abuse, bullying in community, community violence, collective violence, contact sexual abuse 4.93 0–13 — CBCL Parent 
Letourneau et al (2019)21  907 100.00 31.16 53.36 2.02 10 original 0.98 0–10 7.27 CBCL Parent 
McDonald et al (2019)38  1994 100.00 33.87 52.30 3.00 8 original 1.55 0–8 14.70 Adapted CBCL Parent 
Rush (2018)35  114 100.00 37.12 — — 10 original — 0–10 — SDQ Parent 
Schickedanz et al (2018)9  2564 — — — 9.33 Emotional abuse, physical abuse, intimate partner violence, household substance abuse, mental illness in household, parental separation or divorce, emotional neglect, deceased or absent parent 1.38 0–9 10.50 BPI, single-itema Parent 
Stepleton et al (2018)18  259 100.00 33.59 48.40 7.90 8 original 2.95 0–11 49.42 CBCL Parent 
Wurster et al (2020)36  94 93.00 26.44 56.00 1.39 10 original 2.04 0–10 20.20 ITSEA Parent 
Yoon et al (2019)37  495 100.00 — 57.00 11.00 Physical abuse, sexual abuse, emotional abuse, poverty, food insecurity, parent alcohol abuse, parent incarceration, divorce 3.41 0–8 46.30 CBCL Parent 
Study (Year)nParent and Child CharacteristicsACEs MeasureBPs Measure
% MothersAge at ACEs, y% Male SexAge at BPs, yACE CategoriesMeanRange% 4+ ACEsMeasureInformant
Adkins et al (2020)1  50 69.00 42.50 36.00 10.00 10 original — 0–10 19.80 SDQ Parent 
Dennis et al (2019)39  326 100.00 40.30 47.90 9.89 10 original 3.42 0–10 44.50 PROM, CSSI Child 
Doi et al (2020)3  9390 100.00 — 46.20 13.75 Death of parent, parental divorce, intimate partner violence against mother, physical abuse, neglect, psychological abuse — 0–6 — SDQ, DSRS Parent, child 
Esteves et al (2020)4  155 100.00 28.00 53.50 1.50 10 original 2.29 0–10 — CBCL Parent 
Fredland et al (2018)33  266 100.00 30.76 50.70 1.00, 2.00, 3.00 8 original — 0–10 59.30 CBCL Parent 
Hatch et al (2020)5  144 100.00 29.86 50.40 4.23 10 original 3.08 0–10 41.40 CBCL Parent 
Haynes (2019)40  1515 — — 49.10 12.50 8 original — 0–11 22.60 Single-itema Parent 
Khan and Renk (2019)20  146 100.00 32.08 43.80 3.10 10 original 2.10 0–10 26.70 CBCL Parent 
Kumar et al (2018)34  394 100.00 31.56 45.00 6.78 Physical neglect, emotional neglect, parental absence, divorce, or separation, household alcohol or substance use, chronic mental illness, incarcerated member, member treated violently, emotional abuse, physical abuse, bullying in community, community violence, collective violence, contact sexual abuse 4.93 0–13 — CBCL Parent 
Letourneau et al (2019)21  907 100.00 31.16 53.36 2.02 10 original 0.98 0–10 7.27 CBCL Parent 
McDonald et al (2019)38  1994 100.00 33.87 52.30 3.00 8 original 1.55 0–8 14.70 Adapted CBCL Parent 
Rush (2018)35  114 100.00 37.12 — — 10 original — 0–10 — SDQ Parent 
Schickedanz et al (2018)9  2564 — — — 9.33 Emotional abuse, physical abuse, intimate partner violence, household substance abuse, mental illness in household, parental separation or divorce, emotional neglect, deceased or absent parent 1.38 0–9 10.50 BPI, single-itema Parent 
Stepleton et al (2018)18  259 100.00 33.59 48.40 7.90 8 original 2.95 0–11 49.42 CBCL Parent 
Wurster et al (2020)36  94 93.00 26.44 56.00 1.39 10 original 2.04 0–10 20.20 ITSEA Parent 
Yoon et al (2019)37  495 100.00 — 57.00 11.00 Physical abuse, sexual abuse, emotional abuse, poverty, food insecurity, parent alcohol abuse, parent incarceration, divorce 3.41 0–8 46.30 CBCL Parent 

BITSEA, Brief Infant-Toddler Social and Emotional Assessment; BP, behavior problems; BPI, Behavior Problems Index; CBCL, Child Behavior Checklist; CSSI, Children Somatic Symptoms Inventory; DSRS, Depression Self-Rating Scale; ECBI, Eyberg Child Behavior Inventory; ITSEA, Infant-Toddler Social and Emotional Assessment; PMS, Personal Maturity Scale; PPGH, Parent Proxy of Global Health; PROM, PROMIS Pediatric Depression Symptoms Short Form; SDQ, Strengths and Difficulties Questionnaire; —, not applicable.

a

Item asked whether parent was ever told their child met diagnostic criteria for a particular mental disorder by a professional, yielding a binary response of yes or no.

This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.31  A health sciences librarian performed an initial electronic search in PsycINFO, Medline, and Embase (see Supplemental Table 3) as part of a broader search for published and unpublished studies that used a measure of ACEs. Thus, no outcome terms were included in the original search. Text word fields and relevant database headings were searched for “adverse childhood events or experiences” and “ACEs” using adjacency operators and truncation symbols to identify phrase variations. The search was restricted from 1998, when the original ACEs study was published,10  up to November 2018. No language restrictions were applied. An updated search was performed to identify recently published studies, which adhered to the strategy detailed in the initial search (see Supplemental Table 3). In addition, text word fields and relevant database headings were searched using the terms “intergenerational, generational, or cross-generational” and “maternal, paternal, parental, mother, or father” with applied adjacency operators and truncation symptoms to capture variant phrases. Terms were combined by using Boolean terms “OR” and “AND.” The search was restricted from November 1, 2018, up to June 22, 2020. Language restrictions were not applied. Searches were compared for overlap, and duplicates were removed. The reference lists from studies identified for inclusion in both searches were also reviewed for missing studies.

Abstracts and full-text articles were reviewed by the first and third author for inclusion and exclusion criteria (see Fig 1 for PRISMA flow diagram). Inclusion criteria were as follows: (1) reported a measure of parental ACEs; (2) measure of ACEs assessed domains of maltreatment and household dysfunction; (3) reported a measure of child externalizing or internalizing problems assessed before 18 years of age; and (4) reported a statistical association. Studies were excluded for the following reasons: (1) nonempirical (eg, review, case study); (2) not in English; (3) sample did not include typically developing children (eg, intellectual disability); and (4) ACEs measure deviated substantially from the 8- or 10-item measure. Studies of foster and adoptive parent-child dyads were included, given that psychosocial mechanisms of transmission have been identified to explain the association between parental ACEs and child behavioral problems, in addition to biological mechanisms.6 

FIGURE 1

PRISMA flow diagram of the abstract and full-text review screening process. BP, behavior problem; PTSD, posttraumatic stress disorder.

FIGURE 1

PRISMA flow diagram of the abstract and full-text review screening process. BP, behavior problem; PTSD, posttraumatic stress disorder.

Close modal

To ensure independence of samples, the following protocol was implemented. Overlapping samples were identified by cross-referencing longitudinal studies and authorship across publications. If overlap existed among published and unpublished studies (eg, dissertations), the published study was included. Studies with the largest sample size and most comprehensive data were chosen among multiple publications from the same data set. When studies used binary and continuous measures to calculate separate effect sizes for the same child outcome (eg, depression), the continuous outcome (eg, score on a depression scale) was abstracted, rather than the binary outcome (eg, yes or no response to a single-item question). The full-text review interrater reliability (30% of studies) between coders was κ = 0.82, P < .001.

A standard data extraction form was used to code sociodemographic information and effect size data from the included studies. Sociodemographic information included the following: parent sex (% mothers) and age at ACEs and behavior problems assessments (in years), child age at behavior problems assessment (in years), child sex (% boys), proportion of sample with low income level, proportion of single parents in the sample, racial and ethnic distribution of the sample, geographical region of study (ie, country), measures of parent ACEs and child behavior problems, child behavior problems informant (eg, parent, teacher), mean ACE score of the sample, percent of the sample with ≥4 ACEs, total study quality score, study design (cross-sectional versus longitudinal), and publication status (published versus unpublished). Both adjusted and unadjusted effect sizes were abstracted when available. If multiple reference and target groups were reported for logistic regressions, mothers who were exposed to ≥1 and/or ≥4 ACEs (reference group = 0 ACEs) were extracted when available.

To synthesize included studies, the following protocol was used. First, studies were grouped by child outcome (ie, externalizing problems, a subtype of externalizing problems and internalizing problems, or a subtype of internalizing problems). To be grouped by externalizing or internalizing problems, studies had to report a related broadband scale. Subtypes of externalizing or internalizing problems were not subsumed by these groups. Rather, subtypes of externalizing problems (eg, inattention, conduct problems) and internalizing problems (eg, depression, somatization) were considered for separate synthesis. After, studies were considered for further grouping by the type of maternal ACEs reported. However, only 1 study21  reported associations between the type of maternal ACEs and child behavior problems, whereas the remaining studies solely reported associations with mothers’ cumulative ACEs (Table 2). To be considered for synthesis, 2 studies had to be available per outcome. Accordingly, the following syntheses were possible: the association between maternal cumulative ACEs and child externalizing problems (number of studies synthesized per outcome [k] = 11), internalizing problems (k = 11), inattention, hyperactivity, or impulsivity (k = 4), aggression (k = 2), anxiety or depression (k = 5), and somatization (k = 2). One study reported on conduct problems, 1 study reported on separation anxiety, and no studies reported on oppositionality or withdrawal. Therefore, these outcomes are not reviewed herein. Data extraction was conducted by the first and third author. A total of n = 7 studies (43.75%) were double-coded, and reliability values ranged from 0.77 to 1.00. Discrepancies were resolved through consensus coding.

TABLE 2

Results of Included Studies Examining the Association Between Mothers’ Cumulative ACE Scores and Child Behavioral Problems

Study (Year)Sample DescriptionnFinding(s)Interpretation
Externalizing problems     
 Esteves et al (2020)4  Prospective longitudinal pregnancy cohort of mother-child dyads 155 ρ = 0.23, P = .006 Significant, positive association 
 Fredland et al (2018)33  Mothers who were victims of intimate partner violence and their children 266 r = 0.026, nonsignificant (child age 12 mo); r = 0.066, nonsignificant (child age 24 mo); r = 0.323, P < .01 (child age 36 mo) Nonsignificant at child age 12 and 24 mo, but significant, positive association at 36 mo 
 Hatch et al (2020)5  Black or African American mother-child dyads living with low incomes 144 r = 0.33, P < .01 Significant, positive association 
 Khan and Renk (2019)20  National sample of parents recruited through Amazon Mechanical Turk 146 r = 0.40, P < .001; β = 0.21, P < .05a Significant, positive association 
 Kumar et al (2018)34  Mother-child dyads from underserved settlement communities in Nairobi, Kenya 394 OR = 1.21, P < .001 (0 vs ≥1 ACE) Significant, positive association 
 Letourneau et al (2019)21  Prospective longitudinal pregnancy cohort of mother-child dyads 907 r = 0.08, P < .05 Significant, positive association 
 Rush (2018)35  Licensed foster parents and their children 114 r = 0.288, P < .01 Significant, positive association 
 Schickedanz et al (2018)9  Nationally representative sample of parent-child dyads 2564 B = 0.40, 95% CI = −0.2 to 1.0 (0 vs ≥1 ACE)a; B = 1.46, 95% CI = 0.8 to 2.1 (0 vs ≥4 ACE)a Nonsignificant association when comparing 0 vs ≥1 ACE, but significant, positive association when comparing 0 vs ≥4 ACEs 
 Stepleton et al (2018)18  Parents with an active, in-home case with Child Welfare and their children 259 β = 0.10, P < .001a Significant, positive association 
 Wurster et al (2020)36  American Indian and Native American parent-child dyads enrolled in Early Head Start 94 r = 0.32, P < .01 Significant, positive association 
 Yoon et al (2019)37  Adolescent mothers and their children 495 r = 0.36, P < .01 Significant, positive association 
Inattention, hyperactivity, and impulsivity     
 Adkins et al (2020)1  Licensed foster/adoptive parents of children placed by Child Protective Services or private agencies 50 β = 0.25, P = .03a Significant, positive association 
 Fredland et al (2018)33  Mothers who were victims of intimate partner violence and their children 266 r = 0.070, nonsignificant (child age 12 mo); r = 0.008, nonsignificant (child age 24 mo) r = 0.222, P < .01 (child age 36 mo) Nonsignificant at child age 12 and 24 mo, but significant, positive association at 36 mo 
 McDonald et al (2019)38  Prospective longitudinal pregnancy cohort of mother-child dyads 1994 aOR = 1.57, 95% CI = 1.17 to 2.10 (0–2 vs ≥3)a Significant, positive association 
 Schickedanz et al (2018)9  Nationally representative sample of parent-child dyads 2564 aOR = 1.44, 95% CI = 0.8, 2.6 (0 vs ≥1 ACE)a; aOR = 2.07, 95% CI = 1.1 to 3.8 (0 vs ≥4 ACE)a Nonsignificant association when comparing 0 vs ≥1 ACE, but significant, positive association when comparing 0 vs ≥4 ACEs 
Aggression     
 Fredland et al (2018)33  Mothers who were victims of intimate partner violence and their children 266 r = 0.062, nonsignificant (child age 12 mo); r = 0.084, nonsignificant (child age 24 mo); r = 0.259, P < .01 (child age 36 mo) Nonsignificant at child age 12 and 24 mo, but significant, positive association at 36 mo 
 McDonald et al (2019)38  Prospective longitudinal pregnancy cohort of mother-child dyads 1994 aOR = 1.61, 95% CI = 1.21 to 2.13 (0–2 vs ≥3)a Significant, positive association 
Internalizing problems     
 Adkins et al (2020)1  Licensed foster/adoptive parents of children placed by Child Protective Services or private agencies 50 β = 0.27, P = .02a Significant, positive association 
 Esteves et al (2020)4  Prospective longitudinal pregnancy cohort of mother-child dyads 155 ρ = 0.16, P = .070 Nonsignificant 
 Fredland et al (2018)33  Mothers who were victims of intimate partner violence and their children 266 r = 0.070, nonsignificant (child age 12 mo); r = 0.023, nonsignificant (child age 24 mo); r = 0.345, P < .01 (child age 36 mo) Nonsignificant at child age 12 and 24 mo, but significant, positive association at 36 mo 
 Hatch et al (2020)5  Black or African American mother-child dyads living with low incomes 144 r = 0.23, P < .01 Significant, positive association 
 Khan and Renk (2019)20  National sample of parents recruited through Amazon Mechanical Turk 146 r = 0.40, P < .001; β = 0.24, P < .05a Significant, positive association 
 Kumar et al (2018)34  Mother-child dyads from underserved settlement communities in Nairobi, Kenya 394 OR = 1.11, P = 0.013 (0 vs ≥1 ACE) Significant, positive association 
 Letourneau et al (2019)21  Prospective longitudinal pregnancy cohort of mother-child dyads 907 r = 0.04, nonsignificant Nonsignificant 
 Rush (2018)35  Licensed foster parents and their children 114 r = −0.077, nonsignificant Nonsignificant 
 Schickedanz et al (2018)9  Nationally representative sample of parent-child dyads 2564 B = 0.30, 95% CI = −0.1 to 0.7 (0 vs ≥1 ACE)a; B = 1.40, 95% CI = 0.8 to 1.9 (0 vs ≥4 ACE)a Nonsignificant association when comparing 0 vs ≥1 ACE, but significant, positive association when comparing 0 vs ≥4 ACEs 
 Stepleton et al (2018)18  Parents with an active, in-home case with Child Welfare and their children 259 β = 0.10, P < .001a Significant, positive association 
 Wurster et al (2020)36  American Indian and Native American parent-child dyads enrolled in Early Head Start 94 r = 0.26, P < .01 Significant, positive association 
Anxiety and/or depression     
 Dennis et al (2019)39  Mothers with chronic pain and their children 326 r = 0.14, P < .01 Significant, positive association 
 Doi et al (2020)3  Community sample of schoolchildren and their parents living in Kochi Prefecture, Japan 9390 B = 0.43, 95% CI = 0.20 to 0.65 (0 vs ≥1 ACE); B = 0.34, 95% CI = 0.12 to 0.56 (0 vs ≥1 ACE)a Significant, positive association 
 Fredland et al (2018)33  Mothers who were victims of intimate partner violence and their children 266 r = 0.122, P < .05 (child age 12 mo); r = 0.084, nonsignificant (child age 24 mo); r = 0.267, P < .01 (child age 36 mo) Nonsignificant at 24 mo, but significant and positive association at 12 and 36 mo 
 Haynes (2019)40  Community sample of parent-child dyads in South Carolina 1515 OR = 3.18, 95% CI = 1.86 to 5.46 (0 vs ≥ 4 ACE); aOR = 3.01, 95% CI = 1.59 to 5.69 (0 vs ≥4 ACE)a Significant, positive association 
 McDonald et al (2019)38  Prospective longitudinal pregnancy cohort of mother-child dyads 1994 aOR = 1.46, 95% CI = 1.06 to 2.02 (0–2 vs ≥ 3 ACE)a Significant, positive association 
Somatization     
 Dennis et al (2019)39  Mothers with chronic pain and their children 326 r = 0.02, nonsignificant Nonsignificant 
 Fredland et al (2018)33  Mothers who were victims of intimate partner violence and their children 266 r = 0.108, nonsignificant (child age 12 mo); r = −0.040, nonsignificant (child age 24 mo); r = 0.249, P < .01 (child age 36 mo) Nonsignificant at child age 12 and 24 mo, but significant, positive association at 36 mo 
Study (Year)Sample DescriptionnFinding(s)Interpretation
Externalizing problems     
 Esteves et al (2020)4  Prospective longitudinal pregnancy cohort of mother-child dyads 155 ρ = 0.23, P = .006 Significant, positive association 
 Fredland et al (2018)33  Mothers who were victims of intimate partner violence and their children 266 r = 0.026, nonsignificant (child age 12 mo); r = 0.066, nonsignificant (child age 24 mo); r = 0.323, P < .01 (child age 36 mo) Nonsignificant at child age 12 and 24 mo, but significant, positive association at 36 mo 
 Hatch et al (2020)5  Black or African American mother-child dyads living with low incomes 144 r = 0.33, P < .01 Significant, positive association 
 Khan and Renk (2019)20  National sample of parents recruited through Amazon Mechanical Turk 146 r = 0.40, P < .001; β = 0.21, P < .05a Significant, positive association 
 Kumar et al (2018)34  Mother-child dyads from underserved settlement communities in Nairobi, Kenya 394 OR = 1.21, P < .001 (0 vs ≥1 ACE) Significant, positive association 
 Letourneau et al (2019)21  Prospective longitudinal pregnancy cohort of mother-child dyads 907 r = 0.08, P < .05 Significant, positive association 
 Rush (2018)35  Licensed foster parents and their children 114 r = 0.288, P < .01 Significant, positive association 
 Schickedanz et al (2018)9  Nationally representative sample of parent-child dyads 2564 B = 0.40, 95% CI = −0.2 to 1.0 (0 vs ≥1 ACE)a; B = 1.46, 95% CI = 0.8 to 2.1 (0 vs ≥4 ACE)a Nonsignificant association when comparing 0 vs ≥1 ACE, but significant, positive association when comparing 0 vs ≥4 ACEs 
 Stepleton et al (2018)18  Parents with an active, in-home case with Child Welfare and their children 259 β = 0.10, P < .001a Significant, positive association 
 Wurster et al (2020)36  American Indian and Native American parent-child dyads enrolled in Early Head Start 94 r = 0.32, P < .01 Significant, positive association 
 Yoon et al (2019)37  Adolescent mothers and their children 495 r = 0.36, P < .01 Significant, positive association 
Inattention, hyperactivity, and impulsivity     
 Adkins et al (2020)1  Licensed foster/adoptive parents of children placed by Child Protective Services or private agencies 50 β = 0.25, P = .03a Significant, positive association 
 Fredland et al (2018)33  Mothers who were victims of intimate partner violence and their children 266 r = 0.070, nonsignificant (child age 12 mo); r = 0.008, nonsignificant (child age 24 mo) r = 0.222, P < .01 (child age 36 mo) Nonsignificant at child age 12 and 24 mo, but significant, positive association at 36 mo 
 McDonald et al (2019)38  Prospective longitudinal pregnancy cohort of mother-child dyads 1994 aOR = 1.57, 95% CI = 1.17 to 2.10 (0–2 vs ≥3)a Significant, positive association 
 Schickedanz et al (2018)9  Nationally representative sample of parent-child dyads 2564 aOR = 1.44, 95% CI = 0.8, 2.6 (0 vs ≥1 ACE)a; aOR = 2.07, 95% CI = 1.1 to 3.8 (0 vs ≥4 ACE)a Nonsignificant association when comparing 0 vs ≥1 ACE, but significant, positive association when comparing 0 vs ≥4 ACEs 
Aggression     
 Fredland et al (2018)33  Mothers who were victims of intimate partner violence and their children 266 r = 0.062, nonsignificant (child age 12 mo); r = 0.084, nonsignificant (child age 24 mo); r = 0.259, P < .01 (child age 36 mo) Nonsignificant at child age 12 and 24 mo, but significant, positive association at 36 mo 
 McDonald et al (2019)38  Prospective longitudinal pregnancy cohort of mother-child dyads 1994 aOR = 1.61, 95% CI = 1.21 to 2.13 (0–2 vs ≥3)a Significant, positive association 
Internalizing problems     
 Adkins et al (2020)1  Licensed foster/adoptive parents of children placed by Child Protective Services or private agencies 50 β = 0.27, P = .02a Significant, positive association 
 Esteves et al (2020)4  Prospective longitudinal pregnancy cohort of mother-child dyads 155 ρ = 0.16, P = .070 Nonsignificant 
 Fredland et al (2018)33  Mothers who were victims of intimate partner violence and their children 266 r = 0.070, nonsignificant (child age 12 mo); r = 0.023, nonsignificant (child age 24 mo); r = 0.345, P < .01 (child age 36 mo) Nonsignificant at child age 12 and 24 mo, but significant, positive association at 36 mo 
 Hatch et al (2020)5  Black or African American mother-child dyads living with low incomes 144 r = 0.23, P < .01 Significant, positive association 
 Khan and Renk (2019)20  National sample of parents recruited through Amazon Mechanical Turk 146 r = 0.40, P < .001; β = 0.24, P < .05a Significant, positive association 
 Kumar et al (2018)34  Mother-child dyads from underserved settlement communities in Nairobi, Kenya 394 OR = 1.11, P = 0.013 (0 vs ≥1 ACE) Significant, positive association 
 Letourneau et al (2019)21  Prospective longitudinal pregnancy cohort of mother-child dyads 907 r = 0.04, nonsignificant Nonsignificant 
 Rush (2018)35  Licensed foster parents and their children 114 r = −0.077, nonsignificant Nonsignificant 
 Schickedanz et al (2018)9  Nationally representative sample of parent-child dyads 2564 B = 0.30, 95% CI = −0.1 to 0.7 (0 vs ≥1 ACE)a; B = 1.40, 95% CI = 0.8 to 1.9 (0 vs ≥4 ACE)a Nonsignificant association when comparing 0 vs ≥1 ACE, but significant, positive association when comparing 0 vs ≥4 ACEs 
 Stepleton et al (2018)18  Parents with an active, in-home case with Child Welfare and their children 259 β = 0.10, P < .001a Significant, positive association 
 Wurster et al (2020)36  American Indian and Native American parent-child dyads enrolled in Early Head Start 94 r = 0.26, P < .01 Significant, positive association 
Anxiety and/or depression     
 Dennis et al (2019)39  Mothers with chronic pain and their children 326 r = 0.14, P < .01 Significant, positive association 
 Doi et al (2020)3  Community sample of schoolchildren and their parents living in Kochi Prefecture, Japan 9390 B = 0.43, 95% CI = 0.20 to 0.65 (0 vs ≥1 ACE); B = 0.34, 95% CI = 0.12 to 0.56 (0 vs ≥1 ACE)a Significant, positive association 
 Fredland et al (2018)33  Mothers who were victims of intimate partner violence and their children 266 r = 0.122, P < .05 (child age 12 mo); r = 0.084, nonsignificant (child age 24 mo); r = 0.267, P < .01 (child age 36 mo) Nonsignificant at 24 mo, but significant and positive association at 12 and 36 mo 
 Haynes (2019)40  Community sample of parent-child dyads in South Carolina 1515 OR = 3.18, 95% CI = 1.86 to 5.46 (0 vs ≥ 4 ACE); aOR = 3.01, 95% CI = 1.59 to 5.69 (0 vs ≥4 ACE)a Significant, positive association 
 McDonald et al (2019)38  Prospective longitudinal pregnancy cohort of mother-child dyads 1994 aOR = 1.46, 95% CI = 1.06 to 2.02 (0–2 vs ≥ 3 ACE)a Significant, positive association 
Somatization     
 Dennis et al (2019)39  Mothers with chronic pain and their children 326 r = 0.02, nonsignificant Nonsignificant 
 Fredland et al (2018)33  Mothers who were victims of intimate partner violence and their children 266 r = 0.108, nonsignificant (child age 12 mo); r = −0.040, nonsignificant (child age 24 mo); r = 0.249, P < .01 (child age 36 mo) Nonsignificant at child age 12 and 24 mo, but significant, positive association at 36 mo 

aOR, adjusted odds ratio; B, unstandardized regression coefficient; OR, odds ratio; r, Pearson’s correlation; β, standardized regression coefficient; ρ, Spearman’s rank correlation coefficient.

a

Model was adjusted for covariates.

Study quality was assessed by using the 15-item National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies32  (see Supplemental Table 4). Criteria were scored as 0 = criterion not met or not reported and 1 = criteria met. Scores on each criterion were summed, with a possible range of 0 to 15. Studies with scores of ≤5 are considered to have low methodologic quality and were removed from the systematic review.

The electronic search yielded 3049 studies after duplicates were removed (see Fig 1 for PRISMA flow diagram), and 139 studies underwent full-text review. In total, 16 studies (18 813 dyads) met full inclusion criteria for the systematic review.

Study and sample characteristics are provided in Table 1 and Supplemental Table 5. Descriptive information on measures used in the included studies is provided in Table 1. Sample size ranged from 89 to 9390 (M = 1175.81). Samples were composed primarily of mothers (M = 99.85%) who were 33.08 years of age (range: 28.00 to 42.50 years) at the time of ACEs reporting. Twelve studies reported on biological dyads, and 2 studies reported on foster or adoptive dyads. Children were ∼10.46 years of age (range: 1.50 to 13.75 years) at the time of behavior problems assessment, and 48.19% were boys. Averaging the 14 studies reporting the racial and ethnic distribution of their sample, 1.21% of participants were Asian or Pacific Islander; 11.84% were Black or African American; 1.16% were Indigenous, Native American, or American Indian; 6.37% were Hispanic; 70.75% were white; and 12.95% were biracial, multiracial, or reported as other or in a combined racial and ethnic group (eg, Asian and Black participants). Of the 10 studies reporting sample income level, 3 studies reported a high proportion of participants with low income. Of the 10 studies reporting single parenting status, no studies reported a high proportion of single parent participants. Few studies reported on parents’ education level. Most studies were conducted in North America (United States, n = 12; Canada, n = 2; Japan, n = 1; Kenya, n = 1). Twelve studies reported the prevalence of ACEs among mothers, with an average of 20.07% (range: 7.27% to 59.30%) reporting ≥4 ACEs. The mean ACE score across 11 studies was 1.92 (range: 0.98 to 4.93). The mean study quality score was 7.94 of 15.00 (range: 6.00 to 10.00; see Supplemental Table 6). All studies fell above the cut-score for low methodological quality (ie, a score of ≤5.00) and were included in the review.

Eleven studies examined the association between mothers’ cumulative ACEs and children’s externalizing problems.4,5,9,18,20,21,3337  All reported significant associations, indicating mothers’ childhood adversity was positively related to children’s externalizing problems. In a sample with no reported sociodemographic risks, Schickedanz et al9  found significantly higher risk for child externalizing problems among parents exposed to ≥4 ACEs compared with parents exposed to no ACEs. However, this association was not found when comparing parents exposed to ≥1 ACE versus no ACEs. In contrast, Kumar et al34  found children of mothers exposed to ≥1 ACE had a 1.21 times greater likelihood of externalizing problems compared with children of mothers exposed to no ACEs, in a sample with high rates of food insecurity, low income, and high mean ACE scores. Fredland et al33  reported a significant correlation between maternal ACEs and child externalizing problems when children were 36 months of age in a sample of mothers denoted as victims of intimate partner violence but nonsignificant findings when children were 12 or 24 months of age. However, 3 other studies with varying levels of sociodemographic risk examined associations when children were between 17 and 24 months of age and indicated significant results.4,21,36  Findings held across 3 studies reporting effect sizes adjusted for demographic factors,9,18,20  maternal mental health, and negative parenting behaviors.20  Altogether, maternal ACEs were consistently associated with child externalizing problems.

Inattention, Hyperactivity, and Impulsivity

Across 4 studies reporting an association between maternal ACEs and child inattention, hyperactivity, and/or impulsivity, all reported significant and positive associations.1,9,33,38  Schickedanz et al9  found children of parents exposed to ≥4 ACEs, compared with parents exposed to no ACEs, had a 2.07 times greater likelihood of an attention-deficit/hyperactivity disorder diagnosis (as reported by parents). However, this association was not found when comparing parents exposed to ≥1 ACE versus no ACEs. McDonald et al38  also indicated children of mothers exposed to ≥3 ACEs had a 1.57 times greater likelihood of externalizing problems compared with children of mothers exposed to ≤2 ACEs. Fredland et al33  reported a significant correlation between maternal ACEs and child inattention/hyperactivity when children were 36 months of age but nonsignificant findings when children were 12 or 24 months of age. Three studies reported adjusted effect sizes and findings remained significant when demographic covariates were included.1,9,38 

Aggression

In 2 studies, researchers examined the relationship between maternal ACEs and child aggression. In both studies, significant, positive associations were identified.33,38  Fredland et al33  reported a significant correlation between maternal ACEs and child aggression when children were 36 months of age but nonsignificant findings when children were 12 or 24 months of age. McDonald et al38  found the likelihood of aggression was 1.61 times greater for children aged 36 months with mothers exposed to ≥3 ACEs compared with ≤2 ACEs when demographic covariates were considered.

In 11 studies, researchers examined the association between mothers’ cumulative ACEs and children’s internalizing problems.1,4,5,9,18,20,21,3336  Eight of the 11 studies reported significant associations,1,5,9,18,20,33,34,36  indicating mothers’ childhood adversity was positively related to children’s internalizing problems. In a sample with no reported sociodemographic risks, Schickedanz et al9  found significantly higher risk for child internalizing problems among parents exposed to ≥4 ACEs, compared with parents exposed to no ACEs. However, this association was not found when comparing parents exposed to ≥1 ACE versus no ACEs. In contrast, Kumar et al34  found children of mothers exposed to ≥1 ACE had a 1.11 times greater likelihood of externalizing problems, compared with children of mothers exposed to no ACEs in a sample with high rates of food insecurity, low income, and high mean ACE scores. Fredland et al33  reported a significant correlation between maternal ACEs and child externalizing problems when children were 36 months of age in a sample of mothers denoted as victims of intimate partner violence but nonsignificant findings when children were 12 or 24 months of age. However, in 1 other study with American Indian and Native American participants, researchers examined associations when children were ∼17 months of age and found significant results.36  Significant findings held among the 4 studies that reported effect sizes adjusted for demographic factors,1,9,18,20  maternal mental health, and negative parenting behaviors.20  Nonsignificant findings were indicated by 3 studies with no reported sociodemographic risk factors.4,21,35  Altogether, 8 studies reported significant associations among maternal ACEs and child internalizing problems1,5,9,18,20,33,34,36 ; however, nonsignificant findings were identified among 3 studies with no sociodemographic risks.4,21,35 

Anxiety and Depression

In 5 studies, researchers examined associations between maternal ACEs and child anxiety and/or depression, and all reported significant, positive associations.3,33,3840  Fredland et al33  reported a significant correlation between maternal ACEs and child anxiety and depression when children were 12 and 36 months of age but nonsignificant findings when children were 12 months of age. McDonald et al38  found the likelihood of anxiety and depression was 1.46 times greater for 36-month-old children with mothers exposed to ≥3 ACEs compared with those exposed to ≤2 ACEs, considering demographic covariates. Haynes40  reported the likelihood of an anxiety and depression diagnosis (as reported by parents) was 3.18 times higher risk among parents exposed to ≥4 ACEs, compared with parents exposed to no ACEs, for the unadjusted model, and 3.01 times higher when the model was adjusted for demographic characteristics and parental mental health. Finally, Doi et al3  found significantly higher risk for child depression among mothers exposed to ≥1 ACEs, compared with parents exposed to no ACEs in the unadjusted and adjusted model, which considered demographic characteristics.

Somatization

In 2 studies, the association between maternal ACEs and child somatization was examined.33,39  In a sample of mothers with chronic pain and their children, Dennis et al39  reported nonsignificant findings. Fredland et al33  reported a significant correlation between maternal ACEs and child somatization when children were 36 months of age but nonsignificant findings when children were 12 and 24 months of age.

Across studies, mothers’ cumulative ACEs were consistently associated with children’s increased risk for externalizing problems, including aggression and inattention, hyperactivity, and impulsivity. In addition, associations between mothers’ cumulative ACEs and children’s internalizing problems, as well as anxiety and depression, were largely consistent. Inconsistencies were identified among 2 studies on child somatization. These inconsistencies may be attributable to the relatively small number of studies on particular child outcomes (eg, somatization) or differences in sociodemographic risks of included samples, such as the prevalence of ACEs among mothers and socioeconomic status of families. For example, the relation between maternal ACEs and child internalizing problems in samples with low sociodemographic risks may be less evident among mothers with a lower prevalence of ACEs (eg, 0 ACEs) in comparison with mothers with a greater prevalence of ACEs (eg, ≥4 ACEs). That is, child internalizing difficulties may be exacerbated at the intersection of high sociodemographic risk and maternal ACEs. However, further research is needed to quantitatively examine this hypothesis. Overall, findings are consistent with life course frameworks,41  which postulate experiences from childhood not only have implications for health and mental health across the life span, but also intergenerational consequences for the mental health and wellbeing of offspring.

Biological and psychosocial mechanisms have been proposed to account for the relationship between ACEs and children’s internalizing and externalizing problems. In terms of biological mechanisms, experiences of childhood adversity may result in epigenetic modifications to placental functioning and fetal development42,43  via altered maternal stress processing,44  increase the likelihood of perinatal complications and risky pregnancy behaviors (eg, smoking, substance use, preeclampsia, and gestational diabetes6,45,46 ), and contribute to allostatic load culminating from the cumulative impact of ACE exposures and mental health difficulties.43,47  In turn, these maternal outcomes of ACEs have been identified as important risk factors for the development of offspring stress dysregulation and behavioral difficulties.42,4852  Thus, intervention efforts aimed to alleviate the negative impact of ACEs on maternal mental health and stress dysregulation may successively mitigate transgenerational effects on offspring behavioral outcomes, and these interventions may be most successful when implemented in preconception or perinatal stages of offspring development.

In regard to psychosocial mechanisms, childhood trauma may predispose mothers to mental health difficulties, such as anxiety, depression, or posttraumatic stress disorder. Subsequently, mental health difficulties may impede the development of healthy relationships both with offspring and with significant others. Prenatal and postnatal mental health difficulties are directly associated with children’s behavior problems53,54  and have also been shown to mediate the association between maternal ACEs and child behavior problems.55  Mothers who are exposed to higher numbers of ACEs are more likely to be involved in conflictual and violent partner relationship,56,57  which are strongly associated with the development of child behavior problems.33  Furthermore, ACEs are associated with socioeconomic challenges, such as lower income and education,58  and these challenges may instigate and exacerbate stress within the home environment. Altogether, family environments characterized by stress, harsh or insensitive parenting, or parent conflict, may serve as important prevention points for children’s maladaptive behavioral functioning in the context of maternal ACEs.

Overall, maternal ACEs appeared consistently related to children’s externalizing and internalizing problems. To detect and mitigate these associations in practice settings, assessing for experiences of maternal ACEs in the presence of child behavior problems may be justified. Consistent with recommendations from researchers and clinicians, when screening for maternal ACEs in primary care, it is suggested that care providers use a trauma-informed approach59  to screening, whereby providers understand how to prevent mothers’ retraumatization when querying about childhood adversities and identify appropriate services and supports for mothers who disclose ACEs.17  Importantly, service routes may not be specific to ACEs themselves but rather to the various correlates and outcomes associated with exposure to childhood adversity, such as ongoing mental health difficulties, negative parenting practices, revictimization (eg, domestic violence),14,56  and socioeconomic disparities.22  It is also recommended that practitioners collect aggregate-level rather than item-level reports of ACEs to ensure greater patient privacy.14 

In terms of future directions, studies of intergenerational associations among father-child dyads and in foster or adoptive studies are greatly needed to examine psychosocial explanatory pathways of transmission and to disperse blame from mothers. Additional research is also needed to determine if there are specific types of maternal ACEs (eg, household dysfunction, child maltreatment) more strongly associated with offspring behavioral difficulties. Relatedly, further empirical study is needed to examine whether sociodemographic risk factors, such as socioeconomic status, play a moderating or mechanistic role in regard to associations between maternal ACEs and child behavior problems to inform for whom and when associations may be strongest.

Several study limitations should be noted. First, included studies were primarily conducted in North America and findings may not generalize to other countries. Second, the 8- and 10-item ACE measures do not capture all adversities that may be geographically related (eg, forced migration) or associated with historical oppression (eg, systemic racism) and likely play a profound role in the intergenerational transmission of adversity. Third, findings are restricted to mother-child dyads because of a lack of published research on father-child dyads. Fourth, all mothers reported on their ACEs retrospectively. Retrospective self-reports may be susceptible to reduced accuracy60  because of reporter motivation and memory biases.61  Fifth, the majority of child behavior problems measures were parent-reported, which may be subject to response biases, particularly among parents with psychological distress attributable to ACEs.62  Finally, data in clinical samples were not available and child behavior problems were assessed via questionnaires. Studies in clinical samples and using gold-standard assessments of child behavior problems (eg, semistructured interviews) are needed.

This research adds support for the growing body of literature suggesting maternal ACEs confer an intergenerational risk for children’s internalizing and externalizing problems. Considering the relatively small-to-moderate associations among maternal ACEs and child behavior problems, it may be important to examine additional antecedents of child behavior problems when screening for parental ACEs in pediatric and primary care, to determine if more proximal risk factors (eg, parental mental health, hostile parenting behaviors) are more appropriate treatment targets. Importantly, the impact of ACEs on mental health outcomes is not deterministic because research suggests social support,5,57,63  safe, stable, and nurturing relationships with others,64  and sport participation65  can serve as protective factors. Thus, it may be important to consider buffers of intergenerational transmission in the context of screening, prevention, and intervention efforts. Further investigations on the mechanisms of transmission, as well as on the cumulative risk and potential interplay of maternal and paternal ACEs, on child behavioral outcomes is needed to further inform this body of research.

We thank Cheri Nickel, MLIS, for conducting the initial literature search for this project and Chloe Devereux for her assistance with data extraction and cleaning.

FUNDING: Dr Madigan was funded by the Canada Research Chairs Program; Ms Cooke and Dr Racine were funded by Alberta Innovates; and Ms Cooke was funded by a Vanier Canada Graduate Scholarship. The funding sources had no role in publication-related decisions.

Ms Cooke contributed to study conceptualization, abstract search, abstract review, full-text review, data extraction, preparation, and interpretation, as well as to writing the initial and revised draft of the manuscript; Dr Racine contributed to study conceptualization, data interpretation, and writing and reviewing the manuscript; Mr Pador contributed to abstract review, full-text review, data extraction, data preparation, data interpretation, and writing and reviewing the manuscript; Dr Madigan contributed to study conceptualization, data interpretation, supervision, and writing, revising, and reviewing the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

ACE

adverse childhood experience

k

number of studies synthesized per outcome

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

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