Identifying expanded adverse childhood experiences and examining their relationship with health outcomes: a systematic review protocol
10 affiliations
- 1Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- 2Center for Public Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- 3Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, Pennsylvania, USA
- 4Center for Violence Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- 5Division of General Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- 6Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- 7Holman Biotech Commons, University of Pennsylvania Libraries, Philadelphia, Pennsylvania, USA
- 8Department of Social and Behavioral Sciences, College of Public Health, Temple University, Philadelphia, Pennsylvania, USA
- 9Department of Psychiatry & Behavioral Science, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania, USA
- 10Department of Clinical, Educational & Health Psychology, Division of Psychology & Language Sciences, University College London, London, UK
Abstract
Introduction: Adverse childhood experiences (ACEs) are associated with poor health outcomes, with higher cumulative exposure conveying more risk. Although earlier ACE studies focus on household-level adversities, growing evidence explores traumatic childhood experiences originating outside the home (expanded ACEs). Expanded ACEs may co-occur with household-level ACEs, causing misclassification bias if not measured. A comprehensive list of expanded ACEs has not been identified, and no unified framework exists to consider their impacts. This systematic review will identify expanded ACEs published in peer-reviewed literature and examine their associations with physical and mental health outcomes and behaviours by demographic subgroups, offering the first unified framework for expanded ACEs’ impacts on health.
Methods and analysis: Six databases were systematically searched in February 2026 for global, peer-reviewed studies published in English since database inception: PubMed/Medline, Embase, CINAHL, PsycInfo, CENTRAL and Scopus. Eligibility includes studies involving humans without restriction to date, setting, population or location; studies with ACEs originating outside the home as the exposure; and studies with outcomes including physical or mental health outcomes anchored to International Classification of Diseases, 10th revision or Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition codes or behaviours.
Researchers (RAs) screen titles/abstracts using pre-established eligibility criteria on training batches of 30–50 articles with faculty oversight. Once agreement consistently reaches 80%, RAs may use a hybrid screening process that prioritises independent, dual screening, relying on single-screening with fidelity checks to stay within budget and timeline, while maintaining rigour. Title/abstract screening is followed by full-text review and extraction. Study quality will be assessed using validated tools, with limitations reported. Data will be summarised via quantitative synthesis or narrative summary as appropriate.
Ethics and dissemination: The University of Pennsylvania #26-7542 determined this work is not human subjects research. Dissemination will occur through peer-reviewed presentations and publications.
PROSPERO registration number: CRD420261432925.
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BibTeX
@article{forke2026identifying,
title = {{Identifying expanded adverse childhood experiences and examining their relationship with health outcomes: a systematic review protocol}},
author = {Christine M Forke and Roy Wade and Jennifer Lege and Yaara Zisman-Ilani and Peter F Cronholm},
journal = {BMJ Open},
year = {2026},
month = oct,
doi = {10.1136/bmjopen-2026-125469},
url = {https://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2026-125469},
note = {CC BY-NC 4.0},
}
RIS
TY - JOUR
TI - Identifying expanded adverse childhood experiences and examining their relationship with health outcomes: a systematic review protocol
AU - Christine M Forke
AU - Roy Wade
AU - Jennifer Lege
AU - Yaara Zisman-Ilani
AU - Peter F Cronholm
PY - 2026
DA - 2026/10/28
JO - BMJ Open
DO - 10.1136/bmjopen-2026-125469
UR - https://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2026-125469
AB - Introduction: Adverse childhood experiences (ACEs) are associated with poor health outcomes, with higher cumulative exposure conveying more risk. Although earlier ACE studies focus on household-level adversities, growing evidence explores traumatic childhood experiences originating outside the home (expanded ACEs). Expanded ACEs may co-occur with household-level ACEs, causing misclassification bias if not measured. A comprehensive list of expanded ACEs has not been identified, and no unified framework exists to consider their impacts. This systematic review will identify expanded ACEs published in peer-reviewed literature and examine their associations with physical and mental health outcomes and behaviours by demographic subgroups, offering the first unified framework for expanded ACEs’ impacts on health. Methods and analysis: Six databases were systematically searched in February 2026 for global, peer-reviewed studies published in English since database inception: PubMed/Medline, Embase, CINAHL, PsycInfo, CENTRAL and Scopus. Eligibility includes studies involving humans without restriction to date, setting, population or location; studies with ACEs originating outside the home as the exposure; and studies with outcomes including physical or mental health outcomes anchored to International Classification of Diseases, 10th revision or Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition codes or behaviours. Researchers (RAs) screen titles/abstracts using pre-established eligibility criteria on training batches of 30–50 articles with faculty oversight. Once agreement consistently reaches 80%, RAs may use a hybrid screening process that prioritises independent, dual screening, relying on single-screening with fidelity checks to stay within budget and timeline, while maintaining rigour. Title/abstract screening is followed by full-text review and extraction. Study quality will be assessed using validated tools, with limitations reported. Data will be summarised via quantitative synthesis or narrative summary as appropriate. Ethics and dissemination: The University of Pennsylvania #26-7542 determined this work is not human subjects research. Dissemination will occur through peer-reviewed presentations and publications. PROSPERO registration number: CRD420261432925.
SN - 2044-6055
SN - 2044-6055
ER -