Our greatest untapped resource
Authors: None The Lancet Public Health
Journal: The Lancet Public Health (2017)

“Young people are the world's greatest untapped resource”, wrote Ban Ki-moon in a Comment accompanying the Lancet Commission on Adolescent Health, published last year. With 1·8 billion adolescents aged 10–24 years in the world today, adolescent health has only recently been recognised as key to sustainable societies. The Lancet Commission coined the centrality of adolescent health and wellbeing as a triple dividend, with potential benefits for the adolescent, their future adult life, and even future generations. Evidence that young people exposed to adversity are more at risk of poor health outcomes later in life is mounting. In this issue of The Lancet Public Health, Karen Hughes and colleagues assess the effect of multiple adverse experiences occurring during childhood or adolescence on health. In their systematic review and meta-analysis, Hughes and colleagues looked at adverse childhood experiences (ACE) that affect children directly (such as maltreatment, abuse, and neglect) and indirectly through their living environment (such as substance use, mental illness, parental conflict), and health outcomes. Individuals with at least four ACEs were at increased risk for all outcomes examined (substance use, sexual health, mental health, weight and physical exercise, violence, and physical health status and conditions). The association was the strongest for problematic drug use and self-directed and interpersonal violence. Importantly, these findings also describe ACE risks for the next generation—an “intergenerational transmission of complex adversity”. For Stuart Kinner and Rohan Borschmann, writing in the accompanying Comment, “the effects of early adverse life experiences on subsequent health trajectories are evidently profound and diffuse.” Hughes and colleagues' finding “further strengthens the case for upstream public health approaches, particularly in disadvantaged populations in which the prevalence of both ACE exposure and poor health outcomes are comparatively high”, they note. “Minimisation of exposure to early adversity and building of resilience in the face of such adversity are important to reduction of the burden of disease, improvement of public health, and reduction of health inequalities”, they add. Adding to the body of evidence on lasting effects of traumatic experience in childhood, Roger Webb and colleagues study, published in the July issue of The Lancet Public Health, used a national Danish cohort of more than 1 million people to examine the risks of self-harm or violent offending during late adolescence and early adulthood (up to 35 years of age) among people admitted to hospital following injuries or poisonings during their childhood (before age 15 years). They reported that around one in four men admitted to hospital for violence in childhood were convicted of a violent offence in adulthood, and one in four girls admitted to hospital for self-harm or violence had later hospital admissions for self-harm. For Grant Sara and Julia Lappin, reflecting on the strength of these associations, childhood trauma could well be “psychiatry's greatest public health challenge”. There is indeed grounds for psychiatry to tackle the central role of childhood trauma in mental health. But, as Hughes and colleagues' study showed, the diversity of poor health outcomes associated with childhood adversity goes well beyond mental health. Childhood trauma and adversity should be everyone's greatest public health challenge. According to the Global Burden of Disease, injuries, mental health disorders, and sexual and reproductive health issues are the leading causes of morbidity and mortality in young people (aged 10–24 years). Developing and evaluating specific interventions and addressing barriers (such as stigma, privacy, and confidentiality) will be key to reducing the burden of disease and risks for diseases in later life. Importantly, adversity, injury, and abuse during childhood and adolescence are potentially modifiable risk factors to the burden of ill health and as such offer clear opportunities for action. Data from studies such these are important to make the invisible visible. Intersectoral approaches to reduce exposure to childhood adversity and to build resilience—around the four pillars that are family, education, peers, and media—will be crucial if we are to improve adolescent health and wellbeing later in life. Current conflicts, together with mass population movements affecting millions of young people worldwide, will probably make this burden heavier. Protecting and investing in our “greatest untapped resource” is one of our greatest public health challenges.