Adverse childhood experiences and elder abuse victimization nexus: A systematic review and meta-analysis

Kofi Awuviry-Newton; Bernadette Saunders; Nestor Asiamah; Kwamina Abekah-Carter; Daniel Doh

doi:10.1371/journal.pone.0316902

. 2025 Feb 5;20(2):e0316902. doi: 10.1371/journal.pone.0316902

Adverse childhood experiences and elder abuse victimization nexus: A systematic review and meta-analysis

Kofi Awuviry-Newton ^1,^2,^*, Bernadette Saunders ¹, Nestor Asiamah ³, Kwamina Abekah-Carter ^2,⁴, Daniel Doh ^2,⁵

Editor: Rafi Amir-ud-Din⁶

PMCID: PMC11798435 PMID: 39908285

Abstract

Adverse childhood experiences (ACEs) are important life course events that can influence elder abuse victimisation (EAV) among older adults. This systematic review and meta-analysis aimed to provide synthesised and consolidated evidence on the existing associations between ACEs and EAV. A systematic search was conducted across six databases, including PubMed, PsycINFO, CINAHL Complete, Scopus, Google Scholar, and the Web of Science. All studies that addressed associations between ACEs, in singular or multiple form, and EAV were included in the review. Meta-analysis of the extracted odds ratios (ORs) and confidence intervals (CIs) was conducted using the common-effect inverse-variance model. Nine studies (cross-sectional design = 7; cohort design = 2) met the inclusion criteria. Included studies examined multiple ACEs and multiple EAVs associations (N = 3); at least single ACE and multiple EAVs (N = 3); any single form of ACE and multiple EAVs (N = 3); multiple ACEs–any single form of EAV nexus (N = 2); multiple ACEs–financial elder abuse association (N = 2); and multiple ACEs–physical elder abuse nexus (N = 2). Pooled ORs and CIs showed statistically significant results for all ACEs and EAVs associations whether in singular or multiple form. The results indicate that interventions designed to reduce ACEs, in singular or multiple form, early in life targeting residential and community-dwelling older adults may be relevant in reducing the incidence of EAV. The life course perspective s be integrated into the planning for support services for children, families, and older adults to prevent EAV in singular or multiple forms in later life.

Background

The growing prevalence and incidence of elder abuse victimization (EAV) reported in residential and community (home care) settings across the world poses both a public health and a human rights concern. A systematic review of elder abuse prevalence in community settings revealed that 1 out of 6 older adults (aged 60 years and above) report experiencing abuse of various forms [1]. For older adults living in residential and long-term care facilities, the prevalence and experience are worse with evidence reporting that two-thirds of aged care staff admit committing abuse in the past year [2]. In addition to the reported increase in abuse during the Coronavirus disease– 2019 (COVID-19) [3], the prevalence of abuse in many countries, including low- and middle-income countries, is expected to increase with the increasing rate of population ageing [1, 4, 5]. Increasing experiences of elder abuse are associated with adverse childhood experiences (ACEs) such as high levels of childhood maltreatment [6].

EAV, in this review, will refer to older adults’ experiences of a single or repeated act or lack of appropriate action, occurring within any trusting relationship that causes harm or distress to older adults in residential or community settings [7]. Examples of this victimisation include older adults’ experiences of ageism, financial exploitation, sexual abuse, physical and psychological assault or abuse, and neglect [8]. Recently, available studies that employed a life course perspective revealed that EAV in later life may be influenced by childhood experiences of adverse circumstances including abuse [9, 10]. However, to our knowledge, no systematic syntheses or reviews currently exist to explore the nature of this connection/pathway. ACEs refer to any direct harm resulting from the childhood experience of abuse and neglect as well as the indirect harm emanating from any negative family or social environments [11, 12]. Specific examples of ACEs include childhood sexual abuse, parental criminality, parental substance use, and violence against the mother [13]. In addition to the original list of ACEs [13], more recent research has offered broadened definitions that include childhood physical abuse, family conflict, exposure to family violence, family financial problems, childhood discrimination, and the cumulative harmful effects of at least two domains of ACEs [11]. We contend that childhood adversities or abuse may have a connection with EAV through several pathways. One of the pathways, explored in this study, is that older adults who experienced adverse circumstances in their childhood, living in any setting, may carry disempowerment with them throughout life, and are more likely to be re-victimized in the community or a residential setting [14]. The connections between ACEs and EAV are relevant in developing early interventions to reduce the incidence of abuse in later life.

Studies on the associations between ACEs and adverse outcomes vary in their designs, methodologies, locations, findings, and conclusions. For example, a study conducted in China revealed that social and economic instability during childhood influence an increase in the prevalence of poor health outcomes, such as obesity, difficulty with daily living, and exhibiting depressive symptoms [15]. Further, many systematic reviews explore ACEs and varying adverse outcomes, but not EAV. For instance, systematic reviews have provided evidence on ACEs, or effects of multiple ACEs, on health outcomes such as sexual, mental, and physical health, and higher utilisation of healthcare [11, 16, 17]. In addition to an earlier study [18], more recent research has focused on the association between ACEs and EAV [9, 19, 20]. For instance, in the United States (US), a longitudinal study showed that childhood adversities can have a significant direct effect on EAV [9]. However, what is lacking is synthesized evidence on the ACEs–EAV association. Synthesizing evidence on this association will contribute to understanding, or revealing, a clear pathway of the association and evidence on how to mitigate this public health concern.

As applied elsewhere [18], we employed the life-course perspective as a useful framework for interpreting the findings of the systematic review and presenting evidence for policies, research, and practice about aspects of developmental experiences that need to be tackled to reduce the incidence of EAV in later life. According to Elder [21], the life-course perspective elucidates the potential effects of accumulative advantages or disadvantages on individuals over time resulting from their relationship with social structures. The framework posits that early developmental experiences–in life stages such as early childhood, adolescence, young adulthood, middle age, and late adulthood–influence later life experiences [21, 22].

This systematic review aimed to understand the connections between ACEs and EAVs, as well as gain insight into factors moderating the relationships between ACEs and EAVs. An enhanced understanding of this evidence using a life-course perspective would assist in the development of appropriate interventions for older adults who experienced single or multiple ACEs, prevent the occurrence of ACEs, and improve cross-cultural and longitudinal research on the relationships between ACEs and EAVs. The understanding from this systematic review will strengthen the existing practice approaches, support services, and policies available to older adults experiencing abuse in old age and children experiencing ACEs of various forms.

Methods

Protocol

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist [23] was used to guide the systematic review and meta-analysis (see S1 File). The protocol of the current review has been submitted to PROSPERO, with a registration number CRD42023452985.

Study eligibility criteria

Two authors (KAN and KAC) did the screening independently and met on Zoom to address any disagreement and achieve consensus. Two authors (BS and NA) were brought in to review the papers for eligibility and address any disagreements that were not settled by KAN and KAC. All studies that explored the connection between ACEs and EAV and satisfied the following criteria were included in the systematic review:

Older adults (60years and older) as the main study participants
Studies measuring ACEs in general or any of the domains and associations with EAV. The domains of ACEs include childhood factors and parental factors (see Table 1 for details).
Studies published in English in refereed peer-reviewed journals.
Studies on EAV including ageism, psychological abuse, physical abuse, financial abuse, neglect, or sexual abuse (see Table 1 for details).

Table 1. List of keywords for identifying articles for adverse childhood experience–elder abuse victimization systematic review.

Category 1- Adverse childhood experience (ACEs)	Category 2—Elder abuse victimization	Category 3 –Older adults
#1 Childhood factors	Elder abuse	Older people
Childhood adversities	ageism	Elderly
Child ageism	physical assault*	Elders
Childcare abuse	psychological aggression*	Seniors
Childhood neglect	active neglect*	Senior citizens
Childhood sexual abuse	passive neglect*	Aged
Childhood emotional abuse	Sexual abuse*	Frail
Childhood abuse	Active neglect*	Older persons
Childhood neglect	Abandonment*
Childhood trauma	financial abuse*
childhood maltreatment
Childhood vulnerability
Childhood disempowerment
Childhood discrimination
#2 Parental/family factors
Parental criminality
Parental divorce
Parental mental illness
Parental violence
Economic adversity
Family violence
Parent Past abuse
Parent past trauma

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The initial search strategy was developed in PubMed and later searched in the other five databases including CINAHL Complete, APA PsycINFO, Web of Sciences, Scopus, and Google Scholar. The keywords with * were searched with category 3 keywords with OR and the results were combined with category 1 keywords.

Study inclusion was not restricted to any research approach, year of publication, location of study, or type of analytical method used to examine the association between ACEs and EAV. These inclusion strategies allowed for any study available on the ACEs–EAV association to be included in the systematic review. Articles identified in the databases searched were exported to Endnote, a reference manager, to allow for duplicate removal and title and abstract screening, as per the study’s inclusion criteria. All articles that potentially met eligibility criteria were retrieved after a full-text screen of all potential articles. After consulting with the other three authors, all articles meeting the eligibility criteria were retained.

Search strategies

The search was conducted in English and performed in PubMed, CINAHL Complete, APA PsycINFO, Web of Science, Scopus, and Google Scholar in August 2023, covering articles published in or before 2023. The search strategy included Medical Subject Headings (MeSH) terms, keywords, and free terms related to the systematic review. The Boolean operators–OR and AND–were instrumental with the search terms in identifying the included studies. The search strategy used the following Boolean descriptors with all keywords under each of the categories described in Table 1. Like keywords were searched separately with “OR” for each category (1 and 2) and “AND” was used to combine all categories. The keywords with * were searched with category 3 keywords with OR and the results were combined with category 1 keywords.

Study selection

After the database search, the total number of studies (N = 9,453) was exported to Endnote for the removal of duplicates. After this process, two authors (KAN and KAC) independently did title and abstract screening of the remaining articles (N = 8,653) to determine their eligibility. Where there was disagreement between these authors, the second and fifth authors (BS and DD) resolved them via consultation. Eventually, 9 studies met the eligibility criteria and were included in synthesis and meta-analysis where applicable (See Fig 1).

Quality assessment

The Joanna Briggs Institute appraisal checklists for analytical cross-sectional and cohort studies were used to assess the methodological quality of the included papers [24, 25]. The checklists were made up of 8 and 11 questions for analytical cross-sectional and cohort studies, respectively. The results of the methodological quality assessment are presented in Table 2.

Table 2. Results of quality assessment of the selected articles.

Study	Checklist questions											Total	%
Study	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Q11	Total	%
Asyraf et al.	1	1	1	1	1	1	1	1				8	100%
Burnes et al.	1	1	1	NA	NA	NC	1	NC	NC	NC	1	5	45%
Chen & Fu	0	1	1	1	0	0	1	1				5	63%
Dong & Wang	1	1	1	1	1	1	1	1				8	100%
Easton et al.	1	NC	1	1	1	NC	1	1	NC	NC	1	7	64%
Giraldo-Rodríguez et al.	1	1	1	0	1	1	1	1				7	88%
Kong & Easton	1	1	1	1	1	1	1	1				8	100%
McDonald & Thomas	1	1	1	1	1	1	1	1				8	100%
Wiklund et al.	1	1	1	1	1	1	1	1				8	100%

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Note: the results in the table are based on the JBI (Joanna Briggs Institute) checklists for cross-sectional and cohort studies; 1 represents “yes” (i.e., the checklist item was met by the paper), 0 represents “no” (i.e., checklist item was not met by the paper); NC–not clear (i.e., there was insufficient information in the paper to decide), NA–not applicable (i.e., the checklist item is not applicable due to the nature of the study); studies corresponding to eight questions are cross-sectional studies whereas studies corresponding to 11 questions are cohort studies; % represents the proportion of checklist items met for each paper; higher % score indicates higher quality of the paper.

Data extraction and analysis

After eligible studies were identified, two authors (KAC and KAN) independently did the initial data extraction using an extraction tool developed by the authors. The third author (NA) reviewed all extracted data and cross-checked the original studies for a thorough and comprehensive data extraction. Any disagreement between the two reviewers (KAC and KAN) was resolved via a consultation with the second (BS), the third (NA), and the fifth author (DD).

Examples of study details extracted were (authors, year, sample size, country, and study design as well as participants’ details such as age range, and sex), the outcome, and control variables measured in the studies (See Table 3).

Table 3. Details of studies included in the systematic review.

Study	Country	Sample size	% Female	Age, mean	Study design	Adverse childhood experience measure	Elder abuse victimization measure	Results
Asyraf, Dunne [14]	Malaysia	1,984	54.7%	≥ 60	Cross-Sectional study	Adverse Childhood Experience Questionnaire (ACE-IQ) designed by the World Health Organisation Examples of the 13 items include emotional abuse. physical abuse; sexual abuse; violence against household members; living with household. members who were substance abusers; living with household members who were mentally ill or suicidal; living with household members who were imprisoned; growing up with one or no parents, parental separation or divorce during childhood; emotional neglect; physical neglect; Bullying; exposure to community violence; and exposure to collective violence.	Elder abuse victimisation using 27 items in the National Elder Abuse and neglect study from Ireland adapted from Revised Conflict Tactics scales–Cumulative Single measures including: Physical elder abuse Psychological elder abuse Financial elder abuse Sexual elder abuse	Reporting three ACEs (OR = 2.32, 95% CI 1.56, 3.47) increased risk of elder abuse victimisation. Reporting four or more ACEs (OR 1.71, 95% CI 1.14, 2.56) increased the risk of elder abuse (overall abuse experience). Reporting any two ACEs had no association with elder abuse victimisation in later life (OR = 1.25, 95%CI 0.90, 1.74) Reporting any one ACE had no association with elder abuse victimisation in later life (OR = 1.25, 95%CI 0.90, 1.74) Reporting four or more ACEs was associated with any abuse type experienced in later life (OR = 1.70, 95%CI, 1.6, 2.47). Reporting three ACEs was associated with any abuse type experienced in later life (OR = 2.67, 95%CI, 1.84, 3.87). Reporting two ACEs was associated with financial abuse in later life (OR = 1.40, 95%CI, 1.01, 1.94) Reporting three ACEs was associated with financial abuse in later life (OR = 2.54, 95%CI, 1.73, 3.75) Reporting three ACEs was associated with psychological abuse in later life (OR = 2.30, 95%CI, 1.28, 4.16) Reporting four or more ACEs was associated with psychological abuse in later life (OR = 2.16, 95%CI = 1.21, 3.86) Reporting four or more ACEs was associated with physical abuse in later life (OR = 14.1, 95%CI, 1.57, 127.1) Reporting four or more ACEs was associated with sexual abuse in later life (OR = 8.94, 95%CI 1.05, 75.8)
Burnes, Pillemer [19]	Canada	23,468	52.6%	69.4	Cohort Study	Child maltreatment using 9 mistreatment behaviours or items measured from a modified version of the Childhood Experiences of Violence Questionnaire	Cumulative Elder Abuse measured from three measures or subtypes including. Emotional elder abuse (using four items) Physical elder abuse (using six items Financial elder abuse (using three items)	A rise in each child maltreatment level (36 levels) had an association with increased in elder Abuse (multiple) (OR, 1.01; 95% CI, 1.01–1.01). A rise in each child maltreatment level in childhood increased the risk of emotional abuse in later life (OR, 1.01; 95% CI, 1.01–1.01), A rise in each child maltreatment level in childhood increased the risk of physical abuse in later life (OR, 1.01; 95% CI, 1.01–1.02) A rise in each child maltreatment level in childhood was associated with increased risk of financial abuse in later life (OR, 1.01; 95% CI, 1.01–1.02). Each increase in ACE (3 total experiences) had a significant association with financial abuse in later life (OR, 1.30; 95% CI, 1.08–1.58).
Chen and Fu [29]	China	1,002	53.6%	74.9	Cross-Sectional study	Retrospective self-report items (15 questions) were used to measure Adverse Childhood experience of participants prior to turning 18 years old (some of the items include socio-economic difficulty of original family, parental divorce, frequent quarrels between parents, frequent physical punishment by parents, starvation etc	Elder abuse victimisation (6-item measure) Participants’ victimization experiences during old age were measured using six self-constructed items, including experiencing physical assault, psychological. Aggression, active neglect, passive neglect, abandonment, and financial abuse. The physical and psychological aggression items were developed based on the revised Conflict Tactics Scales (CTS2)	Having at least 4 ACEs was a risk factor for elder abuse victimization (OR = 3.06, 95%CI, 1.77, 5.30). Frequent physical punishment by parents was associated with a higher risk of elder abuse victimisation (OR = 2.29, 95%CI, 1.12, 4.70). Poor socio- economic status of the original family was associated with a higher risk of elder abuse victimisation (OR = 1.76, 95%CI, 1.02, 3.04) Starvation in childhood had no significant association with elder abuse in later life (OR = 1.58, 95%CI 0.83, 2.99) Parental divorce during childhood had no significant association with elder abuse in later life (OR = 3.02, 95%CI 0.83, 10.9). Frequent quarrels between parents during childhood had no significant association with elder abuse in later life (OR = 1.98, 95%CI 0.95, 4.09)
Dong and Wang [27]	USA	3,157	56.4%	≥ 60	Cross-Sectional study	Child maltreatment before the age of 18years (measure with 5-items Extended Hurt, Insult, Threaten, Scream scale	Elder abuse experience (10-items) a self-reported measure modified from the Hwalek-Sengstok Elder Abuse Screening Test and the Vulnerability to Abuse Screening Scale	Reporting childhood maltreatment experience had increased odds of elder abuse victimisation (OR = 2.08; 95% CI, 1.57–2.75)
Easton and Kong [9]	USA	5,968	53.47%	71	Cohort study	Childhood Adversities (7-item measure—emotional abuse, physical abuse, neglect, family dysfunction, parental divorce, witnessing domestic violence, and living with a household member with a substance problem)	Elder abuse victimisation measured using Abusive Behaviour Inventory	Childhood adversities had significant association with elder abuse victimization (0.11, p<0.001). Childhood adversities also had an indirect implication on elder abuse through physical health (0.00, p<0.001) and depressive symptoms (0.01*, p<0.001
Kong and Easton [28]	USA	5,968	53.5%	71	Cross-Sectional study	Childhood neglect (1 item) Childhood physical/verbal abuse (2 items) Childhood sexual abuse (4 items)	Elder abuse victimization (using Abusive Behavior Inventory	Frequent exposure to childhood emotional abuse increased the risk of elder abuse victimization (OR = 1.37, 95% CI, 1.06, 1.77) The odds of elder abuse victimization were about two times higher for persons with a history of child sexual abuse compared with those with no such reported history (OR = 3.34, 95% CI, 1.88, 5.94). Childhood neglect had no significant association with elder abuse victimization (OR = 1.00, 95%CI, 0.92, 1.10) Childhood physical abuse was not significantly associated with elder abuse victimization (OR = 1.18, 95%CI 0.96, 1.44)
McDonald and Thomas [18]	Canada	267	76.8%	≤ 75	Cross-Sectional study	Childhood psychological abuse Childhood physical abuse Childhood sexual abuse	Psychological abuse, Physical abuse, Sexual abuse, financial abuse	History of childhood abuse increased the risk of experiencing one type of abuse in later life (OR = 1.81, 95% CI, 1.01–3.26).
Giraldo-Rodríguez, Mino-León [10]	Mexico	18,416	100%	≥ 60	Cross-Sectional study	Childhood psychological, Childhood physical, Childhood sexual abuse (occurred before age 15)	Four categorical items (psychological, economic, physical, and sexual abuse) during the last 12 months by a relative or acquaintance.	Reporting a combination of psychological and sexual childhood abuse experience increased the odds of experiencing elder abuse victimisation (OR = 3.89; 95% CI, 3.09, 4.91). Reporting a combination of psychological, physical, and sexual childhood abuse increased the odds of experiencing elder abuse victimisation (OR = 3.55, 95% CI; 3.16,3.99) Reporting a combination of physical and sexual childhood abuse increased the odds of experiencing elder abuse victimisation (OR = 2.62; 95% CI, 2.40, 2.88). Reporting a combination of psychological and physical childhood abuse increased the odds of experiencing elder abuse victimisation (OR = 2.21, 95% CI, 2.0, 2.37) Reporting a childhood psychological abuse increased the odds of experiencing elder abuse victimisation (OR = 2.21, 95% CI, 1.94, 2.50) Reporting physical childhood abuse increased the odds of experiencing elder abuse victimisation (OR = 1.28, 95% CI, 1.17, 1.42) Reporting childhood sexual abuse increased the odds of experiencing elder abuse victimisation (OR = 2.32, 95% CI, 2.02, 2.64) Those who experienced one type of childhood abuse were 1.46 more likely to experience elder abuse victimisation in later life (OR = 1.46, 95% CI, 1.35, 1.58) Who experienced two types of childhood abuse were 2.27 times more likely to experience revictimization in later life (OR = 2.27, 95% CI, 2.10, 2.47) Those who experienced three types of childhood abuse were 3.58 times more likely to experience revictimization in later life (OR = 3.58, 95% CI, 3.04, 4.23) Women who reported having experienced three types of child abuse increased their risk of elder abuse.
Wiklund, Ludvigsson [20]	Sweden	135	54.1%	>65	Cross-Sectional study	Abuse before the age of 65years	Elder abuse victimization	Being abused before the age of 65 as a background factor was associated with an increased risk of elder abuse in later life (OR = 5.4; 95% CI 1.9–15.7).

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A narrative synthesis and meta-analysis were used to analyze the findings. Using the odds ratios (ORs) and confidence intervals (CIs) of the included studies, findings were interpreted as having a statistically significant association between outcome measures–EAVs measures and control variables–ACEs measures. A narrative was employed to group similar findings based on the number of studies reporting an association with the specific association nexus. This grouping generated themes providing structure for the presentation of the findings.

After the narrative review was completed for a particular theme, a meta-analysis of the extracted ORs and CIs was conducted using the common-effect inverse-variance model in STATA 16.1. Pooled ORs, CIs, and heterogeneity tests were used to present consolidated associations for the themes identified, where applicable. When multiple measures were reported in the same study, we included all in the meta-analysis. Using Stata 16.1, we employed I² to assess the presence of heterogeneity in results across studies, and when I² is greater than 40%, a random-effects model was used due to the presence of significant heterogeneity [26].

Results

The literature review search resulted in 9,453 articles, with a total of 800 duplicates removed which resulted in 8,653 for screening (see S2 File). After title and abstract screening were completed, a total of 136 articles were assessed for eligibility via a full-text screening (see Fig 1). The full-text screening resulted in 9 articles (all used quantitative designs) that met eligibility criteria for the systematic review and meta-analysis where appropriate.

Included study characteristics

Table 3 details the characteristics of the included studies. These studies reported an association between ACEs and EAV. Studies were mostly conducted in the Global North (N = 7) [9, 10, 14, 18–20, 27, 28], predominantly in the United States of America (N = 3) [9, 27, 28] followed by Canada (N = 2) [18, 19]. The rest of the studies were conducted in the Global South particularly China and Malaysia (N = 2) [14, 29]. None were conducted in an African country. Of the nine studies, three were conducted in an institutional setting, such as health and education, whereas the remaining (N = 6) were conducted in the community.

The sample sizes of the included studies ranged from 135 to 23,468, and participants were predominantly females.

ACEs measures

Included studies revealed varying forms of ACE measures. Some studies measured ACEs cumulatively [9, 14, 27, 29] while others measured forms of ACEs separately [10, 18–20, 28]. The studies reported using different types of measurement tools with unequal and unique sets of questions to measure ACEs. The studies included the following questionnaires: the ACEs International Questionnaire (ACE-IQ) comprised of 29 items [14]; the Child Maltreatment Questionnaire that measured 36 items [19]; a retrospective self-report (15 questions) [29]; a 5-item child maltreatment questionnaire [27]; the childhood adversities questionnaire (7-item measure) [9]; a childhood neglect (1-item), physical/verbal abuse (2-item), and sexual abuse (4-item) questionnaire [28]; the childhood psychological, physical, and childhood sexual abuse questionnaire [18]; the childhood psychological, physical, and sexual abuse before age 15 questionnaire [10] and a questionnaire measuring abuse before the age of 65 [20].

EAVs measures

Even though multiple EAVs was the most common outcome measure among the studies [9, 14, 19, 28, 29], single forms of EAV were reported, as well, including physical elder abuse [10, 14, 18, 19], financial elder abuse [14, 18, 19], psychological elder abuse [10, 14, 18], sexual elder abuse [10, 18, 19], emotional elder abuse [10, 19], and economic elder abuse [10].

The included studies used distinct scales and question items to measure EAV, including the Abusive Behavior Inventory [9, 28]; a self-reported measure modified from the Hwalek-Sengstok Elder Abuse Screening Test and the Vulnerability to Abuse Screening Scale (10 items) [27], six self-constructed items [29]; and a three items (emotional, physical, and financial elder abuse) questionnaire [19]. The 27 items in the National Elder Abuse and Neglect Study from Ireland were adapted from the Revised Conflict Tactics Scales [14], and four self-reported items [10, 18]. One of the included studies did not indicate the EAV measure it used [20].

Connections between single or multiple ACEs and multiple EAV

Seven studies examined the association between multiple ACEs and multiple EAVs. The four studies that examined the association between multiple ACEs and multiple EAV showed a consensus direction of the relationship. Burnes, Pillemer [19] and Dong and Wang [27] reported that a history, or increasing incidence of child maltreatment, was associated with an increase in EAV in later life. Similarly, experiencing multiple ACEs had a significant positive association with multiple EAVs [9]. Moreover, a history of abuse of any kind before the age of 65 years was associated with a high chance of EAV [20]. The pooled odds ratio from a meta-analysis shows a statistically significant association between experiencing ACEs and EAV (OR = 2.21, 95%CI: 1.69, 2.90), with a slight heterogeneity existing across studies (I² = 65.9%; p = 0.087) (see Fig 2).

Fig 2 — **Note:** *Study 2 = Dong and Wang (2019); Study 3 = Wiklund et al*. *(2022)*.

Some studies examined the effect of having a history of co-occurring ACEs on EAV in later life. While most of the results were consistent, some contradictions were apparent. Experiencing either three or at least four ACEs was associated with EAV [10, 14, 29]. While a significant association with EAV was found when an older adult experienced one or two ACEs [10], Asyraf, Dunne [14] found no significant association. Specifically, older adults who had experienced psychological-sexual, psychological-physical-sexual, physical-sexual, and psychological-physical childhood abuse combinations experienced a heightened risk of EAV in later life [10]. Pooling odds ratios in a meta-analysis (Fig 3), there was a statistically significant positive association between a history of at least one ACE and multiple EAVs (OR = 1.89, 95%CI: 1.80, 1.99). Despite this, heterogeneity existed across studies (I² = 96.0%; p<0.001) signifying a great variability in the results.

Fig 3 — **Note:** Study 1, 2 & 3 = Asyraf et al. (2021); Study 4 = Chen and Fu (2022); Study 4, 6 & 7 = Giraldo-Rodríguez et al. (2022).

Three studies examined the association between reporting a single form of ACE and multiple EAVs in later life. In the US and Mexico, reports of the association between a history of childhood physical abuse and an increased risk of multiple EAVs in later life differed [10, 28]. While in the Mexican study, childhood physical abuse among women was associated with multiple EAVs in later life [10], a lack of statistical significance was reported in the US [28]. In both Mexico and the US, childhood sexual abuse was significantly associated with multiple EAVs in later life [10, 28]. Childhood neglect, frequent exposure to childhood emotional abuse [28], childhood psychological abuse [10], frequent physical punishment by parents, and poor socio-economic status of the original family [29] singly increased the risk of multiple EAVs in later life. Parental divorce during childhood did not have a significant association with multiple EAV in later life [29]. Fig 4 shows the pooled OR of the association between a history of single form of ACE and multiple EAVs in later life (OR = 1.42, 95%CI: 1.35, 1.49; I² = 93.8%; p<0.001).

Fig 4 — **Note:** Study 1, 2, 3, 4 & 5 = Chen and Fu (2022)); Study 6, 7 & 8 = Giraldo-Rodríguez et al. (2022); Study 9, 10, 11 &12 = Kong and Easton (2019).

Connections between multiple ACEs and a single form of EAV

Overall, two studies examined the association between multiple ACEs and a single form of EAV and both reported that multiple ACEs were associated with the risk of experiencing a single form of EAV in later life [14, 18]. In addition, Asyraf, Dunne [14] reported that experiencing at least three ACEs was associated with a single form of EAV in later life. The pooled OR in a meta-analysis (Fig 5) showed a statistically significant positive association between multiple ACEs and a single form of EAV (OR = 1.89, 95%CI: 1.80, 1.99), with slight heterogeneity across studies (I² = 53.0%; p<0.119).

Fig 5 — **Note:** Study 1 & 2 = Asyraf et al. (2021); Study 3 = McDonald & Thomas (2013).

Connections between multiple ACEs and financial abuse experience in later life

Three studies examined the association between multiple ACEs and financial elder abuse experience in later life [14, 19, 29]. All three studies showed a consensus result that an increase in ACEs or the occurrence of an ACE was associated with financial elder abuse in later life [14, 19, 29]. Specifically, a study conducted in Canada reported that an increase in ACE levels had a significant positive association with financial elder abuse experiences in later life [19]. Similarly, a Malaysian study further found that experiencing two or three ACEs was associated with financial elder abuse in later life [14]. In China, a study that measured the association between child maltreatment–a form of ACEs–reported that an increase in child maltreatment levels was associated with an increased risk of financial elder abuse experience in later life [29]. When the ORs were pooled in a meta-analysis (Fig 6), there was a statistically significant positive association between multiple ACEs and financial elder abuse in later life (OR = 1.01, 95%CI: 1.01, 1.02), with significant heterogeneity across studies (I² = 90.7; p<0.001).

Fig 6 — **Note:** Study 1 & 2 = Asyraf et al. (2021); Study 3 = Burnes et al. (2022)); Study 4 = Chen & Fu (2022).

Connections between multiple ACEs and physical abuse experience in later life

Two studies [14, 29] specifically examined the association between ACEs and physical elder abuse, and both studies revealed a significant positive association between ACEs and physical elder abuse. The Chen and Fu [29]’s study conducted in China reported that an increase in the incidence of child maltreatment in childhood increased the risk of physical elder abuse in later life. The Asyraf, Dunne [14]’s study in Malaysia reported that an association of ACEs with EAV depended on the number of ACEs experienced; a childhood experience of four or more ACEs was associated with physical elder abuse [29]. The pooled ORs in a meta-analysis (Fig 7) showed a statistically significant positive association between multiple ACEs and physical elder abuse in later life (OR = 1.01, 95%CI: 1.01, 1.02), with significant heterogeneity across studies (I² = 81.9%; p<0.05).

Fig 7 — Note: Study 1 = Asyraf et al. (2021) & Study 2 = Chen and Fu (2022).

Connections between multiple ACEs and emotional, psychological, and sexual elder abuse experiences in later life

Two studies explored the association between multiple ACEs and emotional, psychological, and sexual elder abuse altogether [14, 29]. One of these studies reported that an increased incidence of childhood maltreatment elevated the risk of emotional elder abuse experienced in later life [29]. Asyraf, Dunne [14] reported that three or more ACEs was associated with psychological elder abuse in later life. Moreover, reporting four or more ACEs was associated with sexual elder abuse in later life [14].

Moderating factors of the connections between ACE and EAV

Two studies explored the factors that moderated the association between ACE and EAV [9, 10]. Giraldo-Rodríguez, Mino-León [10] found that women who reported having experienced three types of child abuse were at heightened risk of EAV. In addition, poor physical health and depressive symptoms moderated the association between ACEs and EAV [9].

Discussion

In this study, we examined the existing association between ACEs and EAV and employed a life course perspective to explore the relevance of addressing childhood and middle adulthood factors that contribute to EAV. We sourced the data from nine published articles that met the inclusion criteria for the study. We consider the nine selected papers as low volume, indicating limited scholarly conversation on the association between ACEs and EAV. This limited conversation has ongoing implications for policies and programs addressing elder abuse and child protection. This low volume of papers contributes to understanding why practices and policies tackling elder abuse have lagged despite its effects [8, 30].

The results further show different measures of ACEs and EAV, raising questions about the reliability and validity of measures. For instance, only one study used a standardized instrument (International questionnaire (ACE-IQ)) to measure ACEs [14], whereas the remaining studies used different instruments to measure an aspect of ACEs such as childhood neglect, childhood physical, and childhood sexual abuse [10, 28]. Likewise, different measures such as the Revised Conflict Tactics Scales [14], and Abusive Behaviour Inventory [9] composed of different questions and domains were used to measure EAV. Due to these inconsistencies, comparisons of study findings across time and a variety of different settings might be difficult to achieve, warranting the need for a standardized measurement approach that has relevance to a broader range of studies on ACEs.

Furthermore, ACEs were associated with the risk of experiencing a single form of EAV in later life. In particular, the selected studies established a significant positive association between ACEs and financial elder abuse experience, physical elder abuse, and emotional, physical, and sexual elder abuse. Our results further show that gender, physical health, and depressive symptoms moderate the association between ACEs and EAV. Specifically, an older woman with an experience of multiple ACEs or any one form of ACE is more likely to experience EAV in later life. Likewise, living with poor physical health with an experience of single or multiple ACEs increases the likelihood of experiencing EAV in later life. Moreover, expressing depressive symptoms and having a previous single or multiple ACEs increase the risk of experiencing EAV. Even though the present study has shown some evidence that gender, physical health status, and presence of depressive symptoms moderate ACEs–EAV association, only two studies were identified that support these findings. These moderated associations should, therefore, be considered by researchers, policymakers, and practitioners with care. The paucity of evidence to support the moderating powers of gender, physical health status, and depression on the ACEs–EAV association calls for significantly greater research attention from different geographical settings. Irrespective of the fact that this evidence has not been firmly established, interventions tackling EAV should attend to the unique needs of women/girls, those living with poor physical health, and those with depression.

The evidence from our analysis is consistent with other theoretical and empirical literature on elder abuse. Theoretically, the association between ACEs and EAV aligns with the life-course perspective, which argues that events occurring at different stages of life, especially ACEs, are risk factors for elder abuse [18, 30]. For example, early life events, including childhood abuse, childhood exposure to domestic violence, and childhood neglect heighten the risk of EAV in later life [28, 30]. Storey [31] describes ACEs as prior victimization and constant factors that increase the risk of elder abuse victimization.

From a life course perspective, the association between ACEs and EAV reinforces the need for intervention in childhood to prevent the occurrence of ACEs and mitigate adversities stemming from ACEs throughout life. Interventions addressing ACEs over the life stages, such as exposure to family violence, will likely impact the incidence of EAV [32]. However, there is no evidence of a prospective longitudinal study that tracks specific child abuse prevention interventions and their effect on the incidence of EAV in later life. Rather current interventions are mostly remedial for children whose effects are uncertain and inconclusive [33].

The systematic review and meta-analysis have strengths and limitations. A key strength is the consolidation of research on the strength and nature of association between ACEs and EAV. The current study can motivate and inform the design of more longitudinal studies to examine the associations between ACEs and EAV, in single or multiple forms, as well as their moderating factors in these relationships. A key limitation is the small number of studies eligible for inclusion in this study. Though nine studies collectively comprise a total sample of 60,365, a larger number of studies could have produced more robust findings. Moreover, though there was no study excluded based on grey literature status, an exclusion criterion might have automatically excluded grey literature relevant to this analysis. Additionally, the scope of the conversation is limited to the number of available published research evidence and the global North, calling for more longitudinal studies on ACEs–EAV associations and moderating factors in different geographical contexts including developing countries.

Conclusion and implications

There is growing evidence of an association between ACEs and EAV moderated by gender, and physical and mental health. Given the evidence of the association between ACEs and EAV demonstrated in our analysis, it is important to develop interventions that prevent ACEs early in life and that support older adults living in both residential and independent homes. Reducing the incidence of ACEs in childhood will likely also reduce the incidence of EAV or re-victimization as supported by the life course perspective. A life course perspective propels the need for effective support and services for children and families, as the prevention of adversity in childhood will also positively impact elder abuse prevention.

Critical findings

There is a growing evidence of an association between ACEs and EAV moderated by gender, physical and mental health
A low volume of research on the association between ACEs and EAV limits scholarly discussion on this topic.
Consistency in the measurement of ACEs and EAV is lacking, raising questions about the reliability and validity of measures.
There is no evidence of a prospective longitudinal study that tracks specific child abuse prevention interventions and their effect on the incidence of EAV

Implications for practice, research, and policy

Practitioners who work with children and older adults should be conscious of developing interventions that prevent ACEs early in life and that support older adults who live in either residential or independent homes.
The current study has provided foundational evidence of the need for more longitudinal studies to examine the associations between ACEs and EAV, in single or multiple forms, as well as their moderating factors to understand how to better serve the changing needs of older adults and children.
Policymakers should apply a life course perspective, which propels the need for effective support and services for children and families who experience victimization and its consequences at all stages of life.

Supporting information

S1 File. PRISMA 2020 checklist: The PRISMA checklist for systematic reviews and meta-analyses.

(DOCX)

pone.0316902.s001.docx^{(33KB, docx)}

S2 File. Studies identified.

(XLSX)

pone.0316902.s002.xlsx^{(1.1MB, xlsx)}

Data Availability

All relevant data are within the paper. This paper is a systematic review and meta-analysis so primary papers used are all in the paper.

Funding Statement

The author(s) received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0316902.r001

Decision Letter 0

Kristen Slack

25 Jul 2024

PONE-D-24-07611

Adverse childhood experiences and elder abuse victimization nexus: A systematic review and meta-analysis

PLOS ONE

Dear Dr. Awuviry-Newton,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

Please address Reviewer 1 numbered comments as follows:

1. Provide a more concise overview of the findings in the abstract.

2. Provide a citation supporting the claim of a higher prevalence of EAV in low- and middle-income countries compared to higher income countries.

3. The sentence in question reads as if there is only one pathway from ACEs to EAV, which is not true. Please revise this sentence to reflect that the pathway described is one of several potential pathways, of particular relevance to the present study, and provide relevant citations.

4. I believe this paragraph is relevant. However, please shorten and focus on other systematic reviews linking ACEs to other outcomes and to the highlighted claim regarding the absence of systematic reviews on ACEs and EAV.

5. Please be sure to temper the claim that there has been "a significant number of bodies of research on this association". The outcome of the systematic review itself suggests that this is not the case and contradicts a later claim that there is a "low volume" of scholarship on this topic in research (Critical finding, page 20).

6. Please thoroughly review the submission for typos.

7. The criteria are met for a systematic review.

8. Please expand discussion on measurement inconsistencies and use more caution in the discussion about moderating factors, as described by the Reviewer.

9. Please expand the discussion on the justification for applying a life course perspective, as described by the Reviewer.

10. Be sure to address the comments of Reviewer 1 in terms of what to emphasize in more detail. I would also like to see a brief mention of possible limitations of excluding grey literature from the search process.

Please address Reviewer 2 comments as follows:

1. I agree that the inclusion of ageism as a form of EAV could lead to inflated rates of EAV, at least in terms of how it is typically conceptualized. Please elaborate on the motivation for its inclusion and if possible, provide the number of articles included in the review that were based only on the link between ACEs and ageism in populations 60 and over. If one or more were included based on only this specific association, please discuss the implications of including it on the overall findings from the review.

2. Inclusion and exclusion criteria should offer more details, as noted by the Reviewer.

3. Please address the Reviewer's question about whether inclusion required a finding of a statistically significant relationship.

4. Please review details offered about specific studies to ensure accurate reporting.

5. Please clarify what is meant by cumulative EAV.

6. Please review the conclusion section after making the revisions outlined above and add other relevant takeaways, if warranted.

==============================

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Additional Editor Comments:

Thank you for the opportunity to review your submission. I encourage you to revise and resubmit your manuscript by following the guidance below for minor revisions.

Please address Reviewer 1 numbered comments as follows:

1. Provide a more concise overview of the findings in the abstract.

2. Provide a citation supporting the claim of a higher prevalence of EAV in low- and middle-income countries compared to higher income countries.

6. Please thoroughly review the submission for typos.

7. The criteria are met for a systematic review.

8. Please expand discussion on measurement inconsistencies and use more caution in the discussion about moderating factors, as described by the Reviewer.

9. Please expand the discussion on the justification for applying a life course perspective, as described by the Reviewer.

Please address Reviewer 2 comments as follows:

2. Inclusion and exclusion criteria should offer more details, as noted by the Reviewer.

3. Please address the Reviewer's question about whether inclusion required a finding of a statistically significant relationship.

4. Please review details offered about specific studies to ensure accurate reporting.

5. Please clarify what is meant by cumulative EAV.

6. Please review the conclusion section and add more details about the findings and their relative strengths, given the small number of studies to date.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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Reviewer #1: Yes

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

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Reviewer #1: Thanks for the opportunity to review the manuscript titled Adverse Childhood Experiences and Elder Abuse Victimization Nexus: A systematic review and meta-analysis. Please find my comments below:

1. The abstract is long and the report of the results was hard to follow. I recommend a concise and thorough summary of the results in the abstract.

It is unclear why the issue is especially relevant for low- and middle-income countries? There is no clear explanation even after checking the citation.

3. The sentences related to ‘one pathway’ on page 5 do not have any in-text citations. Also, this section should be discussed more thoroughly based on the review of prior studies.

4. The paragraph about the ‘associations between ACEs and adverse outcomes’ on page 5 does not seem relevant to this study.

5. I disagree with the sentence: “following an emerging recognition of the damaging impact of ACEs on EAV in later life, there has been a significant number of bodies of research on this association.” This is simply not accurate, as this systematic review included only 9 studies. The authors need to provide a better rationale and significance for this study. Given the small number of existing studies and the emerging nature of this topic, I am not sure if this systematic review would have been necessary.

6. There were typos throughout the introduction section.

7. The methodology of this paper appears to be thorough, but I wonder how the small number of papers (n = 9) may affect the pooled results.

8. In discussion, I recommend expanding the discussion about measurement consistencies: how they are inconsistent and what are the problems associated with the inconsistent measurement. Also, the discussion about moderating factors should be approached carefully since they were based on two studies only.

9. On page 19: I recommend expanding the discussion about ‘the association between ACEs and EAV aligns with the life course perspective’. How does it align and are there other theories that can explain the association? Authors can consider bringing in the prior literature about lifetime revictimization.

10. The discussion about the strengths and limitations of the study was very brief, which needs to be strengthened and clearly specify the contribution of this study.

Reviewer #2: 1. The authors state the following as it relates to forms of EAV: “Examples of this victimisation include older adults’ experience of ageism, financial exploitation, sexual abuse, physical and psychological assault or abuse, and neglect (Dong, 2015).” Ageism is generally not regarded as a form of EAV, but rather as a risk factor. Including ageism as a form of EAV would indicate a prevalence of 100% among older adults, since all older adults are exposed to ageism, albeit in different ways based on identity.

2. As it relates to study eligibility for inclusion in the review, did you consider qualitative versus quantitative studies, year of publication, location of study, or type of analysis that examined the relationship between ACEs and EAV?

3. To be included in the review, did the study need to have reported a significant association between ACEs and EAV, or did it also include studies that found no significant relationship?

4. The authors are encouraged to review the accuracy of information captured on studies included in the review. For example, the Burnes et al (2022) study did not use a three items questionnaire to measure EAV, nor were there 36 items included in the child maltreatment questionnaire.

5. What is meant by cumulative EAV? Do the authors mean aggregate or total EAV that includes any subtype?

6. The following conclusion reported in the discussion seems too strong, given that the respective results were based on only one study: “Our results further show that gender, physical health, and depressive symptoms moderate the association between ACE and EAV.”

**********

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Reviewer #1: No

Reviewer #2: No

**********

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PLoS One. 2025 Feb 5;20(2):e0316902. doi: 10.1371/journal.pone.0316902.r002

Author response to Decision Letter 0

27 Sep 2024

Dear Kristen

Thank you very much for the opportunity to respond to the reviewer’s comments. We want to emphasize that the suggestions made by the reviewers have improved the manuscript. We have addressed the reviewer’s comments below:

Response to Reviewer’s comments

Please address Reviewer 1 numbered comments as follows:

1. Provide a more concise overview of the findings in the abstract.

Response:

A more concise abstract has been provided.

2. On Page 4: it is stated that “… the prevalence of abuse in many countries, especially low- and middle-income countries is expected to increase with the increasing rate of population ageing (WHO, 2022)”. It is unclear why the issue is especially relevant for low- and middle-income countries? There is no clear explanation even after checking the citation.

Response:

Thank you for this comment. I have modified the sentence and included another reference and it now reads as “In addition to the reported increase of abuse during the Coronavirus disease – 2019 (COVID-19) (Chang, 2016), the prevalence of abuse in many countries, including low- and middle-income countries is expected to increase with the increasing rate of population ageing (World Health Organization, 2024; Yon et al., 2017).” The article published by WHO in 2022 was based on one of the studies which is a systematic review and meta-analysis, reporting a high prevalence of elder abuse in low- and middle-income countries as well. Out of the 28 studies included in the systematic review, 7 were based in low- and middle-income countries.

3. Provide a citation supporting the claim of a higher prevalence of EAV in low- and middle-income countries compared to higher income countries.

Response:

Thank you. The two citations (World Health Organisation (2024) and Yon et al., (2017) have been provided.

4. The sentence in question reads as if there is only one pathway from ACEs to EAV, which is not true. Please revise this sentence to reflect that the pathway described is one of several potential pathways, of particular relevance to the present study, and provide relevant citations.

Response:

The sentence has been revised and referenced. It now reads as “One of these pathways explored in this study is that older adults who experience adverse circumstances in their childhood, living in any setting, may carry disempowerment with them throughout later life, and are more likely to be re-victimized in the community or when living in a residential setting (Asyraf et al., 2021)”

5. I believe this paragraph is relevant. However, please shorten and focus on other systematic reviews linking ACEs to other outcomes and to the highlighted claim regarding the absence of systematic reviews on ACEs and EAV.

Response:

Thanks for this suggestion. I have made the argument more concise. It now reads as “For instance, systematic reviews have provided evidence on ACEs, or effects of multiple ACEs on health outcomes such as sexual, mental, and physical health, and higher utilisation of healthcare (Hughes et al., 2017; Kalmakis & Chandler, 2015; Petruccelli et al., 2019)

6. Please be sure to temper the claim that there has been "a significant number of bodies of research on this association". The outcome of the systematic review itself suggests that this is not the case and contradicts a later claim that there is a "low volume" of scholarship on this topic in research (Critical finding, page 20).

Response:

We have acknowledged this discordance and addressed it accordingly. The claim now reads as “Moreover, following an emerging recognition of the impact of ACEs on EAV in later life, there have been some papers published on the association (Burnes et al., 2022; Easton & Kong, 2021; McDonald & Thomas, 2013; Wiklund et al., 2022)

7. Please thoroughly review the submission for typos.

Response

We have read the entire manuscript for typo corrections.

7. The criteria are met for a systematic review.

Response:

Thank you very much for this comment. We appreciate this feedback.

Response:

We have expanded the discussion on measurement and their potential impacts. Also, we have modified our discussion on the moderating factors elaborating on the possible implications for research, policy and practice.

9. Please expand the discussion on the justification for applying a life course perspective, as described by the Reviewer. On page 19: I recommend expanding the discussion about ‘the association between ACEs and EAV aligns with the life course perspective’. How does it align and are there other theories that can explain the association? Authors can consider bringing in the prior literature about lifetime revictimization. The discussion about the strengths and limitations of the study was very brief, which needs to be strengthened and clearly specify the contribution of this study.

Response:

Thank you for the suggestions to elaborate on the justification for applying the life course perspective. We have provided relevant information including the justification for the life course perspective in the introduction making it easier for the reader to understand the discussion of the life course perspective in the discussion section.

Response:

Thank you for these comments. I have included in the discussion that, “Moreover, though there was no study excluded based on grey literature status, the inclusion of this as an exclusion criterion might have automatically excluded grey literature that reported on the association between ACEs and EAV in the first place.”

Please address Reviewer 2 comments as follows:

I agree that the inclusion of ageism as a form of EAV could lead to inflated rates of EAV, at least in terms of how it is typically conceptualized. Please elaborate on the motivation for its inclusion and if possible, provide the number of articles included in the review that were based only on the link between ACEs and ageism in populations 60 and over. If one or more were included based on only this specific association, please discuss the implications of including it on the overall findings from the review.

Response:

Thank your for your comment on EAV and ageism. Ageism is a bias against older adults groups based on their age, which may take the form of discrimination at all levels against such individuals and groups, up to and including victimisation and bullying (Pillemer, Burnes, & MacNeil, 2021). Investigating the connection between ageism and elder mistreatment. Nature Aging, 1(2), 159-164.). In view of this, we included ageism as a synonym for elder abuse victimisation. We want to profoundly say that none of the studies included specifically measured the association between ACEs and ageism.

2. Inclusion and exclusion criteria should offer more details, as noted by the Reviewer. As it relates to study eligibility for inclusion in the review, did you consider qualitative versus quantitative studies, year of publication, location of study, or type of analysis that examined the relationship between ACEs and EAV?

Response

We have provided more information on the inclusion strategies. Under the “study eligibility criteria”, we have included that the Inclusion of studies was not restricted to any research approach, year of publication, location of study, or type of analytical method used to examine the association on ACEs and EAV. These inclusion strategies allowed for any study available on the ACEs – EAV association to be included in the systematic review.

3. Please address the Reviewer's question about whether inclusion required a finding of a statistically significant relationship. To be included in the review, did the study need to have reported a significant association between ACEs and EAV, or did it also include studies that found no significant relationship?

Response:

The significance level as reported by the study did not determine its inclusion in the systematic review. The most relevant inclusion indicator was for the study to report examining as association between ACEs and EAV.

4. Please review the details offered about specific studies to ensure accurate reporting. The authors are encouraged to review the accuracy of information captured on studies included in the review. For example, the Burnes et al (2022) study did not use a three items questionnaire to measure EAV, nor were there 36 items included in the child maltreatment questionnaire.

Response:

We have reviewed the included studies for accurate reporting.

5. Please clarify what is meant by cumulative EAV.

Response:

We have replaced the cumulative EAV with ‘multiple’ to represent an experience of more than one elder abuse victimisation. This could include experiencing say emotional abuse and physical abuse together, or emotional abuse, physical abuse and financial abuse.

6. Please review the conclusion section after making the revisions outlined above and add other relevant takeaways, if warranted.

Response:

Thank you very much. We have reviewed the conclusion of the review to capture all important take home messages.

Attachment

Submitted filename: Response to Reviewer.docx

pone.0316902.s003.docx^{(38.6KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0316902.r003

Decision Letter 1

Kristen Slack

30 Oct 2024

PONE-D-24-07611R1Adverse childhood experiences and elder abuse victimization nexus: A systematic review and meta-analysisPLOS ONE

Dear Dr. Awuviry-Newton,

Please submit your revised manuscript by Dec 14 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Kristen Slack

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

This is a strong paper that makes an important contribution to the research literature. While you sufficiently addressed reviewers’ concerns in this revision, a thorough editing of the manuscript for grammar and syntax was not apparent. PLOS ONE does not provide on-staff editorial assistance, so the job of an editorial board member includes reviewing manuscripts for grammar, punctuation, syntax, and clarity consistent with the journal’s requirements. In future submissions, please take this into account as it will significantly speed up the review process. While I have many comments, they are all minor and require a wording change or attention to the use of singular vs. plural nouns, use of commas, and the like. I have uploaded my Word document with my editorial changes and additional comments to make your review of my changes easier to work with, rather than listing the needed changes here.

Attachment

Submitted filename: Responses to Revision 1 ACES and EAV.docx

pone.0316902.s004.docx^{(39.2KB, docx)}

PLoS One. 2025 Feb 5;20(2):e0316902. doi: 10.1371/journal.pone.0316902.r004

Author response to Decision Letter 1

4 Nov 2024

Responses to Comments

Dear Editor,

We thank you very much for the comments raised, which have improved the paper immensely. We have addressed the comments in the manuscript and also below;

Journal Requirements:

Response

I have reviewed the reference list for accuracy. The reference is complete and correct.

Additional Editor Comments:

Response

Thank you very much for the thorough proofreading of the manuscript. We have addressed all comments raised in the manuscript.

General comments:

1. Use “in singular or multiple form” rather than “by form or multiple” throughout manuscript. Example from the abstract: “All studies that addressed associations between ACEs, by form or multiple in singular or multiple form, and EAV were included in the review.” I note that you did attend to this prior comment from me in this revision, but in some instances in the manuscript, the word “cumulative” still appears. I note that measures capturing multiple forms of ACEs or EAVs can be measured dichotomously (e.g., having multiple vs. none or having particular combinations), and not necessarily cumulatively (i.e. a sum or count), so use these two terms with intentionality. For example, when I see the word “cumulative”, I expect the model coefficient for a predictor to represent the predicted change in an association for each additional number of something (e.g., ACEs) included in a count variable. It may be that you have intentionally chosen to use one of these terms over the other—I am just requesting that you double-check and where appropriate, use consistent terminology.

Response

I have perused the entire manuscript and now consistent with the use of “in singular or multiple form”.

2. Once you spell out “adverse childhood experiences” within the main text following the abstract, and give the acronym “(ACEs)”, you can use ACE throughout the manuscript. If you choose to use the fully spelled out term interchangeably throughout, then, at a minimum, be consistent in subsection titles (use “ACEs” or use “adverse childhood experiences”).

Response

This has been taken care of in the entire manuscript.

3. Check that singular vs. plural is used correctly (e.g., in the abstract, “odds ratios (OR)” is plural but “confidence interval (CI) is singular. When referring to one as plural, the other should be plural.

Response

I have corrected this in the abstract and in the manuscript as well.

4. Check appropriate use of commas throughout manuscript. Some, but not all, examples are given below.

When you refer to EAV, you sometimes use EAVs. It would sound strange to say “elder abuse victimizations” if you are simply referring to any form of EAV. Please check throughout the document to make sure you intend to use a plural form of EAV.

Response

I have corrected this problem in the entire manuscript.

5. Check for unnecessary double-spacing within sentences.

Response

I have removed all unnecessary spaces within the manuscript.

6. The comments above should be addressed throughout the manuscript. In some comments below, I have identified where these types of changes should be made, but not all instances were flagged.

Abstract:

Add an “s” to “association”: Included studies examined multiple ACEs and multiple EAV associations (N=3)

Awkwardly worded sentence: The results indicate that interventions designed to reduce ACEs, by form or multiple in singular or multiple form, early in life and to support residential-and community-dwelling older adults may be relevant in reducing the incidence of EAV

“The life course perspective should be integrated….”

Response

I have addressed all of these comments raised here in the manuscript.

Background:

(Page 3)

7. Make “pose” plural: “The growing prevalence and incidence of elder abuse victimization (EAV) reported in residential and community (home care) settings across the world poses both a public health and a human rights concern.”

Add comma after second use of the word “countries”: “…the prevalence of abuse in many countries, including low- and middle-income countries, is expected to increase…”

Change wording: “Increasing levels of elder abuse co-occur with high levels of child maltreatment and adverse childhood experiences (ACEs) (Madigan et al., 2023).”

Response

We have rectified the above issue in the manuscript.

8. Since the word “adults’ “ is a possessive plural, delete “the” and make “experience” plural: “EAV, in this review, will refer to the older adults’ experiences of a single or repeated act or lack of appropriate action…”

Add comma after “knowledge”, change “enunciate” to “elucidate”: “However, to our knowledge, no systematic syntheses or reviews currently exist to enunciate explore the nature of this connection/pathway”.

(Page 4)

“Specific examples of ACEs include childhood sexual abuse, parental criminality and divorce , childhood disempowerment, and childhood discrimination (Hughes et al., 2017).”

What does “This” refer to?: “This includes the cumulative harmful effects of at least two domains of ACEs (Hughes et al., 2017).”

Response:

We have addressed all the above comments in the manuscript.

9. In the following sentence, change “these” to “the” since you are referring to the singular noun “One”: “One of these pathways explored in this study…”

Change wording: “There has been research Studies on the associations between ACEs and adverse outcomes, with use varying vary in their designs, methodologies, locations, findings and conclusions.”

Drop the “s” in “influences”: “For example, a study conducted in China revealed that social and economic instability during childhood influences an increase in…”

Add comma after second “ACEs”: “For instance, systematic reviews have provided evidence on ACEs, or effects of multiple ACEs, on health outcomes such as…”

Simplify sentence: “Moreover, following an emerging recognition of the impact of ACEs on EAV in later life, there have been some In addition to an earlier study (McDonald & Thomas, 2013), more recent research has focused on the association between ACEs and EAV (Burnes et al., 2022; Easton & Kong, 2021; McDonald & Thomas, 2013; Wiklund et al., 2022).

Response

The above comments have been addressed in the manuscript.

(Page 5):

10. Change wording: “Synthesizing evidence on this association will be significant in contribute to understanding, or revealing, a clear pathway of the association and evidence on how to mitigate this public health concern.”

Change wording: “In this study, As applied elsewhere (McDonald & Thomas, 2013), we employed the life-course perspective as a useful framework to understand for interpreting the findings of the systematic review as applied elsewhere (McDonald & Thomas, 2013)…”

Use plural for “experience”: “…about aspects of developmental experiences…”

Add “a” or “the”: “According to Elder (2006), a life-course perspective elucidates the potential effects of accumulative advantage or disadvantage of individuals – social structure relationship on individuals over time. ”

Drop this sentence or elaborate on this example and provide a citation: “To illustrate this, the experience of a child living in an institution such as a school or a family setting will continue to be important in later life.”

Combine sentences: “Accordingly, This systematic review aimed to understand the connections between ACEs and EAVs, as well as . We also need to gain insight into factors moderating the relationships between ACEs – EAVs relationships.

Change wording: “Understanding An enhanced understanding of this evidence using a life-course perspective would assist in the development of appropriate interventions for older adults who experience abuse , prevent the occurrence of ACEsthrough the understanding of life-course perspectives, and provide an urgent and clear a clearer pathway for more improve cross-cultural and longitudinal research on the relationships between ACEs and EAV.”

Response

All the comments raised above have been addressed in the manuscript.

(Page 6):

11. Change wording: “Two authors (KAN and KAC) did the screening independently and met on Zoom to address any disagreement for and achieve consensus.”

Change wording: “Studies on elder abuse victimization, or aspect on elder abuse types , such as ageism, psychological abuse,…”

Change wording: “Inclusion of studies were Study inclusion was not restricted…”

Change wording; add comma after “manager”, remove comma after “removal”: “Articles that resulted from the identified in databases searched were exported to Endnote, a reference manager, to allow for duplicate removal, and title and abstracts screening, as per the study’s inclusion criteria.”

Response

All comments above have been addressed in the manuscript.

(Page 6-7):

Remove comma after “retrieved”; change wording: All articles that potentially met eligibility criteria were retrieved, after the a full test screen of all potential articles was conducted. Afterwards After consulting with the other three authors, all articles meeting the eligibility criteria were retained. After consulting with the other three authors.

Response

We have addressed the above comments.

(Page 7):

12. Add comma after “August 2023”: “The search was conducted in English and performed in PubMed, CINAHL Complete, APA PsycINFO, Web of Science, Scopus, and Google Scholar in August 2023, covering articles published in or before 2023.”

Respone

We have addressed the above comment in the manuscript.

(Page 8):

13. Add comma before “respectively”: The checklists were made up of 8 and 11 questions for analytical cross-sectional and cohort studies, respectively.

Change wording: “After eligible studies had been included were identified,…”

Should “structures” be singular?: “This grouping generated themes providing structures for the presentation of the findings.”

Response

We have addressed comments above in the manuscript.

(Page 9):

14. Make “interval” plural”: After the narrative review was completed for a particular theme, a meta-analysis of the extracted odds ratios and confidence intervals.”

Add comma after ratios and drop the word “and”: “Pooled odds ratios, and confidence intervals and heterogeneity were used to present consolidated associations for the themes identified, where applicable.”

Change wording: “After title and abstract screening had been was completed…”

Change wording: “The full text screening resulted in a total of 9 articles (all employed quantitative methods) that met eligibility criteria for the systematic review…”

Change wording: “None was were conducted in an African country.”

Response

The above comments have been addressed in the manuscript.

(Page 10):

15. Change wording and address plural/singular and tense corrections: “The sample sizes of the included studies rangeds from 135 to 23,468, with the and participants were being predominantly females in all included studies.”

“Participants in the included studies were aged 60 years and above, who reported ACEs and EAV experiences in later life.”

Change wording: “Some of the studies measured ACEs cumulatively on cumulative (Asyraf et al., 2021; Chen & Fu, 2022b; Dong & Wang, 2019; Easton & Kong, 2021) whiles others used a measured types of ACE separately (Burnes et al., 2022; Giraldo-Rodríguez et al., 2022; Kong & Easton, 2019; McDonald & Thomas, 2013; Wiklund et al., 2022) to measure childhood experience.”

Change wording: “The studies reported using different types of measurement tools with unequal and unique sets of questions to measure ACEs.”

Change wording: “….and a questionnaire measuring an abuse before the age of 65. Years questionnaire

Delete sentence as it is redundant with first sentence in the paragraph: “All of these questionnaires were used to measure ACEs either on cumulative or in part.”

Response

We have addressed all the comments above in the manuscript.

(Page 11):

Change wording: “Even though cumulative EAV (cumulative) was the main the most common outcome measure among the studies (Asyraf et al., 2021; Burnes et al., 2022; Chen & Fu, 2022b; Easton & Kong, 2021; Kong & Easton, 2019), other single forms of EAV outcomes contributing to our understanding of EAV were reported, as well, including These single outcome measures included experience of” physical elder abuse…”

Change wording: “The included studies used distinct scales and question items to measure EAV, including The included studies used sets of questions including the Abusive Behavior Inventory…”

Check official name of measure, as I’ve only seen it referenced with “scales” capitalized and singular: “…Revised Conflict Tactics scales (Asyraf et al., 2021)…”

Change wording in section title: Is it “multiple” or cumulative”?—be sure you are using these terms purposively. “Multiple” forms could be operationalized in a non-cumulative way (e.g., a dichotomous variable). If you always mean cumulative, then section title should use that word instead of “multiple”; either capitalize each separate word in ACEs or use small case for “adverse” in section title; also, “experience” should be plural, correct?: “Connections between Adverse childhood experiences and multiple elder abuse victimization”

Change wording and check whether “multiple” should be “cumulative” and the reverse: ” Seven studies examined the association between ACEs (multiple or single forms) or part and cumulative EAV.”

Response

The comments have been addressed in the manuscript.

(Page 12):

Delete “in”: “Burnes et al. (2022) and Dong and Wang (2019) reported that a history, or increasing incidence of in child maltreatment…”

Include direction (e.g., “positive” association) of the relationship: “Similarly, ACEs had a significant association with EAV (Easton & Kong, 2021).”

Change wording; also, should “ACE” be plural here? If not, change to “at least one ACE and”: “The pooled odds ratio from a meta-analysis shows a statistically significant association between experiencing ACEs and multiple EAV…”

Change wording: “Some of the studies examined the effect of having a history of a co-occurring abuse/ACEs on EAV in later life. While most of the results were consistent, some contradictions were apparent. Experiencing either three or at least four ACEs was associated with EAV (Asyraf et al., 2021; Chen & Fu, 2022b; Giraldo-Rodríguez et al., 2022). While a significant association with EAV was also suggested when a child experienced one or two ACEs (Giraldo-Rodríguez et al., 2022), Asyraf et al. (2021) experienced found no significant association.

Clarify the implication of this statement: “Despite this, heterogeneity existed across studies…”

Response

The above comments have been addressed in the manuscript.

(Page 13):

Use “While” not “Whiles”: “Whiles in the Mexican study….”

Consider simply saying the following: “In both a similar geographic contexts (Mexico and the

Attachment

Submitted filename: Responses to Revision 1 ACES and EAV.docx

pone.0316902.s005.docx^{(46.5KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0316902.r005

Decision Letter 2

Rafi Amir-ud-Din

18 Dec 2024

Adverse childhood experiences and elder abuse victimization nexus: A systematic review and meta-analysis

PONE-D-24-07611R2

Dear Dr. Awuviry-Newton,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Rafi Amir-ud-Din

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

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Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #2: Yes

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Reviewer #2: Yes

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Reviewer #2: Yes

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Reviewer #1: The authors did an excellent job addressing the reviewers' concerns. I am content with their revision.

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PLoS One. doi: 10.1371/journal.pone.0316902.r006

Acceptance letter

Rafi Amir-ud-Din

17 Jan 2025

PONE-D-24-07611R2

PLOS ONE

Dear Dr. Awuviry-Newton,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 File. PRISMA 2020 checklist: The PRISMA checklist for systematic reviews and meta-analyses.

(DOCX)

pone.0316902.s001.docx^{(33KB, docx)}

S2 File. Studies identified.

(XLSX)

pone.0316902.s002.xlsx^{(1.1MB, xlsx)}

Attachment

Submitted filename: Response to Reviewer.docx

pone.0316902.s003.docx^{(38.6KB, docx)}

Attachment

Submitted filename: Responses to Revision 1 ACES and EAV.docx

pone.0316902.s004.docx^{(39.2KB, docx)}

Attachment

Submitted filename: Responses to Revision 1 ACES and EAV.docx

pone.0316902.s005.docx^{(46.5KB, docx)}

Data Availability Statement

All relevant data are within the paper. This paper is a systematic review and meta-analysis so primary papers used are all in the paper.

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PERMALINK

Adverse childhood experiences and elder abuse victimization nexus: A systematic review and meta-analysis

Kofi Awuviry-Newton

Bernadette Saunders

Nestor Asiamah

Kwamina Abekah-Carter

Daniel Doh

Roles

Abstract

Background

Methods

Protocol

Study eligibility criteria

Table 1. List of keywords for identifying articles for adverse childhood experience–elder abuse victimization systematic review.

Search strategies

Study selection

Fig 1. Study inclusion procedure in line with the PRISMA 2020 guidelines.

Quality assessment

Table 2. Results of quality assessment of the selected articles.

Data extraction and analysis

Table 3. Details of studies included in the systematic review.

Results

Included study characteristics

ACEs measures

EAVs measures

Connections between single or multiple ACEs and multiple EAV

Fig 2. Multiple ACEs was associated with multiple EAVs in later life.

Fig 3. A history of at least one ACE was significantly associated with multiple EAVs.

Fig 4. A history of single forms of ACE was significantly associated with multiple EAVs in later life.

Connections between multiple ACEs and a single form of EAV

Fig 5. A history of multiple ACEs was significantly associated with a single form of EAV.

Connections between multiple ACEs and financial abuse experience in later life

Fig 6. A history of multiple ACEs was associated with financial elder abuse in later life.

Connections between multiple ACEs and physical abuse experience in later life

Fig 7. A history of multiple ACEs was significantly associated with physical elder abuse in later life.

Connections between multiple ACEs and emotional, psychological, and sexual elder abuse experiences in later life

Moderating factors of the connections between ACE and EAV

Discussion

Conclusion and implications

Critical findings

Implications for practice, research, and policy

Supporting information

Data Availability

Funding Statement

References

Decision Letter 0

Kristen Slack

Roles

Author response to Decision Letter 0

Decision Letter 1

Kristen Slack

Roles

Author response to Decision Letter 1

Decision Letter 2

Rafi Amir-ud-Din

Roles

Acceptance letter

Rafi Amir-ud-Din

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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