A/HRC/43/39 institutionalization, especially for younger children and those who spend long periods in institutions.44 60. As regards long-term effects, exposure to trauma has been associated with depression, low self-esteem and substance abuse in late adolescence and early adulthood. Adverse childhood experiences can also compromise the development of healthy coping strategies, which can in turn affect health behaviour, physical and mental health and life opportunities and bring on premature death. 45 Adverse childhood experiences have been linked to increased risk for alcohol and substance use disorders, suicide, mental health conditions, heart disease, other chronic illnesses and health risk behaviour throughout life. 61. Adverse childhood experiences have also been linked to reduced educational attainment, employment and income, which directly and indirectly affect health and wellbeing. At least 5 of the 10 leading causes of death have been associated with exposure to adverse childhood experiences, including several contributors to declines in life expectancy.46 Depression, heavy drinking, smoking, lower educational attainment, lack of health insurance and unemployment are significantly associated with them.47 62. Cumulative exposure to violence in more than two contexts (for example, witnessing violence at home, sexual abuse, parenting stress) leads to greater behavioural and emotional problems in children, as well as post-traumatic stress disorder.48 63. One study found that for both men and women, there was a strong and significant relationship between childhood violence and violence in adulthood that was not restricted to violence within a similar category. Childhood exposure was associated with a 2.2–5 times higher occurrence of adult violence.49 C. Differences between children’s experience of violence across the life cycle 64. The nature of the impact of violence on children’s mental health depends on their experience of violence across the life course. 65. The experience of violence can set in as early as pregnancy, with a high risk of problems in the child’s nervous system and brain. Domestic violence against pregnant women by their partners, spouses and other members of the family is the most substantial risk before birth. 66. Normal and healthy development of infants through to preschool age depends upon secure relationships with caregivers. Disruption of this process, for instance by exposure to violence, can interfere with all aspects of children’s development. More specifically, children may not acquire a healthy level of trust and autonomy. 50 In infancy, secure attachment may be derailed, sleep and eating disturbances introduced and even brain development may be altered. 67. Pre-schoolers have not achieved the ability to control their own emotions. The literature sets out some of the behavioural effects of being exposed to violence at this age, 44 45 46 47 48 49 50 12 Lorraine Sherr, Kathryn J. Roberts and Natasha Gandhi, “Child violence experiences in institutionalised/orphanage care”, Psychology, Health & Medicine, vol. 22, supplement No. 1 (2017). Melissa T. Merrick and others, “Vital signs: estimated proportion of adult health problems attributable to adverse childhood experiences and implications for prevention – 25 states 2015–2017”, Morbidity and Mortality Weekly Report, vol. 68, No. 44 (November 2019). Ibid. Ibid. See Jane G. Stapleton and others, “The mental health needs of children exposed to violence in their homes”. See Siri Thoresen and others, “Violence against children, later victimisation, and mental health”. See Joy D. Osofsky, “The impact of violence on children”, The Future of Children, vol. 9, No. 3 (winter 1999).