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Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults - ACE Study

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Research Article
Relationship of Childhood Abuse and
Household Dysfunction to Many of the
Leading Causes of Death in Adults
The Adverse Childhood Experiences (ACE) Study
Vincent J. Felitti, MD, FACP, Robert F. Anda, MD, MS, Dale Nordenberg, MD, David F. Williamson, MS, PhD,
Alison M. Spitz, MS, MPH, Valerie Edwards, BA, Mary P. Koss, PhD, James S. Marks, MD, MPH
Background: The relationship of health risk behavior and disease in adulthood to the breadth of
exposure to childhood emotional, physical, or sexual abuse, and household dysfunction
during childhood has not previously been described.
Methods: A questionnaire about adverse childhood experiences was mailed to 13,494 adults who had
completed a standardized medical evaluation at a large HMO; 9,508 (70.5%) responded.
Seven categories of adverse childhood experiences were studied: psychological, physical, or
sexual abuse; violence against mother; or living with household members who were
substance abusers, mentally ill or suicidal, or ever imprisoned. The number of categories
of these adverse childhood experiences was then compared to measures of adult risk
behavior, health status, and disease. Logistic regression was used to adjust for effects of
demographic factors on the association between the cumulative number of categories of
childhood exposures (range: 0–7) and risk factors for the leading causes of death in adult
life.
Results: More than half of respondents reported at least one, and one-fourth reported $2
categories of childhood exposures. We found a graded relationship between the number
of categories of childhood exposure and each of the adult health risk behaviors and
diseases that were studied (P , .001). Persons who had experienced four or more
categories of childhood exposure, compared to those who had experienced none, had 4-
to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide
attempt; a 2- to 4-fold increase in smoking, poor self-rated health, $50 sexual intercourse
partners, and sexually transmitted disease; and a 1.4- to 1.6-fold increase in physical
inactivity and severe obesity. The number of categories of adverse childhood exposures
showed a graded relationship to the presence of adult diseases including ischemic heart
disease, cancer, chronic lung disease, skeletal fractures, and liver disease. The seven
categories of adverse childhood experiences were strongly interrelated and persons with
multiple categories of childhood exposure were likely to have multiple health risk factors
later in life.
Conclusions: We found a strong graded relationship between the breadth of exposure to abuse or
household dysfunction during childhood and multiple risk factors for several of the
leading causes of death in adults.
Medical Subject Headings (MeSH): child abuse, sexual, domestic violence, spouse abuse,
children of impaired parents, substance abuse, alcoholism, smoking, obesity, physical
activity, depression, suicide, sexual behavior, sexually transmitted diseases, chronic obstruc-
tive pulmonary disease, ischemic heart disease. (Am J Prev Med 1998;14:245–258) © 1998
American Journal of Preventive Medicine
Department of Preventive Medicine, Southern California Perma-
nente Medical Group (Kaiser Permanente), (Felitti) San Diego,
California 92111. National Center for Chronic Disease Prevention
and Health Promotion, Centers for Disease Control and Prevention,
(Anda, Williamson, Spitz, Edwards, Marks) Atlanta, Georgia 30333.
Department of Pediatrics, Emory University School Medicine, (Nor--
denberg) Atlanta, Georgia 30333. Department of Family and Com-
munity Medicine, University of Arizona Health Sciences Center,
(Koss) Tucson, Arizona 85727.
Address correspondence to: Vincent J. Felitti, MD, Kaiser Perma-
nente, Department of Preventive Medicine, 7060 Clairemont Mesa
Boulevard, San Diego, California 92111.
245Am J Prev Med 1998;14(4) 0749-3797/98/$19.00
© 1998 American Journal of Preventive Medicine PII S0749-3797(98)00017-8

Introduction
O
nly recently have medical investigators in pri-
mary care settings begun to examine associa-
tions between childhood abuse and adult
health risk behaviors and disease.
1–5
These associations
are important because it is now clear that the leading
causes of morbidity and mortality in the United States
6
are related to health behaviors and lifestyle factors;
these factors have been called the “actual” causes of
death.
7
Insofar as abuse and other potentially
damaging childhood experiences contribute
to the development of these risk factors, then
these childhood exposures should be recog-
nized as the basic causes of morbidity and
mortality in adult life.
Although sociologists and psychologists
have published numerous articles about the
frequency
8–12
and long-term consequenc-
es
13–15
of childhood abuse, understanding their rele-
vance to adult medical problems is rudimentary. Fur-
thermore, medical research in this field has limited
relevance to most primary care physicians because it is
focused on adolescent health,
16–20
mental health in
adults,
20
or on symptoms among patients in specialty
clinics.
22,23
Studies of the long-term effects of child-
hood abuse have usually examined single types of abuse,
particularly sexual abuse, and few have assessed the im-
pact of more than one type of abuse.
5,24–28
Conditions
such as drug abuse, spousal violence, and criminal activity
in the household may co-occur with specific forms of
abuse that involve children. Without measuring these
household factors as well, long-term influence might be
wrongly attributed solely to single types of abuse and
the cumulative influence of multiple categories of
adverse childhood experiences would not be assessed.
To our knowledge, the relationship of adult health risk
behaviors, health status, and disease states to childhood
abuse and household dysfunction
29–35
has not been
described.
We undertook the Adverse Childhood Experiences
(ACE) Study in a primary care setting to describe the
long-term relationship of childhood experiences to
important medical and public health problems. The
ACE Study is assessing, retrospectively and prospec-
tively, the long-term impact of abuse and household
dysfunction during childhood on the following out-
comes in adults: disease risk factors and incidence,
quality of life, health care utilization, and mortality. In
this initial paper we use baseline data from the study to
provide an overview of the prevalence and interrelation
of exposures to childhood abuse and household dys-
function. We then describe the relationship between
the number of categories of these deleterious child-
hood exposures and risk factors and those diseases that
underlie many of the leading causes of death in
adults.
6,7,36,37
Methods
Study Setting
The ACE Study is based at Kaiser Permanente’s San
Diego Health Appraisal Clinic. More than 45,000 adults
undergo standardized examinations there each year,
making this clinic one of the nation’s largest free-
standing medical evaluation centers. All en-
rollees in the Kaiser Health Plan in San
Diego are advised through sales literature
about the services (free for members) at the
clinic; after enrollment, members are ad-
vised again of its availability through new-
member literature. Most members obtain
appointments by self-referral; 20% are re-
ferred by their health care provider. A recent review of
membership and utilization records among Kaiser
members in San Diego continuously enrolled between
1992 and 1995 showed that 81% of those 25 years and
older had been evaluated in the Health Appraisal
Clinic.
Health appraisals include completion of a standard-
ized medical questionnaire that requests demographic
and biopsychosocial information, review of organ sys-
tems, previous medical diagnoses, and family medical
history. A health care provider completes the medical
history, performs a physical examination, and reviews
the results of laboratory tests with the patient.
Survey Methods
The ACE Study protocol was approved by the Institu-
tional Review Boards of the Southern California Per-
manente Medical Group (Kaiser Permanente), the
Emory University School of Medicine, and the Office of
Protection from Research Risks, National Institutes of
Health. All 13,494 Kaiser Health Plan members who
completed standardized medical evaluations at the
Health Appraisal Clinic between August–November of
1995 and January–March of 1996 were eligible to
participate in the ACE Study. Those seen at the clinic
during December were not included because survey
response rates are known to be lower during the
holiday period.
38
In the week after visiting the clinic, and hence
having their standardized medical history already
completed, members were mailed the ACE Study
questionnaire that included questions about child-
hood abuse and exposure to forms of household
dysfunction while growing up. After second mailings
of the questionnaire to persons who did not respond
to the first mailing, the response rate for the survey
was 70.5% (9,508/13,494).
See
related
Commentary
on pages 354,
356, 361.
246 American Journal of Preventive Medicine, Volume 14, Number 4

A second survey wave of approximately the same
number of patients as the first wave was conducted
between June and October of 1997. The data for the
second survey wave is currently being compiled for
analysis. The methods for the second mail survey wave
were identical to the first survey wave as described
above. The second wave was done to enhance the
precision of future detailed analyses on special topics
and to reduce the time necessary to obtain precise
statistics on follow-up health events. An overview of the
total ACE Study design is provided in Figure 1.
Comparison of
Respondents and Nonrespondents
We abstracted the completed medical evaluation for
every person eligible for the study; this included their
medical history, laboratory results, and physical find-
ings. Respondent (n 5 9,508) and nonrespondent
(n 5 3,986) groups were similar in their percentages
of women (53.7% and 51.0%, respectively) and in their
mean years of education (14.0 years and 13.6 years,
respectively). Respondents were older than nonrespon-
dents (means 56.1 years and 49.3 years) and more likely
to be white (83.9% vs. 75.3%) although the actual
magnitude of the differences was small.
Respondents and nonrespondents did not differ with
regard to their self-rated health, smoking, other sub-
stance abuse, or the presence of common medical
conditions such as a history of heart attack or stroke,
chronic obstructive lung disease, hypertension, or dia-
betes, or with regard to marital status or current family,
marital, or job-related problems (data not shown). The
health appraisal questionnaire used in the clinic con-
tains a single question about childhood sexual abuse
that reads “As a child were you ever raped or sexually
molested?” Respondents were slightly more likely to
answer affirmatively than nonrespondents (6.1% vs.
5.4%, respectively).
Questionnaire Design
We used questions from published surveys to construct
the ACE Study questionnaire. Questions from the Con-
flicts Tactics Scale
39
were used to define psychological
and physical abuse during childhood and to define
violence against the respondent’s mother. We adapted
four questions from Wyatt
40
to define contact sexual
abuse during childhood. Questions about exposure to
alcohol or drug abuse during childhood were adapted
from the 1988 National Health Interview Survey.
41
All
of the questions we used in this study to determine
childhood experiences were introduced with the
phrase “While you were growing up during your first 18
years of life...”
Questions about health-related behaviors and health
problems were taken from health surveys such as the
Behavioral Risk Factor Surveys
42
and the Third Na-
tional Health and Nutrition Examination Survey,
43
both of which are directed by the Centers for Disease
Control and Prevention. Questions about depression
came from the Diagnostic Interview Schedule of the
National Institute of Mental Health (NIMH).
44
Other
information for this analysis such as disease history was
obtained from the standardized questionnaire used in
the Health Appraisal Clinic. (A copy of the question-
naires used in this study may be found at www.elsevier.
com/locate/amepre.)
Figure 1. ACE Study design. *After exclusions, 59.7% of the original wave I sample (8,056/13,494) were included in this analysis.
Am J Prev Med 1998;14(4) 247

Defining Childhood Exposures
We used three categories of childhood abuse: psycho-
logical abuse (2 questions), physical abuse (2 ques-
tions), or contact sexual abuse (4 questions). There
were four categories of exposure to household dysfunc-
tion during childhood: exposure to substance abuse
(defined by 2 questions), mental illness (2 questions),
violent treatment of mother or stepmother (4 ques-
tions), and criminal behavior (1 question) in the house-
hold. Respondents were defined as exposed to a cate-
gory if they responded “yes” to 1 or more of the
questions in that category. The prevalence of positive
responses to the individual questions and the category
prevalences are shown in Table 1.
We used these 7 categories of childhood exposures to
abuse and household dysfunction for our analysis. The
measure of childhood exposure that we used was simply
the sum of the categories with an exposure; thus the
possible number of exposures ranged from 0 (unex-
posed) to 7 (exposed to all categories).
Risk Factors and Disease Conditions Assessed
Using information from both the study questionnaire
and the Health Appraisal Clinic’s questionnaire, we
chose 10 risk factors that contribute to the leading
causes of morbidity and mortality in the United
States.
6,7,36,37
The risk factors included smoking, severe
obesity, physical inactivity, depressed mood, suicide
attempts, alcoholism, any drug abuse, parenteral drug
abuse, a high lifetime number of sexual partners
($50), and a history of having a sexually transmitted
disease.
We also assessed the relationship between childhood
exposures and disease conditions that are among the
leading causes of mortality in the United States.
6
The
presence of these disease conditions was based upon
medical histories that patients provided in response to
the clinic questionnaire. We included a history of
ischemic heart disease (including heart attack or use of
nitroglycerin for exertional chest pain), any cancer,
stroke, chronic bronchitis, or emphysema (COPD),
Table 1. Prevalence of childhood exposure to abuse and household dysfunction
Category of childhood exposure
a
Prevalence (%) Prevalence (%)
Abuse by category
Psychological 11.1
(Did a parent or other adult in the household ...)
Often or very often swear at, insult, or put you down? 10.0
Often or very often act in a way that made you afraid that
you would be physically hurt?
4.8
Physical 10.8
(Did a parent or other adult in the household ...)
Often or very often push, grab, shove, or slap you? 4.9
Often or very often hit you so hard that you had marks or
were injured?
9.6
Sexual 22.0
(Did an adult or person at least 5 years older ever ...)
Touch or fondle you in a sexual way? 19.3
Have you touch their body in a sexual way? 8.7
Attempt oral, anal, or vaginal intercourse with you? 8.9
Actually have oral, anal, or vaginal intercourse with you? 6.9
Household dysfunction by category
Substance abuse 25.6
Live with anyone who was a problem drinker or alcoholic? 23.5
Live with anyone who used street drugs? 4.9
Mental illness 18.8
Was a household member depressed or mentally ill? 17.5
Did a household member attempt suicide? 4.0
Mother treated violently 12.5
Was your mother (or stepmother)
Sometimes, often, or very often pushed, grabbed, slapped,
or had something thrown at her?
11.9
Sometimes, often, or very often kicked, bitten, hit with a
fist, or hit with something hard?
6.3
Ever repeatedly hit over at least a few minutes? 6.6
Ever threatened with, or hurt by, a knife or gun? 3.0
Criminal behavior in household
Did a household member go to prison? 3.4 3.4
Any category reported 52.1%
a
An exposure to one or more items listed under the set of questions for each category.
248 American Journal of Preventive Medicine, Volume 14, Number 4

diabetes, hepatitis or jaundice, and any skeletal frac-
tures (as a proxy for risk of unintentional injuries). We
also included responses to the following question about
self-rated health: “Do you consider your physical health
to be excellent, very good, good, fair, or poor?” because
it is strongly predictive of mortality.
45
Definition of Risk Factors
We defined severe obesity as a body mass index (kg/
meter
2
) $35 based on measured height and weight;
physical inactivity as no participation in recreational
physical activity in the past month; and alcoholism as a
“Yes” response to the question “Have you ever consid-
ered yourself to be an alcoholic?” The other risk factors
that we assessed are self-explanatory.
Exclusions from Analysis
Of the 9,508 survey respondents, we excluded 51
(0.5%) whose race was unstated and 34 (0.4%) whose
educational attainment was not reported. We also ex-
cluded persons who did not respond to certain ques-
tions about adverse childhood experiences. This in-
volved the following exclusions: 125 (1.3%) for
household substance abuse, 181 (1.9%) for mental
illness in the home, 148 (1.6%) for violence against
mother, 7 (0.1%) for imprisonment of a household
member, 109 (1.1%) for childhood psychological
abuse, 44 (0.5%) for childhood physical abuse, and 753
(7.9%) for childhood sexual abuse. After these exclu-
sions, 8,056 of the original 9,508 survey respondents
(59.7% of the original sample of 13,494) remained and
were included in the analysis. Procedures for insuring
that the findings based on complete data were gener-
alizable to the entire sample are described below.
The mean age of the 8,506 persons included in this
analysis was 56.1 years (range: 19–92 years); 52.1% were
women; 79.4% were white. Forty-three percent had
graduated from college; only 6.0% had not graduated
from high school.
Statistical Analysis
We used the Statistical Analysis System (SAS)
46
for our
analyses. We used the direct method to age-adjust the
prevalence estimates. Logistic regression analysis was
employed to adjust for the potential confounding ef-
fects of age, sex, race, and educational attainment on
the relationship between the number of childhood
exposures and health problems.
To test for a dose-response relationship to health
problems, we entered the number of childhood expo-
sures as a single ordinal variable (0, 1, 2, 3, 4, 5, 6, 7)
into a separate logistic regression model for each risk
factor or disease condition.
Assessing the Possible Influence of Exclusions
To determine whether our results were influenced by
excluding persons with incomplete information on any
of the categories of childhood exposure, we performed
a separate sensitivity analysis in which we included all
persons with complete demographic information but
assumed that persons with missing information for a
category of childhood exposure did not have an expo-
sure in that category.
Results
Adverse Childhood Exposures
The level of positive responses for the 17 questions
included in the seven categories of childhood exposure
ranged from 3.0% for a respondent’s mother (or
stepmother) having been threatened with or hurt by a
gun or knife to 23.5% for having lived with a problem
drinker or alcoholic (Table 1). The most prevalent of
the 7 categories of childhood exposure was substance
abuse in the household (25.6%); the least prevalent
exposure category was evidence of criminal behavior in
the household (3.4%). More than half of respondents
(52%) experienced $1 category of adverse childhood
exposure; 6.2% reported $4 exposures.
Relationships between
Categories of Childhood Exposure
The probability that persons who were exposed to any
single category of exposure were also exposed to an-
other category is shown in Table 2. The relationship
between single categories of exposure was significant
for all comparisons (P , .001; chi-square). For persons
reporting any single category of exposure, the proba-
bility of exposure to any additional category ranged
from 65%–93% (median: 80%); similarly, the probabil-
ity of $2 additional exposures ranged from 40%–74%
(median: 54.5%).
The number of categories of childhood exposures by
demographic characteristics is shown in Table 3. Statis-
tically, significantly fewer categories of exposure were
found among older persons, white or Asian persons,
and college graduates (P , .001). Because age is
associated with both the childhood exposures as well as
many of the health risk factors and disease outcomes,
all prevalence estimates in the tables are adjusted for
age.
Relationship between
Childhood Exposures and Health Risk Factors
Both the prevalence and risk (adjusted odds ratio)
increased for smoking, severe obesity, physical inactiv-
ity, depressed mood, and suicide attempts as the num-
ber of childhood exposures increased (Table 4). When
Am J Prev Med 1998;14(4) 249

persons with 4 categories of exposure were compared
to those with none, the odds ratios ranged from 1.3 for
physical inactivity to 12.2 for suicide attempts (Table 4).
Similarly, the prevalence and risk (adjusted odds
ratio) of alcoholism, use of illicit drugs, injection of
illicit drugs, $50 intercourse partners, and history of a
sexually transmitted disease increased as the number of
childhood exposures increased (Table 5). In compar-
ing persons with $4 childhood exposures to those with
none, odds ratios ranged from 2.5 for sexually trans-
mitted diseases to 7.4 for alcoholism and 10.3 for
injected drug use.
Childhood Exposures and
Clustering of Health Risk Factors
We found a strong relationship between the number of
childhood exposures and the number of health risk
factors for leading causes of death in adults (Table 6).
For example, among persons with no childhood expo-
sures, 56% had none of the 10 risk factors whereas only
14% of persons with $4 categories of childhood expo-
sure had no risk factors. By contrast, only 1% of persons
with no childhood exposures had four or more risk
factors, whereas 7% of persons with $4 childhood
exposures had four or more risk factors (Table 6).
Relationship between
Childhood Exposures and Disease Conditions
When persons with 4 or more categories of childhood
exposure were compared to those with none, the
odds ratios for the presence of studied disease con-
ditions ranged from 1.6 for diabetes to 3.9 for
chronic bronchitis or emphysema (Table 7). Simi-
larly, the odds ratios for skeletal fractures, hepatitis
or jaundice, and poor self-rated health were 1.6, 2.3,
and 2.2, respectively (Table 8).
Significance of Dose-Response Relationships
In logistic regression models (which included age,
gender, race, and educational attainment as covariates)
we found a strong, dose-response relationship between
the number of childhood exposures and each of the 10
risk factors for the leading causes of death that we
studied (P , .001). We also found a significant (P ,
.05) dose-response relationship between the number
of childhood exposures and the following disease con-
ditions: ischemic heart disease, cancer, chronic bron-
chitis or emphysema, history of hepatitis or jaundice,
skeletal fractures, and poor self-rated health. There was
no statistically significant dose-response relationship
for a history of stroke or diabetes.
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250 American Journal of Preventive Medicine, Volume 14, Number 4

Assessment of the Influence of Exclusions
In the sensitivity analysis where missing information for
a category of childhood exposure was considered as no
exposure, the direction and strength of the associations
between the number of childhood exposures and the
risk factors and disease conditions were nearly identical
(data not shown). Thus, the results we present appear
to be unaffected by our decision to exclude persons for
whom information on any category of childhood expo-
sure was incomplete.
Discussion
We found a strong dose response relationship between
the breadth of exposure to abuse or household dysfunc-
tion during childhood and multiple risk factors for
several of the leading causes of death in adults. Disease
conditions including ischemic heart disease, cancer,
chronic lung disease, skeletal fractures, and liver dis-
ease, as well as poor self-rated health also showed a
graded relationship to the breadth of childhood expo-
sures. The findings suggest that the impact of these
adverse childhood experiences on adult health status is
strong and cumulative.
The clear majority of patients in our study who were
exposed to one category of childhood abuse or house-
hold dysfunction were also exposed to at least one
other. Therefore, researchers trying to understand the
long-term health implications of childhood abuse may
benefit from considering a wide range of related ad-
verse childhood exposures. Certain adult health out-
comes may be more strongly related to unique combi-
nations or the intensity of adverse childhood exposures
than to the total breadth of exposure that we used for
our analysis. However, the analysis we present illustrates
the need for an overview of the net effects of a group of
complex interactions on a wide range of health risk
behaviors and diseases.
Several potential limitations need to be considered
when interpreting the results of this study. The data
about adverse childhood experiences are based on
self-report, retrospective, and can only demonstrate
associations between childhood exposures and health
risk behaviors, health status, and diseases in adulthood.
Second, some persons with health risk behaviors or
diseases may have been either more, or less, likely to
report adverse childhood experiences. Each of these
issues potentially limits inferences about causality. Fur-
thermore, disease conditions could be either over- or
under-reported by patients when they complete the
medical questionnaire. In addition, there may be me-
diators of the relationship between childhood experi-
ences and adult health status other than the risk factors
we examined. For example, adverse childhood experi-
ences may affect attitudes and behaviors toward health
and health care, sensitivity to internal sensations, or
physiologic functioning in brain centers and neuro-
transmitter systems. A more complete understanding
of these issues is likely to lead to more effective ways
to address the long-term health problems associated
with childhood abuse and household dysfunction.
However, our estimates of the prevalence of child-
Table 3. Prevalence of categories of adverse childhood exposures by demographic characteristics
Characteristic
Sample size
(N)
Number of categories (%)
a
01234
Age group (years)
19–34 807 35.4 25.4 17.2 11.0 10.9
35–49 2,063 39.3 25.1 15.6 9.1 10.9
50–64 2,577 46.5 25.2 13.9 7.9 6.6
$65 2,610 60.0 24.5 8.9 4.2 2.4
Gender
b
Women 4,197 45.4 24.0 13.4 8.7 8.5
Men 3,859 53.7 25.8 11.6 5.0 3.9
Race
b
White 6,432 49.7 25.3 12.4 6.7 6.0
Black 385 38.8 25.7 16.3 12.3 7.0
Hispanic 431 42.9 24.9 13.7 7.4 11.2
Asian 508 66.0 19.0 9.9 3.4 1.7
Other 300 41.0 23.5 13.9 9.5 12.1
Education
b
No HS diploma 480 56.5 21.5 8.4 6.5 7.2
HS graduate 1,536 51.6 24.5 11.3 7.4 5.2
Any college 2,541 44.1 25.5 14.8 7.8 7.8
College graduate 3,499 51.4 25.1 12.1 6.1 5.3
All participants 8,056 49.5 24.9 12.5 6.9 6.2
a
The number of categories of exposure was simply the sum of each of the seven individual categories that were assessed (see Table 1).
b
Prevalence estimates adjusted for age.
Am J Prev Med 1998;14(4) 251

hood exposures are similar to estimates from nationally
representative surveys, indicating that the experiences
of our study participants are comparable to the larger
population of U.S. adults. In our study, 23.5% of
participants reported having grown up with an alcohol
abuser; the 1988 National Health Interview Survey
estimated that 18.1% of adults had lived with an alcohol
abuser during childhood.
41
Contact sexual abuse was
reported by 22% of respondents (28% of women and
16% of men) in our study. A national telephone survey
of adults in 1990 using similar criteria for sexual abuse
estimated that 27% of women and 16% of men had
been sexually abused.
12
There are several reasons to believe that our esti-
mates of the long-term relationship between adverse
childhood experiences and adult health are conserva-
tive. Longitudinal follow-up of adults whose childhood
abuse was well documented has shown that their retro-
spective reports of childhood abuse are likely to under-
estimate actual occurrence.
47,48
Underestimates of
childhood exposures would result in downwardly bi-
ased estimates of the relationships between childhood
exposures and adult health risk behaviors and dis-
eases. Another potential source of underestimation
of the strength of these relationships is the lower
number of childhood exposures reported by older
persons in our study. This may be an artifact caused
by premature mortality in persons with multiple
adverse childhood exposures; the clustering of mul-
tiple risk factors among persons with multiple child-
hood exposures is consistent with this hypothesis.
Thus, the true relationships between adverse child-
hood exposures and adult health risk behaviors,
health status, and diseases may be even stronger than
those we report.
An essential question posed by our observations is,
“Exactly how are adverse childhood experiences linked
to health risk behaviors and adult diseases?” The link-
Table 4. Number of categories of adverse childhood exposure and the adjusted odds of risk factors including current
smoking, severe obesity, physical inactivity, depressed mood, and suicide attempt
Health problem
Number
of
categories
Sample
size
(N)
a
Prevalence
(%)
b
Adjusted
odds
ratio
c
95%
confidence
interval
Current smoker
d
0 3,836 6.8 1.0 Referent
1 2,005 7.9 1.1 ( 0.9–1.4)
2 1,046 10.3 1.5 ( 1.1–1.8)
3 587 13.9 2.0 ( 1.5–2.6)
4 or more 544 16.5 2.2 ( 1.7–2.9)
Total 8,018 8.6 — —
Severe obesity
d
(BMI $ 35)
0 3,850 5.4 1.0 Referent
1 2,004 7.0 1.1 ( 0.9–1.4)
2 1,041 9.5 1.4 ( 1.1–1.9)
3 590 10.3 1.4 ( 1.0–1.9)
4 or more 543 12.0 1.6 ( 1.2–2.1)
Total 8,028 7.1 — —
No leisure-time
physical activity
0 3,634 18.4 1.0 Referent
1 1,917 22.8 1.2 ( 1.1–1.4)
2 1,006 22.0 1.2 ( 1.0–1.4)
3 559 26.6 1.4 ( 1.1–1.7)
4 or more 523 26.6 1.3 ( 1.1–1.6)
Total 7,639 21.0 — —
Two or more weeks of
depressed mood in
the past year
0 3,799 14.2 1.0 Referent
1 1,984 21.4 1.5 ( 1.3–1.7)
2 1,036 31.5 2.4 ( 2.0–2.8)
3 584 36.2 2.6 ( 2.1–3.2)
4 or more 542 50.7 4.6 ( 3.8–5.6)
Total 7,945 22.0 — —
Ever attempted suicide 0 3,852 1.2 1.0 Referent
1 1,997 2.4 1.8 ( 1.2–2.6)
2 1,048 4.3 3.0 ( 2.0–4.6)
3 587 9.5 6.6 ( 4.5–9.8)
4 or more 544 18.3 12.2 (8.5–17.5)
Total 8,028 3.5 — —
a
Sample sizes will vary due to incomplete or missing information about health problems.
b
Prevalence estimates are adjusted for age.
c
Odds ratios adjusted for age, gender, race, and educational attainment.
d
Indicates information recorded in the patient’s chart before the study questionnaire was mailed.
252 American Journal of Preventive Medicine, Volume 14, Number 4

ing mechanisms appear to center on behaviors such as
smoking, alcohol or drug abuse, overeating, or sexual
behaviors that may be consciously or unconsciously
used because they have immediate pharmacological or
psychological benefit as coping devices in the face of
the stress of abuse, domestic violence, or other forms of
family and household dysfunction. High levels of expo-
sure to adverse childhood experiences would expect-
edly produce anxiety, anger, and depression in chil-
dren. To the degree that behaviors such as smoking,
alcohol, or drug use are found to be effective as coping
devices, they would tend to be used chronically. For
Table 5. Number of categories of adverse childhood exposure and the prevalence and risk (adjusted odds ratio) of health
risk factors including alcohol or drug abuse, high lifetime number of sexual partners, or history of sexually
transmitted disease
Health problem
Number
of
categories
Sample
size
(N)
a
Prevalence
(%)
b
Adjusted
odds
ratio
c
95%
confidence
interval
Considers self an
alcoholic
0 3,841 2.9 1.0 Referent
1 1,993 5.7 2.0 (1.6–2.7)
2 1,042 10.3 4.0 (3.0–5.3)
3 586 11.3 4.9 (3.5–6.8)
4 or more 540 16.1 7.4 (5.4–10.2)
Total 8,002 5.9 — —
Ever used illicit drugs 0 3,856 6.4 1.0 Referent
1 1,998 11.4 1.7 (1.4–2.0)
2 1,045 19.2 2.9 (2.4–3.6)
3 589 21.5 3.6 (2.8–4.6)
4 or more 541 28.4 4.7 (3.7–6.0)
Total 8,029 11.6 — —
Ever injected drugs 0 3,855 0.3 1.0 Referent
1 1,996 0.5 1.3 (0.6–3.1)
2 1,044 1.4 3.8 (1.8–8.2)
3 587 2.3 7.1 (3.3–15.5)
4 or more 540 3.4 10.3 (4.9–21.4)
Total 8,022 0.8 — —
Had 50 or more
intercourse partners
0 3,400 3.0 1.0 Referent
1 1,812 5.1 1.7 (1.3–2.3)
2 926 6.1 2.3 (1.6–3.2)
3 526 6.3 3.1 (2.0–4.7)
4 or more 474 6.8 3.2 (2.1–5.1)
Total 7,138 4.4 — —
Ever had a sexually
transmitted disease
d
0 3,848 5.6 1.0 Referent
1 2,001 8.6 1.4 (1.1–1.7)
2 1,044 10.4 1.5 (1.2–1.9)
3 588 13.1 1.9 (1.4–2.5)
4 or more 542 16.7 2.5 (1.9–3.2)
Total 8023 8.2 — —
a
Sample sizes will vary due to incomplete or missing information about health problems.
b
Prevalence estimates are adjusted for age.
c
Odds ratios adjusted for age, gender, race, and educational attainment.
d
Indicates information recorded in the patient’s chart before the study questionnaire was mailed.
Table 6. Relationship between number of categories of childhood exposure and number of risk factors for the leading
causes of death
a
Number of categories
Sample
size
% with number of risk factors
01234
0 3,861 56 29 10 4 1
1 2,009 42 33 16 6 2
2 1,051 31 33 20 10 4
3 590 24 33 20 13 7
$4 545 14 26 28 17 7
Total 8,056 44 31 15 7 3
a
Risk factors include: smoking, severe obesity, physical inactivity, depressed mood, suicide attempt, alcoholism, any drug use, injected drug use,
$50 lifetime sexual partners, and history of a sexually transmitted disease.
Am J Prev Med 1998;14(4) 253

example, nicotine is recognized as having beneficial
psychoactive effects in terms of regulating affect
49
and
persons who are depressed are more likely to
smoke.
50,51
Thus, persons exposed to adverse child-
hood experiences may benefit from using drugs such as
nicotine to regulate their mood.
49,52
Consideration of the positive neuroregulatory effects
of health-risk behaviors such as smoking may provide
biobehavioral explanations
53
for the link between ad-
verse childhood experiences and health risk behaviors
and diseases in adults. In fact, we found that exposure
to higher numbers of categories of adverse childhood
experiences increased the likelihood of smoking by the
age of 14, chronic smoking as adults, and the presence
of smoking-related diseases. Thus, smoking, which is
medically and socially viewed as a “problem” may, from
the perspective of the user, represent an effective
immediate solution that leads to chronic use. Decades
later, when this “solution” manifests as emphysema,
cardiovascular disease, or malignancy, time and the
tendency to ignore psychological issues in the manage-
ment of organic disease make improbable any full
understanding of the original causes of adult disease
(Figure 2). Thus, incomplete understanding of the
possible benefits of health risk behaviors leads them to
be viewed as irrational and having solely negative
consequences.
Because adverse childhood experiences are common
and they have strong long-term associations with adult
health risk behaviors, health status, and diseases, in-
creased attention to primary, secondary, and tertiary
prevention strategies is needed. These strategies in-
clude prevention of the occurrence of adverse child-
hood experiences, preventing the adoption of health
risk behaviors as responses to adverse experiences
during childhood and adolescence, and, finally, help-
ing change the health risk behaviors and ameliorating
the disease burden among adults whose health prob-
lems may represent a long-term consequence of ad-
verse childhood experiences.
Table 7. Number of categories of adverse childhood exposure and the prevalence and risk (adjusted odds ratio) of heart
attack, cancer, stroke, COPD, and diabetes
Disease condition
d
Number
of
categories
Sample
size
(N)
a
Prevalence
(%)
b
Adjusted
odds
ratio
c
95%
confidence
interval
Ischemic heart disease 0 3,859 3.7 1.0 Referent
1 2,009 3.5 0.9 (0.7–1.3)
2 1,050 3.4 0.9 (0.6–1.4)
3 590 4.6 1.4 (0.8–2.4)
4 or more 545 5.6 2.2 (1.3–3.7)
Total 8,022 3.8 — —
Any cancer 0 3,842 1.9 1.0 Referent
1 1,995 1.9 1.2 (1.0–1.5)
2 1,043 1.9 1.2 (1.0–1.5)
3 588 1.9 1.0 (0.7–1.5)
4 or more 543 1.9 1.9 (1.3–2.7)
Total 8,011 1.9 — —
Stroke 0 3,832 2.6 1.0 Referent
1 1,993 2.4 0.9 (0.7–1.3)
2 1,042 2.0 0.7 (0.4–1.3)
3 588 2.9 1.3 (0.7–2.4)
4 or more 543 4.1 2.4 (1.3–4.3)
Total 7,998 2.6 — —
Chronic bronchitis or
emphysema
0 3,758 2.8 1.0 Referent
1 1,939 4.4 1.6 (1.2–2.1)
2 1,009 4.4 1.6 (1.1–2.3)
3 565 5.7 2.2 (1.4–3.3)
4 or more 512 8.7 3.9 (2.6–5.8)
Total 7,783 4.0 — —
Diabetes 0 3,850 4.3 1.0 Referent
1 2,002 4.1 1.0 (0.7–1.3)
2 1,046 3.9 0.9 (0.6–1.3)
3 587 5.0 1.2 (0.8–1.9)
4 or more 542 5.8 1.6 (1.0–2.5)
Total 8,027 4.3 — —
a
Sample sizes will vary due to incomplete or missing information about health problems.
b
Prevalence estimates are adjusted for age.
c
Odds ratios adjusted for age, gender, race, and educational attainment.
d
Indicates information recorded in the patient’s chart before the study questionnaire was mailed.
254 American Journal of Preventive Medicine, Volume 14, Number 4

Primary prevention of adverse childhood experi-
ences has proven difficult
54,55
and will ultimately re-
quire societal changes that improve the quality of family
and household environments during childhood. Recent
research on the long-term benefit of early home visitation
on reducing the prevalence of adverse childhood experi-
ences is promising.
56
In fact, preliminary data from the
ACE Study provided the impetus for the Kaiser Health
Plan to provide funding to participate at 4 locations
(including San Diego County, California) in the Com-
monwealth Fund’s “Healthy Steps” program. This pro-
gram extends the traditional practice of pediatrics by
adding one or more specialists in the developmental and
psychosocial dimensions of both childhood and parent-
hood. Through a series of office visits, home visits, and a
telephone advice line for parents, these specialists develop
close relationships between children and their families
from birth to 3 years of age. This approach is consistent
with the recommendation of the U.S. Advisory Board on
Child Abuse and Neglect that a universal home visitation
program for new parents be developed
57,58
and provides
an example of a family-based primary prevention effort
that is being explored in a managed care setting. If these
types of approaches can be replicated and implemented
on a large scale, the long-term benefits may include,
somewhat unexpectedly, substantial improvements in
overall adult health.
Secondary prevention of the effects of adverse child-
hood experiences will first require increased recogni-
tion of their occurrence and second, an effective un-
derstanding of the behavioral coping devices that
commonly are adopted to reduce the emotional impact
of these experiences. The improbability of giving up an
immediate “solution” in return for a nebulous long-
term health benefit has thwarted many well-intended
preventive efforts. Although articles in the general
medical literature are alerting the medical community
to the fact that childhood abuse is common,
59
adoles-
cent health care is often inadequate in terms of psycho-
social assessment and anticipatory guidance.
60
Clearly,
comprehensive strategies are needed to identify and
intervene with children and families who are at risk for
these adverse experiences and their related out-
comes.
61
Such strategies should include increased com-
munication between and among those involved in
family practice, internal medicine, nursing, social work,
pediatrics, emergency medicine, and preventive medi-
cine and public health. Improved understanding is also
needed of the effects of childhood exposure to domes-
tic violence.
19,62
Additionally, increased physician train-
ing
63
is needed to recognize and coordinate the man-
agement of all persons affected by child abuse,
domestic violence, and other forms of family adversity
such as alcohol abuse or mental illness.
In the meantime, tertiary care of adults whose health
problems are related to experiences such as childhood
abuse
5
will continue to be a difficult challenge. The
relationship between childhood experiences and adult
health status is likely to be overlooked in medical
practice because the time delay between exposure
Table 8. Number of categories of adverse childhood exposure and the prevalence and risk (adjusted odds ratio) of skeletal
fracture, hepatitis or jaundice, and poor self-rated health
Disease condition
Number
of
categories
Sample
size
(N)
a
Prevalence
(%)
b
Adjusted
odds
ratio
c
95%
confidence
interval
Ever had a skeletal
fracture
0 3,843 3.6 1.0 Referent
1 1,998 4.0 1.1 (1.0–1.2)
2 1,048 4.5 1.4 (1.2–1.6)
3 587 4.0 1.2 (1.0–1.4)
4 or more 544 4.8 1.6 (1.3–2.0)
Total 8,020 3.9 — —
Ever had hepatitis or
jaundice
0 3,846 5.3 1.0 Referent
1 2,006 5.5 1.1 (0.9–1.4)
2 1,045 7.7 1.8 (1.4–2.3)
3 590 10.2 1.6 (1.2–2.3)
4 or more 543 10.7 2.4 (1.8–3.3)
Total 8,030 6.5 — —
Fair or poor self-rated
health
0 3,762 16.3 1.0 Referent
1 1,957 17.8 1.2 (1.0–1.4)
2 1,029 19.9 1.4 (1.2–1.7)
3 584 20.3 1.4 (1.1–1.7)
4 or more 527 28.7 2.2 (1.8–2.7)
Total 7,859 18.2 — —
a
Sample sizes will vary due to incomplete or missing information about health problems.
b
Prevalence estimates are adjusted for age and gender.
c
Odds ratios adjusted for age, gender, race, and educational attainment.
d
Indicates information recorded in the patient’s chart before the study questionnaire was mailed.
Am J Prev Med 1998;14(4) 255

during childhood and recognition of health problems
in adult medical practice is lengthy. Moreover, these
childhood exposures include emotionally sensitive top-
ics such as family alcoholism
29,30
and sexual abuse.
64
Many physicians may fear that discussions of sexual
violence and other sensitive issues are too personal
even for the doctor-patient relationship.
65
For example,
the American Medical Association recommends screen-
ing of women for exposure to violence at every en-
trance to the health system;
66
however, such screening
appears to be rare.
67
By contrast, women who are asked
about exposure to sexual violence say they consider
such questions to be welcome and germane to routine
medical care,
68
which suggests that physicians’ fears
about patient reactions are largely unfounded.
Clearly, further research and training are needed to
help medical and public health practitioners under-
stand how social, emotional, and medical problems are
linked throughout the lifespan (Figure 2). Such re-
search and training would provide physicians with the
confidence and skills to inquire and respond to patients
who acknowledge these types of childhood exposures.
Increased awareness of the frequency and long-term
consequences of adverse childhood experiences may
also lead to improvements in health promotion and
disease prevention programs. The magnitude of the
difficulty of introducing the requisite changes into
medical and public health research, education, and
practice can be offset only by the magnitude of the
implications that these changes have for improving the
health of the nation.
We thank Naomi Howard for her dedication to the ACE Study.
This research is supported by the Centers for Disease Control
and Prevention via cooperative agreement TS-44-10/12 with the
Association of Teachers of Preventive Medicine.
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