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The Health and Social Impact of Adverse Childhood Experiences

by Shanta R. Dube, MPH; Vincent J. Felitti, MD; and Robert F. Anda, MD, MS

 

The Adverse Childhood Experiences (ACE) Study is a large-scale, ongoing epidemiological study that assesses the impact of numerous, interrelated, adverse childhood experiences on a variety of health behaviors and outcomes in adulthood. The ACE Study is a collaborative effort between Vincent Felitti, MD of Kaiser Permanente's Department of Preventive Medicine in San Diego and Robert Anda, MD, MS of the Centers for Disease Control and Prevention (CDC) in Atlanta.

The catalyst for this study began in the mid-80s, when Dr. Felitti was running the obesity program at Kaiser Permanente's Department of Preventive Medicine. He was surprised by the high dropout rates among persons who successfully lost weight and set out to find the cause. After interviewing about 200 patients, Dr. Felitti discovered many of them had been abused as children, and this antedated the onset of their obesity. Many patients spoke openly of an association between the two. The counterintuitive aspect was that, for many people, obesity was not their problem; it was their protective solution to problems that previously had never been discussed with anyone. After Dr. Felitti shared these findings with CDC researchers in 1990, they proposed an epidemiological study specifically designed to examine childhood origins of adult health behaviors and outcomes.

The ACE Study was carried out at Kaiser Permanente's San Diego Department of Preventive Medicine Health Appraisal Center (HAC), which provides complete and standardized medical, psychosocial, and preventive health evaluations to adult members of Kaiser Health Plan in San Diego County. In any four-year period, 81% of the adult members obtain this service and over 50,000 members are evaluated yearly. Visit to the HAC is primarily for the purposes of complete health assessments, rather than symptom or illness-based care. The ACE Study includes 17,421 participants; the study population is predominately White (75%), highly educated, and middle aged (mean age, 57 years).

One of the strengths of the ACE Study is that it examines a broad range of adverse childhood exposures. These include eight overall categories of adverse childhood experiences, three of which constitute personal abuse-physical, emotional, or sexual abuse and five which constitute household dysfunction- growing up in a household with (1) an alcoholic or drug user; (2) an incarcerated household member; (3) someone who was chronically depressed, mentally ill, or suicidal; (4) the mother being treated violently; or (5) the parents being separated or divorced. In this study population, these exposures are highly interrelated. Given an exposure to one category, the likelihood of exposure to another is 80% (Felitti et al, 1998). Thus, adverse childhood experiences do not occur in isolation. For example, a child does not grow up with an alcoholic parent or with domestic violence in an otherwise well-functioning household. Thus, contrary to previous research that has typically examined these types of childhood experiences categorically, the ACE Study findings demonstrate that these exposures must be examined as a constellation of childhood adversity.

To assess the cumulative impact of these multiple interrelated adverse childhood experiences, a scale of 0-8 to represent the total number of exposures (ACE score) was constructed. One of the most striking findings is that 64% of persons reported experiencing one or more adverse childhood experience. Recent publications from the ACE Study have repeatedly shown a strong (and graded) relationship between individual categories of adverse childhood experiences (and the ACE score) with major health and social problems of concern in the United States. Adverse childhood experiences are strongly associated with smoking, unintended pregnancies, sexually transmitted diseases, sexual risk behaviors, male involvement in teen pregnancy, suicide attempts throughout the life span, adult alcohol abuse, obesity, and the leading causes of death in the United States (Appendix 1).

Ongoing examination of the ACE Study data indicates that many of the public health problems facing the U.S. population may have their origins in these types of early experiences. For example, as the ACE score increases, the risk of ever being a heavy drinker also increases. Compared to persons who experienced no adverse childhood experiences, there was a 30-fold increased risk for suicide attempts among persons who experienced 7 or more of these experiences. This groundbreaking information provides a new way to view behavioral factors known to increase the risk of death and disability in the United States.

In conclusion, the data from the ACE Study demonstrate that childhood traumatic stressors are common. These stressors have a strong cumulative relationship to a variety of health and social problems of importance. Thus, adverse childhood experiences may be considered a leading determinant of health in the United States.

Appendix 1. Relationship between adverse childhood experiences and multiple health outcomes.

Health Behavior or Outcome : Selected Publications on These Topics

  • Leading causes of death in the United States : Felitti VJ, Anda RF, Nordenberg D, et al. The relationship of adult health status to childhood abuse and household dysfunction. American Journal of Preventive Medicine. 1998;14:245-258.
  • Smoking throughout the lifespan : Anda RF, Croft JB, Felitti VJ, et al. Adverse childhood experiences and smoking during adolescence and adulthood. Journal of the American Medical Association. 1999;282:1652-1658.
  • Unintended pregnancies : Dietz PM, Spitz AM, Anda RF, et al. Unintended pregnancy among adult women exposed to abuse or household dysfunction during their childhood. Journal of the American Medical Association. 1999;282:1359-1364.
  • Sexually transmitted diseases : Hillis SD, Anda RF, Felitti VJ, Nordenberg D, Marchbanks PA. Adverse childhood experiences and sexually transmitted diseases in men and women: a retrospective study. Pediatrics 2000 106(1):E11.
  • Sexual risk behaviors : Hillis SD, Anda RF, Felitti VJ, Marchbanks PA. Adverse childhood experiences and sexual risk behaviors in women: a retrospective cohort study. Family Planning Perspectives. 2001, 33: 206-211.
  • Male involvement in teen pregnancy : Anda RF, Chapman DP, Felitti VJ, et al. Adverse Childhood Experiences and Risk of Paternity in Teen Pregnancy.Obstetrics and Gynecology 2002;100(1): 37 - 45.
  • Suicide attempts throughout the life span : Dube SR, Anda RF, Felitti VJ, Chapman D, Williamson DF, Giles WH. Childhood abuse, household dysfunction and the risk of attempted suicide throughout the life span: Findings from the Adverse Childhood Experiences Study. Journal of the American Medical Association. 2001: 286, 3089-3096.
  • Adult alcohol abuse : Dube SR, Anda RF, Felitti VJ, Edwards VJ, Croft JB. Adverse childhood experiences and personal alcohol abuse as an adult. Addictive Behaviors, 2002. 27(5), 713-725.Anda RF, Whitfield CL, Felitti VJ, et al. Alcohol-impaired parents and adverse childhood experiences: the risk of depression and alcoholism during adulthood. Journal of Psychiatric Services 2002; 53(8):1001-1009.
  • Obesity in adulthood : Williamson DF, Thompson TJ, Anda RF, Dietz WH, Felitti VJ. Adult Body Weight, Obesity, and Self-Reported Abuse in Childhood. International Journal of Obesity. 2002; 26: 1075-1082.