Adverse Childhood Experiences (ACEs) refer to stressful or traumatic events that children face before reaching 18. These include various forms of abuse (physical, emotional, sexual), neglect (emotional, physical), and household challenges such as witnessing domestic violence, living with substance abusers, having an incarcerated relative, or experiencing family separation.
Studies have shown that individuals with a high number of ACEs are at an increased risk for negative outcomes in adulthood, including chronic diseases, mental illness, substance misuse, and reduced life potential. The more ACEs one has, the greater the risk for these outcomes.
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245-258.
Key Points
- Adverse childhood experiences like abuse, violence, and family dysfunction are common and have strong, cumulative effects on adult health risk behaviors and diseases.
- Over half of the study participants reported at least one adverse childhood experience. As the number of adverse experiences increased, so did the risk for smoking, alcoholism, drug abuse, depression, suicide attempts, multiple sexual partners, sexually transmitted diseases, heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease.
- People with 4 or more adverse childhood experiences had up to 12 times higher likelihood of suicide attempts, 7 times higher chance of alcoholism, and 10 times higher risk of injected drug use compared to people with no adverse experiences.
- Adverse childhood experiences tend to be interrelated rather than occurring in isolation. People exposed to one category had a 65-93% chance of exposure to other categories as well.
- The research had some limitations such as reliance on retrospective self-report and the study population being mostly white, middle-aged, and middle-class. However, it highlights the profound, long-term impact of childhood adversity on adult health.
Rationale
Child abuse, neglect, and other adverse childhood experiences have been associated with poorer health outcomes in adulthood (Springs & Friedrich, 1992; Felitti, 1991, 1993).
However, prior studies focused on single forms of adversity and did not assess the cumulative impact of multiple experiences (Briere & Runtz, 1988; Moeller et al., 1993).
This study aimed to examine the relationship between the breadth of exposure to abuse, violence, and family dysfunction in childhood and health risk behaviors, health status, and diseases in adulthood. Understanding these associations can inform more effective prevention and treatment strategies.
Method
This retrospective cohort study surveyed 13,494 adult health maintenance organization (HMO) members who had a standardized medical evaluation at a clinic.
The mailed survey asked about adverse childhood experiences like psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill, suicidal, or imprisoned.
The number of exposure categories (0-7) was compared to the presence of risk factors for leading causes of death and disease conditions using logistic regression models.
Sample:
After exclusions, the final sample was 8,056 people aged 19-92 years, predominantly white (79%) and college-educated (43%). 53% were women.
Statistical Analysis
Logistic regression analyzed the relationship between the number of childhood exposures and health outcomes, adjusting for age, sex, race, and education. Dose-response was tested by entering exposures as an ordinal variable.
Results
- 52% of participants had at least one adverse childhood experience.
- As exposures increased from 0 to 4+, smoking prevalence rose from 7% to 17%, severe obesity from 5% to 12%, depressed mood from 14% to 51%, and suicide attempts from 1% to 18%.
- The odds of alcoholism, drug abuse, sexual partners, and STDs also increased with more exposures.
- Heart disease, cancer, lung disease, skeletal fractures, and fair/poor health showed significant dose-response relationships.
Implications
- This study reveals the surprisingly common and powerful long-term effects of adverse childhood experiences like abuse, domestic violence, and household dysfunction.
- The cumulative impact of adverse childhood experiences explains the adoption of unhealthy coping behaviors like smoking, overeating, alcoholism, drug use, and risky sex. It also elucidates the link to stress-related diseases later in life.
- This highlights the need for primary prevention strategies like home visitation programs and secondary/tertiary prevention through better training of healthcare providers to recognize and address the long-term consequences of childhood adversity.
Future Research
- Understanding ACEs is crucial, as early interventions can prevent future health and social problems, promoting resilience and providing support mechanisms to counteract these early life stressors.
Strengths & Limitations
The study had many methodological strengths, including:
- Large sample size with high response rate (70.5%)
- Assessed range of childhood exposures, not just single types of adversity
- Used logistic regression to control demographic factors
- Found relationships robust to missing data in sensitivity analysis
However, this study was limited in a few ways:
- Retrospective self-report prone to recall bias
- Mostly white, educated, middle-class, so may not generalize
- Can’t determine causality due to study design
Conclusion
This study reveals powerful relationships between the breadth of exposure to childhood adversity and health risk behaviors and diseases in adulthood.
It underscores the profound, long-term impact of adverse developmental experiences.
More research is needed, but these findings suggest that prevention and intervention around childhood adversity could improve public health.
Healthcare providers should be alert for patients whose health problems may have developmental origins.
Further progress relies on compassionately understanding how high-risk health behaviors may represent coping responses in the face of trauma and cumulative stress.
References
Primary Paper
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245-258.
Other References
Briere, J., & Runtz, M. (1988). Multivariate correlates of childhood psychological and physical maltreatment among university women. Child Abuse & Neglect, 12(3), 331-341.
Felitti, V. J. (1991). Long-term medical consequences of incest, rape, and molestation. Southern Medical Journal, 84(3), 328-331.
Felitti, V. J. (1993). Childhood sexual abuse, depression, and family dysfunction in adult obese patients: a case control study. Southern Medical Journal, 86(7), 732-736.
Moeller, T. P., Bachman, G. A., & Moeller, J. R. (1993). The combined effects of physical, sexual, and emotional abuse during childhood: Long-term health consequences for women. Child Abuse & Neglect, 17(5), 623-640.
Springs, F., & Friedrich, W. N. (1992). Health risk behaviors and medical sequelae of childhood sexual abuse. Mayo Clinic Proceedings, 67(6), 527-532.
Further Reading
- Chapman, D. P., Whitfield, C. L., Felitti, V. J., Dube, S. R., Edwards, V. J., & Anda, R. F. (2004). Adverse childhood experiences and the risk of depressive disorders in adulthood. Journal of affective disorders, 82(2), 217-225.
- Dube, S. R., Felitti, V. J., Dong, M., Chapman, D. P., Giles, W. H., & Anda, R. F. (2003). Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study. Pediatrics, 111(3), 564-572.
- Felitti, V. J. (2009). Adverse childhood experiences and adult health. Academic pediatrics, 9(3), 131-132.
- Hamai, T. A., & Felitti, V. J. (2022). Adverse childhood experiences: Past, present, and future. Handbook of interpersonal violence and abuse across the lifespan: a project of the national partnership to end interpersonal violence across the lifespan (NPEIV), 97-120.
Learning Check
- How might experiences of childhood adversity sensitize people biologically and psychologically to engage in high-risk behaviors?
- If adverse childhood experiences tend to co-occur and have cumulative effects, how should prevention/intervention strategies be designed differently than just targeting single types of adversity?
- What biases or limitations might affect participants’ retrospective self-reports of childhood experiences and current health status? How could the study design be improved?
- How might a healthcare provider compassionately uncover whether a patient’s health issues may have origins in adverse developmental experiences? What challenges does this present?
- How might knowledge of the prevalence and impacts of childhood adversity reduce stigma and lead to improved public health policies and outcomes? What barriers stand in the way?
